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Gout treatments and Facts about Uric Acid

Arthritis is a painful condition of the joints that often leads to disability. The word "arthritis" is derived from the Greek roots arthro- meaning joint and the suffix -itis for inflammation. The plural form is "arthritides". Some of the most common forms of arthritis are osteoarthritis, rheumatoid arthritis, and gout.

Thermogram of legs 
Thermogram shows
lower temperature in 
the knees and feet

What is Gout?
Gout occurs when too much uric acid builds up in the blood and uric acid crystals precipitate in the cooler parts of the body such as the joints of the hands or feet. High levels of uric acid may also build up as lumps under the skin called tophi, or as kidney stones. Uric Acid is a waste product of the oxidation of purines which are constituents of nucleic acids such as DNA. Uric acid is normally excreted in the urine to maintain a concentration of uric acid in the blood of approximately 4 mg/dL. When the concentration exceeds 7 mg/dL, crystals of monosodium urate start to form in the tissues. This condition is known as hyperuricemia.

Gout in toe
Gout in toe

What are the symptoms of Gout?
The symptoms of gout are redness of a joint, accompanied by inflammation, stiffness, and intense pain. Many people experience their first gout attack in the big toe, but other joints such as the ankles, wrists, fingers, or elbows may be affected. The pain may be so severe that even the pressure of bed sheets may be unbearable. A gout attack can be brought on by alcohol, or foods high in purines such as shellfish, caviar, sardines, anchovies, meats, or organ meats that are commonly used in sausages. A study over a 12-year period of 47,000 adult men revealed that those who ate the most red meat or seafood increased their risk of gout by as much as 50%.[6]  Many gout attacks get better within a few days, even without treatment, and they may not recur for many months or years.

How is Gout Diagnosed?
Gout is diagnosed based on family history, specific symptoms, and laboratory tests. Diagnosis of gout is confirmed by the determination of high levels of uric acid in the blood, monosodium urate crystals in the fluid of an inflamed joint, more than one attack of acute arthritis, and the involvement of only one joint such as the toe, ankle, or knee.

How is Gout treated?
Because gout episodes are so painful, patients demand some kind of gout treatment, even though the treatments for gout are not very effective and have undesirable side effects. The most common treatments include the administration of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, indomethacin and naproxen. Aspirin is not used because it aggravates hyperuricemia by increasing uric acid retention.[17] These medications can cause stomach pain, bleeding and ulcers, and beyond a certain dosage, they do not provide additional relief.

Corticosteroids, such as prednisone, are prescribed for severe cases of gout. Although these steroids can provide relief, they also have serious side effects, including thinning bones, poor wound healing, and a weakened immune system. Cortisone injections into an affected joint are generally limited to no more than three per year because of the side effects.

Allopurinol, probenecid, and colchicine are sometimes prescribed in daily doses to reduce the risk or lessen the severity of future episodes. Allopurinol blocks the formation of uric acid, probenecid decreases the frequency of attacks of gout by increasing the kidney's excretion of uric acid, and colchicine may relieve swelling and help prevent the frequency of gout attacks. These drugs speed the elimination of uric acid from the body, and they also slow down the rate at which it is produced, but they may cause nausea or skin rashes as side effects.

Some new drugs for the treatment of gout include febuxostat (Uloric) which was introduced in 2009 for the chronic management of hyperuricemia in patients with gout. It is a xanthine oxidase inhibitor that works by decreasing the amount of uric acid made in the body. Febuxostat must be taken daily and it may take several months before it begins to prevent gout attacks. As a side effect, febuxostat may cause increased levels of liver enzymes in the blood that may be a sign of liver damage. Pegloticase (Krystexxa) is a urate oxidase enzyme that catalyzes the conversion of uric acid to allantoin which is five to ten times more soluble than uric acid. In 2010, the FDA approved pegloticase for treatment of gout patients who cannot tolerate or do not respond to conventional therapy. Peglioticase is administered every two weeks by intravenous infusion. Nausea, vomiting and allergic reactions have been reported as side effects.

Along with specifically prescribed medications, patients are advised to drink plenty of water and avoid alcoholic beverages and purine-rich foods such as fish roes, herring, organ meats, legumes, and meats.

Is there a Gout Cure?
Learning about the chemical and physical properties of uric acid and purines can provide a scientific foundation for relieving gout symptoms and for avoiding its occurrence. An understanding of the chemical structure of purines and their origin makes it possible to avoid sources of purines in the diet. The level of uric acid in the body may also be reduced by drinking plenty of water to increase the frequency of urination. However, learning how the solubility of uric acid is affected by temperature and by the acidity of body fluids can be used to formulate some possible home therapies.

