Gout - Causes And Triggers

By Definition – Gout is a disease caused and created mostly by lifestyle choices. These decisions cause an imbalance in uric acid in the body, which in turn prompts the creation of urate crystals. Urate crystals then attack the synovial fluid around joints, ultimately attaching to the joint itself building up to a gout ‘attack’ and a period of considerable stabbing pain for the sufferer.

Our Member Survey Says…

  • 90% of HelpRelievePain.com members that declared they suffer with gout, said they considered ‘Diet’ to be the most important factor in regulating Gout Attacks.
  • The most common method of treating a gout attack was to ‘Take Medication Immediately (92%), followed by ‘Get Plenty Of Rest’ closely behind with 86%

(Results from our member survey completed 10th July 2019, to be redone July 2020)

Gout Is Agony. But It is Not Without Cure. Here We Cover Every Angle – From What Triggers A Gout Attack To How To Treat One Yourself Immediately. Understanding Why Gout Develops And How To Prevent It Will Help You To Never Suffer Again.

What Is Gout?

‘The disease of kings’ as it used to be known, because of Gout’s close relationship with rich foods that only the wealthy could afford to eat, Gout now affects anything from 0.1% to 10% of the population of every country. The higher figures still originate from the more developed countries such as the UK and the US (where it is estimated more than 8.3billion Americans are affected).

And perhaps even more worryingly, as noted by Kuo et al, Gout is also very much a disease on the increase.

An Infographic Depicting 4 Key Myths Surrounding Gout And The Actual Facts Behind Them.

Forming Gout…

Gout is an unpredictable form of inflammatory arthritis characterised by urate crystals accumulating around one or more of your joints resulting in severe episodes of sharp, stabbing pain, redness and inflammation.

The urate crystals form as a result of having high levels of uric acid in your body for a prolonged period of time. These urate crystals congregate because we are either producing too much uric acid too fast or our kidneys are failing to cope with excreting the uric acid.

Hyperuricemia…

Uric acid is created when our bodies break down certain foods containing ‘purines’. Our kidneys should then get rid of them when we urinate. Unfortunately, if we consume too many purines or our kidneys fail to excrete the full amount of uric acid, then a build-up is the result.

The condition when you body is storing more uric acid then it can get rid of it is called ‘hyperuricemia’.

Once urate crystals are formed, they start attaching to your joints, and as they do so, they are attacked by your protective white blood cells. Unfortunately, some of the crystals will inevitably end up in the synovial fluid that surrounds your joints to lubricate them.

Rock hard crystals in the fluid around your most important joints means one thing – war. War around your joints – pain, agony, redness and swelling as your body attacks the urate crystals.

Uric acid is not entirely an enemy – everybody needs to have certain levels of it to remain healthy, but when these levels get higher than the saturation point for monosodium urate (MSU) crystal formation, then the result is crystallisation around certain joints.

A Higher Chance Of Developing Gout…

Typically, the most likely joint to be affected is the big toe because uric acid is highly sensitive to temperature changes and the big toe is one of the coolest parts of the body being further away from the heart than almost any other body part.

Men are statistically more susceptible to gout because there are naturally higher levels of uric acid in the male body.

Having high uric acid levels in your body is however no guarantee that you will develop gout. Indeed it is estimated that 21% of all Americans have higher than normal uric acid levels, but only 5 % actually develop gout from it.

About Us

What Causes Gout Attacks?

Although Gout can affect anyone, there are certain factors that are proven to make you more at risk of developing Gout.

Sex.

Men have a naturally higher level of uric acid in the body and so are more likely to reach the crystallisation point. After menopause however, women’s metabolism changes and they also produce more uric acid, levelling the scale of likelihood.

Age.

For men the average age is between 30 and 50. In women, the big ‘at risk’ stage is older, typically the first 10-15 years after menopause with the likelihood of developing gout rising until both hit 75 years old.

Family History.

If other members of your family suffer with gout, then you would be classified as being at ‘high risk’ of also developing it. This is partly because many of the other risk factors – originating from the way you live, are likely to be the same and also because your chemical balance will also be very similar.

Diet.

Seafood (particularly crustaceans) and meats are very high risk foods for gout sufferers. This is because they contain ‘purines’. In isolation, purines are very healthy, but they produce uric acid as a waste product.

