Gout in athletes: causes and links with training load and pharmacology
Gout is often considered a 'disease of feasts' of older people, but it also occurs in athletes - especially in weightlifters, strength athletes and veterans. The editorial team looked into how training, sports nutrition and pharmacology affect uric acid levels and the risk of attacks.
Uric acid and the mechanism of gout
Uric acid is the end product of the breakdown of purines, which are part of DNA, RNA and energy molecules such as ATP. Humans, unlike most mammals, lack the enzyme uricase, so uric acid is not broken down further and is excreted mainly by the kidneys.
When the concentration of urate in the blood exceeds the solubility limit (about 6.8 mg/dL under physiological conditions), it can crystallize as monosodium urate crystals in the joints and periarticular tissues. It is these crystals that trigger inflammation, not high uric acid itself.
An acute attack occurs when immune cells recognize the crystals, the NLRP3 inflammasome is activated and interleukin-1β is released. The result is sudden severe pain, swelling and redness, most often in the first metatarsophalangeal joint of the big toe.
It is important that most people with hyperuricemia never develop gout. However, the higher the urate level and the longer it persists, the greater the likelihood of attacks. About two-thirds of urate is excreted by the kidneys, so kidney function and competition with other substances for excretion play a key role.
How training load affects urate levels
Moderate regular physical activity is generally associated with better metabolic health and is not considered a risk factor for gout. On the contrary, control of weight and insulin resistance indirectly lowers urate levels.
It is a different matter with very intense or exhausting exertion. During strenuous work the breakdown of ATP to inosine and hypoxanthine increases, which can temporarily raise uric acid production. In parallel, lactate accumulates, which competes with urate for excretion by the kidneys.
| Load factor | Mechanism | Practical significance |
|---|---|---|
| Exhausting intense training | Increased ATP breakdown, lactate | Temporary rise in urate |
| Dehydration, 'making weight' | Blood concentration, less excretion | Typical provoker of attacks |
| Joint microtrauma | Release of already present crystals | The attack is disguised as an injury |
| Regular moderate training | Better metabolic profile | Protective effect |
Dehydration is another practical mechanism. Fluid loss during training in the heat, 'making weight' before weigh-ins and limiting water lead to a concentration of urate and a reduction in its renal excretion. It is precisely during such periods that susceptible athletes more often experience flare-ups.
Joint injury can also provoke an attack if there are already crystal deposits in it. That is why gout is sometimes mistakenly taken for a sports injury of the foot or knee, and the diagnosis is delayed.
Athlete nutrition: protein, fructose, alcohol
A cohort study by Choi and co-authors (NEJM, 2004) showed that high consumption of meat and seafood is associated with an increased risk of gout, while total protein consumption and purine-containing vegetables had no such association, and dairy products were associated with a lower risk.
For athletes this is an important nuance: a high-protein diet in itself is not synonymous with risk. Whey and casein proteins are of dairy origin, and the data on dairy products are rather reassuring. The question is more about large portions of red meat, offal and certain types of fish.
- red meat, offal and some seafood in large quantities;
- sweet drinks with sugar and fructose;
- beer and spirits;
- dehydration and abrupt fasting.
Fructose is a separate topic. Its metabolism in the liver rapidly consumes ATP and increases uric acid production. In a study by Choi and Curhan (BMJ, 2008), sugary drinks were associated with an increased risk of gout in men. Sports drinks and 'gainers' with a lot of fructose should be evaluated from this perspective.
Alcohol, especially beer, increases the risk in a dose-dependent way: beer contains purines, and ethanol enhances urate production and worsens its excretion. Celebrating after competitions with a lot of beer is a classic scenario of a first attack.
Pharmacology that increases the risk
Thiazide and loop diuretics reduce the renal excretion of uric acid and are a well-known cause of hyperuricemia. In sport, diuretics are on the WADA prohibited list as masking agents, and their non-medical use for 'making weight' or 'cutting' is additionally dangerous due to dehydration and electrolyte disturbances.
Low doses of acetylsalicylic acid, cyclosporine and tacrolimus, and the anti-tuberculosis drugs pyrazinamide and ethambutol can also raise urate levels. By contrast, losartan, fenofibrate and SGLT2 inhibitors have a modest uricosuric effect, and a doctor may take this into account when choosing therapy for concomitant conditions.
Regarding anabolic steroids, there is little quality research on a direct effect on the risk of gout. However, the combination of a high-protein diet, increased muscle mass, possible arterial hypertension, worsening kidney function and use of diuretics before performances creates a set of factors that should not be underestimated.
A rapid reduction in urate levels - for example at the start of urate-lowering therapy - can paradoxically provoke attacks due to dissolution of the deposits. That is why such therapy is started under a doctor's supervision with prophylaxis of flare-ups.
Who is in the higher-risk group
Men fall ill much more often than women before menopause: estrogens promote the renal excretion of urate. Age, obesity, arterial hypertension, chronic kidney disease and metabolic syndrome are the main classic risk factors.
Genetics has a substantial effect: variants of urate transporter genes, in particular SLC2A9 and ABCG2, explain a noticeable part of the differences in uric acid levels between people. A family history of gout is a significant signal.
Among athletes the risk is higher in strength-sport athletes and disciplines with weight categories, in veterans who maintain 'competition' diets, and in athletes who have ended their careers and quickly gained weight.
A separate group is athletes with heavy body mass in American football, rugby and weightlifting. They combine a large body mass, high energy requirements and often significant consumption of meat and sweet drinks.
Editorial conclusions
Gout in athletes arises at the intersection of genetics, nutrition, hydration and pharmacology. Regular training generally protects, while the threat is created by dehydration, exhausting exertion, alcohol, fructose and certain drugs.
A high-protein diet in itself is not a sentence: the source of protein matters, and dairy products in studies do not increase the risk.
Diuretics for 'making weight' are simultaneously a violation of anti-doping rules and a real risk factor for an attack. The decision about any prescription agents must be made by a doctor.
We also recommend our materials on the prevention and diagnosis of gout, on water balance during training and on monitoring kidney function in athletes.
References
- Dalbeth N, Merriman TR, Stamp LK. Gout. Lancet. 2016;388(10055):2039–2052.
- Choi HK, Atkinson K, Karlson EW, Willett W, Curhan G. Purine-rich foods, dairy and protein intake, and the risk of gout in men. N Engl J Med. 2004;350(11):1093–1103.
- Choi HK, Curhan G. Soft drinks, fructose consumption, and the risk of gout in men: prospective cohort study. BMJ. 2008;336(7639):309–312.
- Choi HK, Atkinson K, Karlson EW, Willett W, Curhan G. Alcohol intake and risk of incident gout in men: a prospective study. Lancet. 2004;363(9417):1277–1281.
- FitzGerald JD, Dalbeth N, Mikuls T, et al. 2020 American College of Rheumatology guideline for the management of gout. Arthritis Care Res (Hoboken). 2020;72(6):744–760.
- World Anti-Doping Agency. The World Anti-Doping Code International Standard: Prohibited List. Montreal: WADA; оновлюється щорічно.
- Richette P, Doherty M, Pascual E, et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis. 2017;76(1):29–42.
Andriy Melnyk
A strength-sports coach and author of programs for beginner and intermediate levels. Writes about training planning.