Purine Structure 

What are purines?
Purine is the chemical name of a 6-atom ring fused to a 5-atom ring known as imidazo[4,5-d]pyrimidine. Compounds containing this substructure are generically called "purines". The purine structure is present in uric acid, as well as in caffeine, Deoxyribonucleic Acid (DNA), Ribonucleic Acid (RNA), and other important biomolecules such as ATP, GTP, cyclic AMP, NADH, and coenzyme A.  The main source of dietary purines is the DNA and RNA in the cells of the animal and vegetable foods that we eat. DNA and RNA are called nucleic acids because they reside in the nucleus of the cells. Their function is to encode genetic information as long chains of the four bases adenine, guanine, cytosine, and thymine. Uric acid is produced from the oxidation of adenine and guanine in these nucleic acids.


Uric Acid
Uric Acid


Adenine and guanine are components of nucleic acids, but not of the amino acids that form proteins. The nitrogen in proteins is excreted as urea which is formed in the liver through the action of a system of carrier molecules and enzymes that combine two molecules of ammonia with one molecule of carbon dioxide (the Urea Cycle).

2 NH3 + CO2    Urea + H2O
Ammonia and carbon dioxide combine to form urea and water

Monosodium Urate Crystals 
Monosodium urate crystals
viewed with polarizing microscope 

Foods without purines
Foods that do not have cell nuclei are generally purine free. Some purine-free foods are:

  • milk
  • non-fermented milk products
    • cottage cheese
    • mozzarella
    • whey protein
  • egg whites
  • pulp-free fruit juices
 Egg Whites  Milk
Egg whites and milk are purine-free foods.

These foods do not have purines because they do not have cell nuclei. The yolk of an egg contains the nucleic acids, but the egg white is pure protein without purines. Milk contains no purines because it consists of fats, casein and whey proteins, but no cell nuclei. Fermented milk products, such as yogurt and aged cheeses, have purines from the nucleic acids of the bacterial cells that proliferate during fermentation. A study published in the New England Journal of Medicine confirms that a higher level of consumption of dairy products has been associated with a decreased risk of gout and that moderate intake of purine-rich vegetables or protein is not associated with an increased risk of gout.[6] 

To reduce purines, a gout diet should use egg whites and milk products as sources of protein and eliminate or reduce substantially meats and seafood. The eggs may be hard-boiled before the yolks are removed, or the whites may be separated for making omelettes, as illustrated above. Milk, cottage cheese, mozzarella cheese, and whey protein can be used in a variety of recipes such as fruit smoothies, custards, chef salads, and other dishes that can be delicious and low in purines.

Effect of weight-loss diets
Purines cannot be avoided entirely because they are released in the body as the result of recycling dead cells. During a gout attack, it is prudent to avoid excessive exercise and long periods of starvation or caloric restriction that would accelerate the breakdown of body tissues. Crash diets for extremely obese patients are inappropriate because ketosis raises urate concentration and can cause an acute attack.[8]  Dr. George Nuki, professor of rheumatology at the University of Edinburgh in Scotland, has been quoted as saying that there is anecdotal evidence that going on an Atkins diet has exacerbated the problem and precipitated attacks for people with a previous history of gout. However, there have been no controlled studies that indicate that any particular weight-loss plan can cause the painful condition.

Gout is more common in overweight people and the risk of gout attacks increases with higher body weights. So, a gradual loss of weight may be beneficial for overweight people who have high levels of uric acid, even though dieting has the risk of triggering a gout attack. A pilot study of 13 non-diabetic men who had had at least two gouty attacks during the four months before the study found lower levels of serum uric acid after 16 weeks of administering a 1600-calorie diet consisting of 30% protein, 30% fat, and 40% carbohydrate. The average body mass index (BMI) decreased from 30.5 to 27.8, and the weight loss was accompanied by a decrease in the frequency and severity of gout attacks.[11]

Avoid alcoholic beverages, niacin supplements, and sugary soft drinks
Why do alcoholic beverages trigger episodes of gout? One reason is that uric acid is insoluble in alcohol.[1]  As the alcohol content of the blood increases, the blood is not able to dissolve as much uric acid, and the excess crystalizes. Gout problems are compounded because acute and chronic alcohol consumption impair the function of the kidneys. Alcohol increases purine catabolism in the liver and increases the formation of lactic acid which blocks urate secretion by the renal tubules. Excessive alcohol consumption can have severe negative effects in the ability of the kidneys to maintain the body's fluid, electrolyte, and acid-base balance.[7]