If you suffer with gout, then your body is not removing the uric acid properly and so the more purines you digest, the more uric acid you build up. This of course leads to more crystals being formed, more white blood cells called to fight and ultimately more painful gout.

Other foods to avoid include sugar-sweetened drinks and those high in fructose. Although sugary drinks and beer do not contain significant amounts of purines, the fructose has been proven to alter the bodies ability to handle uric acid, so again they need to be avoided.

We cover the discussion of what you should/ should not eat in more detail below.

Obesity.

The bigger you are in comparison to your height, the more uric acid your body will produce. Further to this, your kidneys will typically already be under pressure and the increase in uric acid as you put further weight on, will not be excreted properly leading to more crystals forming.

Higher levels of cholesterol have also been proven to be linked to high uric acid concentrations.

High Blood Pressure.

High blood pressure is also directly related to a build up of uric acid and often poorly functioning kidneys that can not excrete the acid properly.

Recent Surgery or Serious Injury.

For so many pain-related conditions, stress plays a substantial part. Gout is no different. Increased stress following recent surgery or a very serious injury can upset the bodies balance so much that it either produces too much uric acid or does not excrete enough.

Similarly bypass surgery patients and those who have heart disease are at a much higher risk of developing gout.

Medical Conditions.

Medical problems such as kidney disease or high blood pressure will directly affect your bodies’ ability to get rid of uric acid. Other problems such as heart disease, metabolic syndrome or diabetes have all been shown

Medications.

Low-dose aspirin and diuretics (often prescribed for hypertension) can both abnormally increase uric acid levels that, if not stopped, can lead to Gout. On odd occasions, if you have had major organ replacement and are on drugs to stop your body rejecting the new organ, then these drugs can also substantially alter uric acid balances.

Psoriasis.

Sufferers with red, flaky, crusty patches of skin are particularly vulnerable to gout.

Which Foods Could Cause Gout?

What foods cause gout? The simple answer is any food that is high in purines. Since uric acid is the by-product of the body processing purines in your diet and the uric acid is what forms the urate crystals that create your Gout.

It comes down to a simple equation – Gout occurs because you have too much uric acid in your body. In order to reduce gout attacks you have to rebalance the gout equation – this means you either produce less uric acid in your body or you find a way of getting rid of the uric acid faster.

As uric acid is excreted through your kidneys, there are two key factors to avoid – anything that contain purines that generates uric acid and anything that reduces the function of your liver to excrete the maximum amount of uric acid.

The process by which gout is formed in diagram version.

We have complied a basic list of foods/ drugs to avoid below –

  • Kidney. Joint highest in purine levels of all the meats (along with Liver).
  • Liver
  • Red Meats such as pork, beef or lamb.
  • Sea Food especially oily fish such as Trout and mackerel or Shellfish
  • Sugary Drinks
  • Snacks with saturated fats
  • Fatty foods in general
  • Whole Grain Foods. These are particularly high in purines – the major contributor to uric acid. Ironically, processed grains are much lower in purines, so eating processed bread instead of bakery-fresh bread for example, will be better for you Gout
  • Alcohol (If you must drink, then no more than 14 units a week and you should have at least two days off) 

Plus Certain Medications –

  • Diuretics used for high blood pressure or fluid build-ups in your body.
  • Niacin for high cholesterol
  • Drugs prescribed for high blood pressure such as ACE Inhibitors and beta-blockers
  • Low-dose aspirin.
  • Many chemotherapy medicines that reduce your bodies ability to flush itself.
  • Ciclosporin

Symptoms of Gout Disease

Diagnosing Gout is not always a straight forward process as other forms of arthritis can present with very similar symptoms. There are a series of tests that we cover in the section below this that will confirm if you have it.

If however, you suffer any of these symptoms, it is important you go straight to a doctor for diagnosis as treating gout early is vital.

Intense Stabbing Pains. Typically Gout will start with a swollen joint that endures waves of intense pain, followed by pain-free intervals.

In the early days of gout, most attacks will begin at night and most commonly occurs in your big toe, because that is the coolest part of your body, being the furthest away from your heart. However, it can affect any of your joints including your fingers, wrists, hips. elbows, knees and ankles.

Duration. Gout attacks typically last anywhere from 3 to 10 days, with the affected joint gradually returning to normal  

Inflammation and Swelling. Unlike some other inflammatory diseases, gout is likely to be highly visible from the outside as the affected joint will not only become swollen but red as well.

