Causes of gout - the immediate ones

This page about the causes of gout was last reviewed, or updated, on 5 July 2018/

The precise causes of gout in all cases are still not understood. It is a complicated disease that has defied humankind's attempts at a comprehensive solution for over 2,000 years. The immediate cause of gout, and a gout attack, is normally a high level of uric acid. The long term causes of gout - what makes blood uric acid rise - can be kidney diseases,excessive purine intake, insulin resistance, obesity, genetic abnormalities and inheritance, and over ten specialist causes.

But do not be alarmed. Many gout sufferers have controlled their gout using different remedies which are described on this website. A great deal is known, and it's important you understand the causes of gout. That will help you find remedies.  So let's begin with some basics.


Monosodium urate crystals, made of a compound of sodium and monosodium urate from uric acid (MSU) and which are covered by certain types of proteins, are deposited in joints, tendons, kidneys and other body locations such as wrists, hands, fingers, elbows, ankles and knees. They can also be found in tissue.

The favourite (favorite) first location for these gout crystals are the joints of the big toes. A gout attack in the joints of the feet was historically called podagra. 

Over time, these gout crystals can enlarge to form  tophi which are knobbly shaped lumps of these crystals. If this is the case, the gout has worsened. MSU crystals have usually built up over a long period of time.

The immediate cause of gout therefore, is linked to the level of uric acid in the blood, because the MSU crystals are largely made from uric acid. More uric acid means a greater chance of gout developing.


Uric acid acts as an antioxidant in the body. As an antioxidant it acts to destroy the threat of free radicals which if unchecked destroy cells. So it’s not a devil's substance, unless you have gout or too much uric acid in your blood.

The body obtains uric acid from two sources. The most important by far is the liver (75-80%). The remainder comes from our diet. The amount produced by the liver is determined by our genetic code and our biochemistry. 

Uric acid, the precursor of the pain causing crystals, is made from substances called  purines in food and beverages.  Different foods, and different beverages, contain varying levels of purines. Some foods are low purine, others are medium or high in purines.. So both the actions of the liver, and of purines from foods and drinks, are among the causes of gout.

Uric acid supply - uric acid excretion = level  But our intake of purines, and the work of the liver, does not solely determine our blood’s level of uric acid. How much we have in blood and tissues also depends on how much we remove. Most uric acid (about 70%) is filtered through the kidneys and leaves the body in the urine. The remainder (about 30%) is dissolved by bacteria in the intestines.

It only takes a small excess of uric acid (UA) self-production plus the amount we make from purine consumption, above our UA excretion..... and the body's amount of uric acid will rise gradually over the years.

Which is more important for our level of uric acid, supply or excretion? Most gout accounts say that the uric acid level in the blood is the result more of how much we excrete than by how much we self-produce or intake from purines. So a lack of ability to excrete uric acid is the immediate main cause of gout.

In over 2/3 of gout cases the cause is not expelling enough uric acid. It is useful to keep this in mind - getting rid of it satisfactorily is more important than self manufacture or obtaining it from purines in foods and beverages. 

If it isn’t expelled it builds up in the blood and tissues. If uric acid is being efficiently expelled, but you have gout, it is likely that your domestic supply (liver production and purines from diet) is the cause.

A high level of uric acid in the blood is called hyperuricemia. Most people with gout have hyperuricemia (hyperuricaemia) , but here’s a curious fact to keep in mind.  Some people who have gout have normal levels of uric acid, and about 80% of people with high levels of uric acid never get gout.

At what level of uric acid is there a risk of gout ? The amount of uric acid in the blood that’s considered normal is below 6.5 -7.0 mg/dL for men, slightly less for women (6.0 - 6.5 mg/dL) At above 7.0 mg/dL it most likely means hyperuricemia and therefore that level and above can become an immediate cause of gout. 

Uric acid measurements  mg/dL means milligrams per decilitre (deciliter). A decilitre (deciliter) is 100 millilitres (milliliters). Sometimes when you are reading about gout, especially on older texts, you will see the amount expressed as mg/100 millitres (milliliters - ml). This is the same as mg/dL. It's a measurement of the concentration of uric acid in a decilitre, or 100 milliliters of blood.

To gain perspective of how much is 100 millilitres (1 decilitre)  - one litre is 1,000 millilitres. One decilitre (dL) is 1/10th of a litre (liter). Think of a litre (liter) bottle of wine, soft drinks, or spirits and imagine 1/10th contains a liquid.

The higher the mg of uric acid in a dL (100 ml) of blood, the higher the uric acid level. 

The concentration of uric acid in the blood may also be expressed as mmol/L - millimoles per litre (liter). mmol/L is sometimes expressed as µmol/L. mg/dL is a popular measurement in the U.S. In most other countries mmol/L or µmol/L is more commonly used, but not exclusively.

Gout flare ups The most common, more detailed, explanation of a gout flare up is that pain, inflammation and all the other nasty symptoms begin when the immune system “thinks” that the MSU crystals are foreign bodies. A type of white blood cell called neutrophils attack the crystals and this is what causes inflammation and pain. The attack subsides when the crystals are coated by types of proteins. Once coated, the neutrophils do not now “regard” the crystals as foreign bodies, the attack is over and the flare up subsides. 

A truce between your immune system and the MSU gout crystals has been declared but the war is not over. Gout attacks can return at any time especially under the conditions that are causes of gout flare ups (the triggering conditions).

Related pages

What foods cause gout ? Those highest in purines. See our purines in foods list.

Does fructose (fruit sugar and it's in other products) cause gout ? Visit our first page about fructose and gout.

This gout cause is unproven, but it does have lessons for gout prevention

Why does gout so often attack a big toe first? And how can you use this knowledge to help stave off a gout flare up? Visit our page about big toe gout.

                                            The yellow circle accommodates the uric acid crystals

John Bavosi
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