Niacin, also known as nicotinic acid or vitamin B3, has been used for many years to treat hyperlipidemia because it reduces total cholesterol, low density lipoprotein cholesterol (LDL) and triglycerides while it increases high density lipoprotein cholesterol (HDL). Elevated uric acid levels have occurred with niacin therapy, and the high dosages required for this treatment are associated with toxic side effects that include worsening of diabetes control and exacerbation of peptic ulcer disease and gout.[14]

A study of 46,393 men with no history of gout found that, during 12 years of follow-up, 755 eventually developed gout in direct proportion to the consumption of sugar-sweetened soft drinks.[16]  The risk of gout was related to the amount of fructose consumed. Men who consumed two or more servings of sugary drinks per day had an 85% greater risk of developing gout. Fruit juices rich in fructose such as apple juice or orange juice were also associated with a higher risk of gout. Diet soft drinks were not associated with risk of gout.

Effect of Temperature and pH on Uric Acid Solubility
The solubility of monosodium urate is a function of temperature. At normal body temperature, 37°C (98.6°F), the maximum solubility of urate in physiologic saline is 6.8 mg per 100 ml, but at 30°C (86°F) it is only 4.5 mg per 100 ml.[2]  Several studies have shown that gout attacks are more frequent in springtime.[12, 13]  This may be due to the accumulation of monosodium urate crystals in the extremities during the cold winter months. Some home treatments recommend applying ice or a cold pack to the inflamed joint to help to reduce the pain and swelling, but this may aggravate the problem because the low temperature can cause additional uric acid to crystallize.

Uric acid also has higher solubility in solutions of alkali hydroxides and their carbonates than in acidic media. Acidity and alkalinity are measured using the pH (potential of Hydrogen) scale, which ranges from 0 for the most acidic solutions to 14 for the most alkaline solutions. The mid-point at pH 7 is neutral (neither acid, nor alkaline). In acid urine of pH less than 5.5, uric acid crystals precipitate and lead to stone formation. If the urine is neutral or alkaline, uric acid remains in solution and does not precipitate. At 37°C and pH 6.6, the solubility of uric acid is 6 mg per 100 ml, whereas at pH 7.0, uric acid is almost three times more soluble and forms stable solutions at concentrations of 16 mg per 100 ml.[15]  Hydration with bicarbonate solutions has been effective in managing uric acid stones.[4]

Home Treatment for Gout
The elimination of uric acid from the body may be increased using a combined approach consisting of

  1. warming the affected joints to increase the solubility of monosodium urate crystals,
  2. increasing hydration to promote more frequent urination which eliminates uric acid,
  3. increasing the alkalinity of body fluids to allow more uric acid to be dissolved in the urine, and 
  4. reducing dietary purines by replacing meats and seafood with egg whites and milk products.
Foot Bath
Foot Bath
   Baking Soda Water
 Baking Soda

Warming the joints may be accomplished with a foot bath or a heating pad. Hydration requires increasing the volume of drinking water to promote more frequent urination. The advice to drink eight glasses of water per day is based on the general recommendation of the Institute of Medicine that men should consume roughly 3.0 liters (about 13 cups) and women should consume 2.2 liters (about 9 cups) of total water from all beverages and foods. Alkalinization is accomplished by drinking a solution of half a teaspoon of baking soda (sodium bicarbonate, NaHCO3) dissolved in a glass of water.[5]  If you have a sodium restricted diet, this should be done under a doctor's supervision since each half teaspoon of baking soda has 616 mg of sodium. Sodium may be eliminated by using potassium bicarbonate instead of baking soda. Potassium bicarbonate is used to reduce the acidity of wines and may be purchased through stores that sell winemaking supplies.

 pH Test Strips
 pH Test Strips

Baking soda is commonly used as a leavening agent for baking, but it is also a component of tooth pastes and it is frequently used as an antacid. Food grade sodium bicarbonate meets the requirements specified by the U.S. Food and Drug Administration as a substance that is Generally Recognized as Safe (GRAS). The dosage and directions for use as an antacid printed on the label of Arm & Hammer Baking Soda are:

The bicarbonate solution should be taken on an empty stomach, otherwise stomach acid (hydrochloric acid) will react with the bicarbonate to create salt (sodium chloride) and carbonic acid which breaks down into water and carbon dioxide gas. The carbon dioxide expands and increases internal stomach pressure that may cause injury if the stomach is overly full from food or drink. As a precaution, consult with a doctor or pharmacist if you are taking a prescription drug, since antacids may interact with certain prescription drugs. It is also advisable to use test strips to monitor the pH of the urine on a regular basis.

