-Victor

I am repeating here my criticism of medical practice that I have told you about privately regarding the measurement of blood uric acid levels. There is no standardization in current practice for the conditions under which serum uric acid is measured – the amount of time elapsed since last eating, what was eaten, the amount of time elapsed since awakening from sleep.

Contrast this helter-skelter approach to the procedures used for measuring blood sugar. These results are interpreted based on whether or not the patient has fasted overnight, or even with the more controlled glucose tolerance test. At present, knowing your serum uric acid levels has much less meaning than than knowing your blood sugar levels.

There is a way that a gout flare can develop even at a time when serum uric acid concentration is below 6 mg/dl. High serum uric acid concentration is required to form the urate crystals in a joint that are the direct cause of gout. But once formed, these crystals dissolve extremely slowly – over many months. But a gout flare lasts typically 3-10 days. Why doesn’t it last until the crystals are dissolved? Because the immune system coats the crystals with a protein sheath so that their presence is no longer detected by the gout inflammasomes. If that sheath is somehow ruptured, a new gout flare will occur until after the breach is repaired, even though the serum uric acid level may be below 6 mg/dl. The rupture can occur from physical injury, as has happened to me at least twice. The rupture can occur chemically, as often happens when an uricosic drug such as allopurinol is started at too high a dosage. In these cases, the gout flare often starts during waking hours. In the case of gout flares that develop during sleep, my claim is that they are usually the result of a flare in serum uric acid above 6 mg/dl resulting from the hypoxia of sleep apnea.