Periodic Outbursts Of Pain. One of the characteristics of Gout is that it doesn’t give sufferers the consistent slow-burning pain that other forms of arthritis do. Gout pain typically hits you hard, but can then disappear within 24 hours and may not come back for weeks or even months at a time.

There may be some pain left behind in the joint, for the next week or two, but the pain will normally go. People who make significant changes quickly can even eliminate future flare-ups altogether. Only in the later stages of gout when the joints have been significantly damaged are the pain attacks likely to last longer and longer with more joints being affected each time.

Limited Movement. The more advanced you allow your gout to become, the more you are likely to find difficulty with your joints.

Focus. Gout usually only affects one joint at a time, but can attack any number of different joints over time. 

It is important that when you first feel the pain of gout, you get a diagnosis from your doctor. Leaving gout untreated will only lead to permanent damage/ erosion of your joints.

Gout Diagnosis.

In order for your ‘gout’ to be correctly diagnosed, you will need to visit a doctor. He or she will most probably start by asking about your diet – favourite foods in particular and if you drink beer regularly.

Joint Fluid Test. By far the most common test for gout, this test involves a doctor taking a small sample of the fluid around an affected joint and analysing it for the presence of urate crystals. This test can offer an immediate result because, if present, the crystals will be visible from a microscope.

Ultrasound Imaging. The use of an ultrasound for diagnosing gout has become commonplace across Europe although it is not used anywhere near as much in America to date. The role of the ultrasound is again to detect those urate crystals that define your problem as gout, rather than a host of similar conditions.

CT Scan. The advantage of a CT scan is that is can actually define urate crystals even where there is no inflammation or redness whatsoever. Unfortunately, the cost of such a scan means that it is not normally used unless previous tests have failed to yield a sound diagnosis.

Blood Tests. These are easy tests that some family doctors use to give an indication of gout. Unfortunately, they have numerous flaws – not least because what the blood test is actually designed to find (high levels of uric acid) is no guarantee of the presence of gout in the first place.

Some peoples’ bodies can cope with extremely high levels of uric acid without ever actually developing gout. Others have all the symptoms of gout, but don’t have unusual levels at all.

X-Ray. X-rays can be used to rule out some other possible inflammatory diseases, although again they are of very limited use in actually defining your pain as being gout.

Gout Triggers

Gout attacks can come on really fast – with the sudden onset of stabbing pains in a particular joint (most frequently the big toe) frequently being the only warning you’ll get. One minute you might feel fine, then you just catch your foot on something in your lounge and it hurts more than you think it should – chances are in no time you will be in agony as you feel the full force of a gout attack.

So what triggers an attack of gout? An attack is not the same as the underlying cause of gout – the chances are your ‘attack’ has been building quietly for some time. As discussed above, gout itself is the result of hyperuricemia – an excess of uric acid that the kidneys can not get rid of so instead they turn in to urate crystals that form around joints.

Exactly why gout attacks occur when they do is a matter of much debate and little scientific evidence. Research has shown that eating a meal high in purines will not necessarily result in a gout attack straight away. Certainly over time it is likely to, but there are certain gout triggers that have been proven to trigger an account of gout.

Lifestyle Factors…

1. Eating Large Amounts Of Purine-Rich Foods

This one should be of no surprise to anyone currently suffering with gout, but for the newbies.  – purines found in various rich foods lead directly to uric acid production. The more purine rich foods you eat, the higher the amount of uric acid your body will be producing.

2. Drinking Too Much Alcohol

It’s not a fun fact, but unfortunately it is still a fact that drinking even small amounts of alcohol will restrict your kidneys ability to filter and excrete uric acid, leading to a build-up of uric acid and the inevitable agony on it’s way.

3. Dehydration

Not having enough water in your body as a whole appears to increase the concentration of urate crystals in the joint fluid. This then speeds up the onset of your next painful attack.

4. Too Many Sugary Drinks

Much like purine-rich foods, fructose corn syrup is up there as one of the very top uric acid stimulators in your body.

Try to avoid the full fat versions at all costs. On the plus side however, studies in diet fizzy drinks have shown no impact on uric acid levels at all. This is mainly because they don’t contain fructose corn syrup, making them a much more gout-friendly option.