Concern about gout and cancer.
A study published in 2009 investigated whether uric acid, which has antioxidant properties, could protect against cancer. The study found completely the opposite. Gout patients had increased incidence of all types of cancer, including cancers of the oral cavity, pharynx, colon, liver and biliary tract, pancreas, lung, skin (melanoma and nonmelanoma), endometrium and kidney, as well as of malignant melanoma. The authors linked the occurrence of gout to increased incidence of cancer and concluded that "hyperuricemia may be an early manifestation of the carcinogenic process".[18]

Can cherries or tart cherry juice cure gout?
Cherries have been used in folk medicine to reduce inflammation, and cherry juice and various cherry extracts, dried fruit, and juice concentrates have been promoted for treating or preventing gout and arthritis. A research experiment conducted by the U.S. Department of Agriculture on 10 healthy women showed that the concentration of plasma urate decreased, and that urinary urate increased after eating 280 grams (slightly over half a pound) of Bing sweet cherries.[9]  However, there is not enough scientific evidence to support that cherries can cure gout. Since most episodes of gout pain can subside without treatment, it is difficult to determine whether the relief obtained with any therapy is due to the treatment or just coincidence.

On October 17, 2005 the FDA issued warning letters to 29 firms which claimed that cherry and other fruit-based products could cure diseases.[10]  Some of the typical statements that the FDA targeted were:

"Cherry juice concentrate can be effective in reducing pain associated with gout."

"Cherry concentrate has been shown to help with the pain and swelling that is associated with arthritis and gout."

The FDA letters explain that these claims cause the products to be defined as drugs, and because these products are not generally recognized as safe and effective when used as labeled, they are also new drugs which may not be legally marketed in the United States without an approved New Drug Application requiring supporting scientific data.

Celery Seed and other herbal gout cures
Reputable medical sources are very vague about what a person should do to get relief from gout other than avoid eating high purine foods, using nonsteroidal anti-inflammatory drugs (NSAIDs), or obtaining medicines prescribed by a doctor. The intense pain of gout makes people desperate and they are not satisfied with the relief provided by non-prescription NSAIDs such as ibuprofen (Motrin), indomethacin (Indocin), ketoprofen (Orudis), oxaprozin (Daypro), diclofenac (Voltaren), etodolac (Lodine), naproxen (Naprelan), and sulindac (Clinoril).

Some people have found relief from gout pain by eating one tablespoon of celery seeds per day. Celery seed oil, a significant source of sedanolide, is used as a herbal remedy to treat inflammatory-associated conditions such as gout and rheumatism. As in the case of cherries, there is no conclusive scientific evidence that this treatment is effective. The Internet is full of advertisements that sell information about gout treatments or that promote supplements and herbs for which there is no scientific evidence of effectiveness. The herbal remedies include cherries, cherry extracts, cherry juice, celery seed, celery extract, cider vinegar, milk thistle, turmeric (curcumin), artichoke extract, garlic (Allium Sativum), Yucca Schidigera, and various Chinese herbs. There is little chance that cherries or any herbal products will be tested for effectiveness to satisfy the FDA requirements since pharmaceutical companies have no financial incentive to scientifically test cures using natural products for which they do not have exclusive marketing rights through patents or trademarks.

Alkaline Diet
The alkaline diet, also known as the alkaline ash diet, is based on the idea that different types of food can have an effect on the pH balance of the body and decrease the risk of osteoporosis or other diseases through increased alkaline ash production. Current scientific evidence does not support this hypothesis.[19] The pH of the body is tightly regulated. Changes in the diet may affect the pH of the urine because it is a waste product, they may not affect the pH of the blood. In general, alkaline diets encourage the consumption of fruits and vegetables, but exclude grains, meat, cheese, and eggs, which have important nutritional benefits.

