In a recent study in arthritis rheumatism that was published online, gout was confirmed to attack more at night. Published online December 11, 2014, this study was carried out by MD, DrPH, Hyon K. Choi, from School of Medicine, Boston University, Massachusetts, and Sydney University from Australia. According to this study, the widely held assumption that gout is more likely to hike at night and this study held a different opinion that these attacks are more likely to flare after purine or alcohol dietary indulgence.
Speaking to Medscape Medical News, Dr Choi, the current director of Clinical Epidemiology, Harvard Medical School in Boston/ Massachusetts General Hospital, said that the 2.36-fold high risk of night attacks by gout have a direct implication to clinicians treating gout patients.
“There is a possibility that Prophylactic measures that are responsible for preventing gout flares, mostly at night, will be more effective. For instance, those prophylactic drugs for treating gout flares, especially those with short half-lives, can be timed properly to optimize their benefits,” said Dr Choi.
On his part, Gout expert, MD, professor of medicine, University of Pennsylvania and the VA Medical Center at Philadelphia, Pennsylvania, H. Ralph Schumacher Jr, he told Medscape Medical news, “the study is really beautiful and it confirms that widely held view with a carefully obtained prospective data. What was surprising only was how this population was undertreated (approximately less than 45% on allopurinol and like ¼ on prophylactic colchicines). I cannot see any uric acid levels on these patients. In fact, those people who manage their gout properly could be having different patterns to gout as well as fewer flares”.
The Dr Choi team used data retrieved from online gout study carried by the Boston University to examine the risk of acute gout attacks relative to time of the day. The researchers employed 724 patients suffering from gout and they were monitored within a period of one year through the internet, a case-crossover study. The patients were required to report the date of the onset of gout attack, medication use, symptoms and possible risk factors (e.g seafood or alcohol consumption) within the period of 24 and 48 hours leading to the attack. The majority of the participants were white (89%) and also male (78%).
Results showed that risk for gout flares was 2.36 times more at night than they were at daytime. The same flares were 1.26 higher at night than they were during evening hours. The reports also showed 1433 acute gout attacks, whereas 733 of the attacks occurred during midnight and 310 attacks occurred between 8 am -3.00 pm, and finally 390 attacks occurred between 3.00 pm-11.59 pm.
There was evidence that even those patients who did not take alcohol had the same difference of gout attacks in relation to time of the day. The same association remained the same even after accounting for factors such as age, sex, body mass index and the use diuretics, nonsteroidal anti-inflammatory drugs and gout medications.
During gout flares, or during the intercritical moments between attacks, the consumption of alcohol was reported by about 68% of patients, allopurinol use by 45%, colchicine use by 26%, diuretic use by 29% and NSAID use by 54%. Most of the attacks of gout occurred at the lower extremities (92%), and of these, 92% were treated using colchicine, systemic corticosteroids, intra-articular corticosteroids, NSAIDs, or a combination.
Though the mechanism underlying the higher risk of gout attacks at night is still unknown, it’s suspected that factors such as dehydration during sleep, a nighttime dip in blood cortisol levels, lower body temperature at night (a possible risk for crystallization of uric acid) or periarticular dehydration due to sleep position could possibly account for these discrepancies.
According to these researchers, sleep apnea could be a factor since the associated hypoxia leads to the turnover of nucleotide and it generates purines, source of uric acid.
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Dr Choi observed that sleep apnea roughly affects 1/3 of obese men with multiple comorbidities that explains typical gout patient. In the annual meeting for American College of Rheumatology (ACR), 2014, Dr Choi indicated that those patients with sleep apnea had an increased (20%) risk of developing gout attacks.
Commenting on the role of sleep apnea, Dr Schumacher commented, had to say the following: “I’ll be glad and interested if the Boston online study on gout had enough workers who would sleep during the day to see whether they would also flare during day sleep. There are reports indicating that a small increase* in flares in the evenings or in the afternoons. Could this be related to daytime microtrauma which is a different mechanism?” Dr Choi indicated that sleep apnea is a common phenomenon and that the hypoxia associated with it can be treated with noninvasive ventilation positive airway pressure.
This study was financed by the Arthritis Foundation, the National Institutes of Health, and the American College of Rheumatology.