5. Stress

When you are stressed your body reduces it’s reserves of vitamin B5 (also known as pantothenic acid). B5 has long been linked to helping the kidneys to remove uric acid from your body.

It is also universally accepted that when your body is under prolonged stress, it won’t function at 100% and again this can lead to a further build up of uric acid.

6. Extreme Weather Changes

Gout is particularly affected by hot conditions, although no one actually knows quite why.

It is thought it may be linked to a combination of dehydration and heat sensitivity. But this doesn’t explain why people in hotter climates aren’t more affected by gout.

7. Obesity

This is primarily because if you are obese then you almost certainly consume too much fructose (sugar), whether it be through sugary drinks or fatty, processed foods.

8. Wearing Poorly Fitted Shoes

Badly fitted shoes create bruising or trauma on your feet, hopefully not quite as extreme as the photo. But none the less, any cause of inflammation still creates a source for urate crystals to concentrate around and cause a gout attack.

9. Crash Diets

Crash diets are well known to throw your body in to a state of shock. This causes both stress on your body and an emergency response.

The reasons for uric acid levels to increase in response to a crash diet are largely unknown, but it is reasonable to assume that some diets like the once-famed Atkins diet that were extremely high in purine rich foods certainly did not help.

Equally, just as your bodies natural reaction to a crash diet is to shut down and actually store fat, it is also not unreasonable to assume that it could be storing extra uric acid as well. And this fits with patterns that been observed in people undergoing such extreme diets before.

10. Arsenic

I appreciate that sounds ridiculous – of course arsenic will kill you in reasonable amounts. However, there is small amounts of arsenic in pesticides and fertilizers as well as being found naturally in shellfish.

Medical Factors…

11. Joint Injuries (Even As Small As Bruising Yourself).

Much like in point number 9 which was self-inflicted bruising, any injury will cause inflammation which in turn will attract urate crystals.

Once they have gathered, some will make It past the white blood cells in to the synovial fluid and bang, the agony of gout is upon you again.

12. Surgery

Most surgeries have an extremely important purpose, be it to save your life or to improve it. They must have, in order to justify the pain, cost and inherent risk associated with any surgery.

Gout therefore is, and probably should always be an after-thought to this. Unfortunately for gout sufferers, the effect of surgery and it’s recovery, is frequently made more painful because of the onset of a gout attack.

13. Chemotherapy

Again, if you have cancer, avoiding chemotherapy because of gout should never even be given a 2nd thought. Unfortunately however, the destruction of cells caused by chemotherapy can increase production of uric acid in the body, thus bringing on a gout attack when you are at your lowest.

Furthermore, the weakness of your white blood cells to fight against the urate crystals trying to reach the synovial fluid, leaves you wide open to a painful gout attack.

If you are in this position, I’m afraid there is little you can do to avoid it, but just be ready.

As the chemotherapy takes it’s toll and you go through the cycles of painful collapse followed by recovery (depending on the type of chemo), it’s also quite possible a gout attack will make it even worse for a while. And Much like with surgery, knowledge of its ability to trigger an attack, wont help you to avoid it.

At best it will help you to anticipate it and be ready.

14. Sudden Illness

This can both increase inflammation and reduce blood flow.

Reducing blood flow increases the chances of urate crystals stagnating and being able to bond to your joints, while the inflammation will act like a magnet to the crystals.

15. Taking Diuretic Medications (For Leg Swelling, Heart Failure or High Blood Pressure).

These are typically used for leg swelling, heart failure or high blood pressure but unfortunately one known side effect is that they will decrease your kidneys ability to remove uric acid.

16. Taking The Drug ‘Cyclosporine’

This is rare as it is mostly used for organ replacement or crohns disease but again it has a named side effect of decreased renal urate clearance.

17. Infection

infections again ultimately lead to trauma in your body and the trauma to inflammation which attracts the urate crystals.

Why Does Gout Get Worse At Night?

It is now generally accepted that your chances of suffering a gout attack at night are significantly greater than during the middle of the day. However, there is very little actual clinical data available to explain why this is.

Indeed, it wasn’t until 2015 when Hyon K Choi et al were able to report definitive findings in this regard. They had set about investigating if Gout attacks really did occur more at night in his study ‘Nocturnal Risk of Gout Attacks’. Until this time, any evidence of more Gout attacks happening at night was purely anecdotal.