  1. The Merk Index, An encyclopedia of chemicals and drugs. 1976
  2. Boss GR, Seegmiller JE. Hyperuricemia and gout. Classification, complications and management. New England Journal of Medicine. 1979;300:1459-68. PMID: 221806
  3. Berenyi M. Models for the formation of uric acid and urate stones, Int Urol Nephrol. 1972;4(2):199-204. PMID: 4669643
  4. Marangella M., Uric acid elimination in the urine. Pathophysiological implications. Contrib Nephrol. 2005;147:132-48. Uric acid nephrolithiasis results from supersaturation, strongly influenced by low urine pH, rather than altered urate turnover. Alkali and fluid intake prove successful in managing uric acid stones. PMID: 15604613
  5. MedlinePlus - Sodium Bicarbonate (Systemic)
    Dosing for sodium bicarbonate powder to make the urine more alkaline (less acidic):
    Adults and teenagers - One teaspoonful in a glass of water every four hours. Your doctor may change the dose if needed. However, the dose is usually not more than 4 teaspoonfuls a day.
  6. Choi HK, Atkinson K, Karlson EW, Willett W, Curhan G. Purine-rich foods, dairy and protein intake, and the risk of gout in men. N Engl J Med. 2004 Mar 11;350(11):1093-103., PMID: 15014182
    CONCLUSIONS: Higher levels of meat and seafood consumption are associated with an increased risk of gout, whereas a higher level of consumption of dairy products is associated with a decreased risk. Moderate intake of purine-rich vegetables or protein is not associated with an increased risk of gout.
  7. Epstein M., Alcohol's impact on kidney function. Alcohol Health Res World. 1997;21(1):84-92. PMID: 15706766
  8. Michael L Snaith, ABC of Rheumatology: Gout, Hyperuricaemia, and Crystal arthritis, BMJ 1995;310:521-524 (25 February)
  9. Jacob RA, Spinozzi GM, Simon VA, Kelley DS, Prior RL, Hess-Pierce B, Kader AA. Consumption of cherries lowers plasma urate in healthy women. J Nutr. 2003 Jun;133(6):1826-9. PMID: 12771324
    "The decrease in plasma urate after cherry consumption supports the reputed anti-gout efficacy of cherries. The trend toward decreased inflammatory indices (CRP and NO) adds to the in vitro evidence that compounds in cherries may inhibit inflammatory pathways."
  10. U.S. Food and Drug Administration. List of Firms Receiving Warning Letters Regarding Cherry and other Fruit-Based Products with Disease Claims in Labeling, October 17, 2005
  11. Dessein PH, Shipton EA, Stanwix AE, Joffe BI, Ramokgadi J., Beneficial effects of weight loss associated with moderate calorie/carbohydrate restriction, and increased proportional intake of protein and unsaturated fat on serum urate and lipoprotein levels in gout: a pilot study. Ann Rheum Dis. 2000 Jul;59(7):539-43. PMID: 10873964
  12. Schlesinger N, Gowin KM, Baker DG, Beutler AM, Hoffman BI, Schumacher HR Jr., Acute gouty arthritis is seasonal. J Rheumatol. 1998;25:342-344. PMID: 9489831
  13. Gallerani M, Govoni M, Mucinelli M, Bigoni M, Trotta F, Manfredini R., Seasonal variation in the onset of acute microcrystalline arthritis. Rheumatology (Oxford). 1999 Oct;38(10):1003-6. PMID: 10534553
  14. Crouse JR 3rd., New developments in the use of niacin for treatment of hyperlipidemia: new considerations in the use of an old drug. Coron Artery Dis. 1996 Apr;7(4):321-6. PMID: 8853585
  15. Iwata H, Nishio S, Yokoyama M, Matsumoto A, Takeuchi M., Solubility of uric acid and supersaturation of monosodium urate: why is uric acid so highly soluble in urine? J Urol. 1989 Oct;142(4):1095-8. PMID: 2795738
  16. Hyon K Choi and Gary Curhan, Soft drinks, fructose consumption, and the risk of gout in men: prospective cohort study, British Medical Journal, January 2008.
  17. Craig L. Jacobs and Paula J. Stern, An unusual case of gout in the wrist: the importance of monitoring medication dosage and interaction. A case report, Chiropr Osteopat. 2007; 15: 16, Published online 2007 October 9. doi: 10.1186/1746-1340-15-16. [link]
  18. Boffetta P, Nordenvall C, Nyrén O, Ye W., A prospective study of gout and cancer. Eur J Cancer Prev. 2009 Apr;18(2):127-32, PMID: 19337060
  19. Hanley, DA; Whiting, SJ (2013). "Does a high dietary acid content cause bone loss, and can bone loss be prevented with an alkaline diet?". Journal of Clinical Densitometry (published 2 October 2013). 16 (4): 420–5. doi:10.1016/j.jocd.2013.08.014, PMID 24094472

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