Gout by Adam Shand

Gout is a form of arthritis caused when the uric acid in your blood crystallises. The needle shaped crystals get stuck in soft tissue where they cause intense pain.

Your doctor will tell you that gout is caused by having too much uric acid in your blood (hyperuricemia), which is caused by eating a diet high in purines. However, lots of people with high uric acid levels never have gout attacks, and people with low levels sometimes get gout. The low carb and carnivore communities will tell you that gout is caused by consuming too much fructose or alcohol (beer is especially bad). Purines break down into uric acid, and fructose and alcohol make it harder for your kidneys to excrete uric acid. Both of these increase uric acid levels in your blood.

Dr. Pete Delannoy clarifies that it's not high uric acid levels that cause gout, but rather sudden changes (either up or down). This is why people who start taking medications that reduce uric acid levels often have gout attacks. This happened to me when I started taking quercetin.

Similar to fructose and alcohol, excess ketones also make it harder for your kidneys to excrete uric acid. When you start a ketogenic diet (eg. carnivore) your body is inefficient at producing and consuming ketones. This can result in having more ketones than your body can use. While your kidneys are busy excreting the excess ketones, uric acid is not being excreted and the amount of uric acid in your blood increases.

This is why starting a ketogenic diet (or fasting, which is also ketogenic) can cause gout attacks. I had back to back gout attacks for the first two months of carnivore, it was awful.

Despite all of the above, most carnivores report that their gout goes away and never comes back. Some have a couple flares in the beginning as they adapt, and a few unfortunate souls (like me) have persistent problems.

But Is it Gout?

It's difficult to distinguish between the various forms of arthritis, and I found it difficult to get a formal gout diagnosis in NZ (which requires taking a fluid sample from inside a joint and looking for crystals). In my experience, there are a few observations which can indicate gout:

It effects a single joint (most often the big toe).
It reaches full pain within a day.
It comes on overnight.
The joint is visibly swollen, bright red, and hot to touch.
It hurts A LOT and is very sensitive to pressure and touch.
There is no way you can position your body to make the pain go away.
Applying ice to the joint reduces pain (and heat makes it worse).

Preventing Gout

If carnivore doesn't magically fix your gout, there are well studied, reasonably safe pharmaceuticals for lowering uric acid levels which your doctor can tell you all about. There are also supplements which are effective at lower uric acid levels. They all work by either decreasing the amount of uric acid your body produces or increasing the rate you excrete uric acid. It's important to slowly increase/decrease any medication which changes your uric acid levels, as changes can trigger a gout attack.

Avoid alcohol (especially beer), fructose, and foods extremely high in purines (organ meats, shellfish, yeast etc).
There are many online anecdotes from people who found that giving blood reduced the frequency and/or the severity of attacks. The repeated gout attacks I had during adaptation stopped as soon as I gave blood. Sadly, I have no way of knowing if the change was coincidental, but I've continued to give blood regularly.
Dr. David Perlmutter recommends quercetin and luteolin to lower uric acid. I haven't tried luteolin, but quercetin works really well for me. I've been taking it morning and night for a couple of years, but am in the process of weaning myself off in the hopes that I don't need the support any more.
There is evidence that coffee reduces the risk of gout. This matches my experience, when I stop drinking coffee I am more susceptible to gout.
Intense exercise can cause muscle tissue to be broken down into purines and increase uric acid levels.

Treating Gout Attacks

There are pharmaceuticals that work well and your doctor can tell you all about them. I never tried them because I used to react poorly to most medications and was reluctant to use pharmaceuticals unless absolutely necessary.

I found three home remedies which help reduce the pain of a gout attack:

Put apple cider vinegar in a glass of water and drink it. I recommended it to a non-carnivore friend, and he reckoned it helped him as well.
Tart cherry worked better for me than ACV, and there is more evidence supporting its use. I like capsules better than juice (presumably lower fructose), but both worked.
Baking soda works substantially better than either ACV or tart cherry. Put half a teaspoon in a cup of water and drink it right before bed (it's important to take it on an empty stomach). For me, the first dose reduces pain by about 50% overnight. Keep taking morning and night until pain is tolerable (usually 2–3 days for me).

Notes from Dr. Delannoy

I did a consult with Dr. Pete Delannoy in early 2024. Below are some of the notes I have from that conversation.

Vitamin C helps, but if you take too much your kidneys excrete it preferentially to uric acid (same with any organic acid) and so can cause uric acid increases. So you have to get the dose right, he’s taking 250mg a day and that seems to be working for him. Dr. Rick Johnson suggests up to 500mg twice a day.
In theory, one of the advantages of taking allopurinol and keeping uric acid levels low for a prolonged period of time is that crystals stored in bodily tissue will slowly be depleted and thus decrease risk of future gout.
Carnivores are dependent on gluconeogenesis for glucose. Gluconeogenesis is a catabolic process which creates purines and increases uric acid. In theory, eating a small amount of glucose (he suggested half or even a quarter of a round slice of sweet potato) at the end of a meal would stop gluconeogenesis and potentially lower uric acid levels.
Seed crystals can form in any bodily tissue. Dr. Rick Johnson (one of the world's experts on gout) is concerned that prolonged high levels of uric acid could cause crystals to form and damage critical tissues (eg. heart valves).
There is strong correlation between gout and sleep apnoea, it's worth getting tested even if you don't snore.
Be careful with any supplement which has calcium salts. Calcium is required for the process of making seed crystals, and adding them can increase the amount of crystals stored in tissue.

Gout by Adam Shand

But Is it Gout?

Preventing Gout

Treating Gout Attacks

Notes from Dr. Delannoy

Links

0 comments