The study, which ran from February 2003 to February 2011 looked at 724 patients who suffered a combined 1,433 attacks. The study measured the times that people first suffered a gout attack and was able to report back that the respondents were 2.4 times more likely to suffer a gout attack ‘during the night and early morning’.

Another interesting observation from the study was that the increased risk of a gout attack was loosely the same regardless of whether the person had a low or a high purine intake the day before. This would suggest that gout attacks are not necessarily as closely linked to immediate food consumption as you might think.

So…. Why does gout get worse at night? The simple answer is no-one really knows. There is considerable speculation as to why theoretically Gout may be worse, but no actual facts.

Doctors speculate that there are several reasons why the onset of Gout may be much more likely at night –

  1. Lower Body Temperature
  2. Lower Cortisol Levels
  3. Dehydration
  4. Sleep Apnea/ general obesity leading to a difficulty in breathing (lower oxygen in the blood)

Each plausible reason above either would lead to increased uric acid production or hinder the kidneys in clearing the uric acid at night, creating a period of ‘hyperuricemia’ (more uric acid than your body can cope with)

However, the simple truth is that no clinical studies have been done to prove any theory one way or another. Indeed, the fact that the gout attacks in Choi et al’s study bore no relationship to the individuals immediate diet (the day before) would hint to the possibility that immediate changes do not affect your likelihood of having an attack.

If this is true, then gout attacks really are the result of factors accumulating over a period of time.

Common Medications For Gout

As you might expect with gout being so prevalent in developed countries, there are now a huge range of potential drugs available, both over-the-counter and by prescription.

These typically fall in to one of two types – those drugs designed to reduce inflammation and provide pain relief in the middle of an attack and those made to help prevent future attacks.

Drugs To Treat The Pain Of Attacks

NSAIDs (Non-Steroidal Anti-Inflammatory Drugs). This class of drug is specifically designed to tackle the inflammation caused by gout. Typical examples include Ibuprofen (often available over-the-counter) and Naproxen for more advanced inflammation.

Your doctor will normally titrate (adjust) the doses so you have a higher dose immediately following an attack of gout, and then a step-down dose daily dose for prevention of future attacks.

There are however risks with taking NSAIDs/ Ibuprofen daily – the most common ones of which we discussed here ‘The Dangers Of Ibuprofen Usage’.

Corticosteroids. Typical examples include Prednisone and ……… Administered in either tablet or injection form, they are designed to control both gout inflammation and the ensuing pain.

Colchicine. This is a drug specifically designed to reduce gout pain. However, it comes with a frequent occurrence of side effects that include diarrhoea, sickness and nausea to name but a few.

Drugs To Prevent Gout Happening Again –

Remember that gout occurs because of an imbalance in uric acid that leads to urate crystals being formed. Once you have had a gout attack, it is particularly important to keep the uric acid balanced for as long as possible.

This can be done in one of two ways – either reduce the amount of uric acid your body produces or improve the speed with which your kidneys get rid of the acid.

There are medications that can help to achieve either of these goals.

However they will only be prescribed if you have already had several attacks of gout or already have evidence of gout-damaged joints, kidney problems (such as kidney stones or kidney disease) or have already established tophi (bone growths as a result of gout).

Lowering Uric Acid Production.

The medications most commonly used to reduce uric acid production are called xanthine oxidase inhibitors (XOIs). These include Aloprim, Allopurinal, Zyloprim, Lopurin and Febuxostat. Most are taken once daily

Increasing Uric Acid Removal.

Drugs known as ‘Uricosurics’ aim to increase your kidney’s ability to excrete and get rid of uric acid. Popular uricosurics include Lesinurad and Probeneid.

A Sample Of Foods Linked To Reducing Gout

  • Cherries have often been linked with lowering the levels of uric acid in your body. Unfortunately, there is limited definite evidence to either prove or disprove this. Some empirical evidence exists to link a reduced number of gout attacks with eating cherries.
  • Vitamin C. Vitamin C has been proven to reduce the amount of uric acid in your blood, although there has only been a very limited number of trials demonstrating that Vitamin C can control uric acid and none that link it’s use to directly influencing the number/ frequency of gout occurrences. Rather than eating high sugar fruits to get your vitamin C, you can always try a vitamin C supplement.                 
  • Coffee has been proven to reduce uric acid levels, although again the number and quality of trials producing this result could be called in to question. What is perhaps even more interesting is that nobody actually knows why coffee reduces uric acid levels – it just does!
  • Plant Oils
  • Water
  • Skimmed Milk and Other Dairy Products
  • Fruits, but NOT ALL FRUITS. Some sweet fruits such as grapes and apples are so packed with fructose that the negative of increased sugar levels outweighs the  

Damage Caused by Gout

Prior to getting your first gout attack, your blood uric acid levels are likely to be very high with crystals just starting to from. Before you suffer your first attack, you will be in a phase of ‘asymptomatic hyperuricemia’

Gout is agony in itself and for many people is a life-altering condition. The first episode is likely to be both very painful and a real eye opener. At this point, you need to start making substantial changes to avoid further episodes.

However, it is your choice. Some people choose to just carry on and hope for the best. This is ultimately your choice, but you do run the risk of more severe conditions. These include –

Kidney Stones. The same Urate crystals that attack your joints can get stuck in your urinary tract. This causes kidney stones and can result in real pain when trying to pee.

Recurrent Gout. Gout could just be a one-off with skilful management and changes in your lifestyle, but if ignored then flare ups can become a recurrent problem. If continually ignored, then your symptoms will eventually lead to more long-lasting damage to the affected joints, with permanent erosion the end result.

Advanced Gout. If left permanently, gout will eventually start leaving little bundles of urate crystals under your skin. These lumps are referred to as tophi (pronounced TOE-fie) and are likely to develop near affected areas such as hands, feet, elbows or along your achilles tendon.

Tophi Formation. It normally takes several years from the time of your first gout attack for tophi to form, but occasionally you can develop them before ever experiencing an exacerbation.

Without immediate treatment, the damage caused by gout will increase considerably with individual attacks becoming more frequent and last for longer.

The Final Word –

Gout is undoubtedly one of the most painful diseases you can suffer with – characterised by sudden, sharp attacks without warning. 

It is a form of inflammatory arthritis, but unlike rheumatoid and osteoarthritis IT IS REVERSIBLE. Changes in lifestyle, in diet and in approach can prevent future attacks and keep the level of urate crystals to a manageable level. 

Since Gout is caused by too many purines, or a poorly functioning liver, then helping either side will have a positive effect – and countering both will make it possible to avoid future attacks altogether if caught early enough.

Perhaps the most important message of all, is to respond quickly. Treat a gout attack fast and if you’re going to make the required changes to your lifestyle, then do it early – before the damage becomes lasting.

Certainly the longer you suffer with Gout, the harder it is to reduce it’s impact with a few changes – primarily because the long-lasting damage to your joints or kidneys will become irreversible. This will then make re-altering the uric acid balance much harder.

So the take away point here is clear – learn about gout, follow the treatment advice above and DO IT NOW. Once gout is diagnosed by your local doctor, don’t wait to make changes – because it will only get harder the more attacks you have.

Frequently Asked Questions

Surgery itself does not cause Gout. Stress (both mental stress and medical stress) can alter the uric acid levels in your body. These altered levels have been shown to aid the development of gout or in some cases, (when gout is already forming in the background), bring on a gout attack.

Yes – Gout forms around joints in the body. There are many joints in your spine and, although it is quite rare, spinal gout is a possibility.

Eating the wrong foods, drinking too much alcohol, not drinking enough water – everything as listed above.

Yes. Kidney failure is ultimately caused by kidney disease. Kidney disease is both a mjor reason for Gout AND something that can be caused by a blockage caused by a build-up of urate crystals. In this sense, the major contributor to Gout (urate crystals) can damage the kidneys – so Yes is the answer.

A Selection Of Other Articles On Gout...

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Further Gout-Related Reports...

References –

1. Chang-Fu Kuo, Matthew J. Grainge, Weiya Zhang & Michael Doherty (2015) Global epidemiology of gout: prevalence, incidence and risk factors. Nature Reviews Rheumatology
 
2. Hyon K. Choi, MD, DrPH, Jingbo Niu, MD, DSc, Tuhina Neogi, MD, PhD, FRCPC, Clara A. Chen, MHS, Christine Chaisson, MPH, David Hunter, MBBS, PhD, and Yuqing Zhang, DSc (2015) Nocturnal Risk of Gout Attacks. Arthritis and Rheumatology. Volume 67 Issue 2