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The only way you will get uric acid down from 9.4 to 5 is to get uric acid lowering therapy NOW.
Please don't do what I, and many others, did and try to get it down through diet and lifestyle changes.
Let us look on the plus side of that strategy for a moment. Yes, there is evidence to suggest that weight loss and diet can help. Gradual weight loss is the key – one pound a week and two at the most, otherwise your uric acid levels will rocket. Diet must be calorie-controlled with low iron (basically low meat).
Now, the downside. It takes time to adapt your diet to something that you can live with, and it takes time to lose weight. Every day you are trying to get healthier, the uric acid crystals are building up. You will not notice every day, but those crystals are forming. Your immune system locks them away, but they can still eat away at bones and tendons. Occasionally you will get a flare, take some pain killers and continue. During all this time, your gout is slowly getting worse and worse, and you are moving further and further away from any chance of controlling it through weight loss.
The time for the meds is NOW. If the weight loss / lifestyle improvement strategy does work, you are protected while you get it in place. Your regular uric acid tests will tell you when the meds are no longer needed. If it does not work, you have saved yourself considerable discomfort.
If allopurinol, or some other uric acid lowering medication, is prescribed properly, the doctor will be monitoring your uric acid. At first, weekly to get uric acid level down to 5mg/dL. Then monthly to ensure everything is OK for 6 months. After that, every 3 months or so is sufficient, but anytime you change dose or make significant lifestyle changes (new exercise program or new diet), you need to increase the uric acid test frequency again.
If this level of medical supervision is not available to you, you can check your uric acid at home with a meter, but the priority has to be getting on uric acid lowering treatment ASAP.
Good move on the allopurinol – geet your uric acid down below 6mg/dL first, then focus on weight loss. The allopurinol will hold your uric acid down and stop exercise / weight loss sending it back up into the danger zone.
Be very aware that the allopurinol will do nothing for pain relief. It will stop new uric acid crystals forming which is exactly what you want (part 1).
It will also do exactly what you want (part 2) by helping old crystals to dissolve. That, my friend, is a double-edged sword. You need to do it to get the uric acid crystal deposits out of your joints and other tissues, thus reducing the risk of long term joint damage. The downside is that you might get occasional gout flares. Never stop taking the allopurinol, but keep colchicine available and take two at the first sign of a twinge.
You need to think long-term about this. Keep taking the allopurinol, and as I said before, focus first on keeping uric acid below 6mg/dL (better to aim at 5). Continue to get uric acid tested regularly.
Weight loss of around one pound a week is the best target. It is more sustainable and less shocking to the system. After 100 weeks, you MIGHT be able to lower the allpurinol dose. If not, take another 100 weeks. It doesn't matter how long it takes, just keep the allopurinol going as long as you need it. If that's forever, so what – at least your quality of life is improved.
What a revelation!
I too am caught in the “vicious cycle” or “Catch-22” situation. For years I've been trying to lose weight, so I can get rid of the gout attacks. I'm currently at my heaviest (340's) , and it's been uber-frustrating. I turned 39 on June 26th and made a pledge to lose 100lbs by age 40. I promised myself to at least walk a mile a day to start the quest. Well, I was doing that and lost about 6-7 lbs in about a week, then went hiking, then walked another day, then cut the grass and BAM! Ankle flared up HUGE and not the worst flare ever, but still painful. Dealt with it for about 3-4 days, pain went away, but the swelling remained. It gradually worked it's way to my opposite knee and I've been fighting this thing for about a month.
I just got the prescription for Allopurinol again (I had it once before, but told myself I'd work out more so I wouldn't need it) and I aim to actually stay on it this time. My doctor told me before, and now I have you guys' opinion too, that I'll always need this drug, thin or not. Just wish I'd have been doing it sooner. Sorry to ramble, but this was like a godsend for me. I had no idea others got it from exercise.
A tip that MAY help…I think that doing pool work (both swimming and running laps) is a great way to fool your body into thinking you're not working as hard (or your feet, knees, and load-bearing joints anyway) so you can go “balls out” and not flare? It also makes my feet and knees have “bounce” like they used to sometimes.
My fertile (or furtive?) imagination keeps returning to this topic, and is currently pushing me to consider the obvious theme of military ranks.
My first thought was to call upon an ex-navy man of these parts for a full list of naval ranks, but I think it would be more entertaining to consider ranks from all military and non-military forces. Certainly, as we are an international forum, from all countries, but also slang and fictional ranks could be interesting. Once we have a suitable collection I think a democratic vote for ranking is all we need.
An alliteration addiction actuates me to advance Admiral Allo for attention and approval.
In similar vain, consider Captain Colchicine and kindly keep Kommander Krystexxa.
Humor outranks alliteration but is hard to find in the world of gout.
I must leave this for now and resume my driving duties. President Probenecid is waiting to return to Roger the Cabinboy.
From everything I have read so far, there is a tiny proportion of the population who can have a severe reaction to allopurinol. It is so rare that documentation is scarce, but the consequences are severe enough that medical consensus is to start with a 100mg dose and increase week-by-week until the uric acid level is lowered to target.
Just like reported news in the media, good stories are rare, and so it is with reports on allopurinol. You mainly hear about people who have problems, but rarely from people who have taken it year after year without problems.
I have made a start on trying to collect data on long term health issues with allopurinol, and have found that there is very little evidence. There are some oblique references to kidney problems from the metabolytes of allopurinol if insufficient fluid is taken, or if the urine becomes too acid. I am struggling to find any meaningful risk assessments, so if anyone sees anything relevant, I'd love to see it.
The “pill a day forever” fear seems to be strongly linked to the middle-aged revelations that life is not going to last forever and this is the first step of the “daily pill ritual” that our elderly friends and relatives seem to delight in making the highlight of their life. Next step the nursing home? “Surely there is a solution that doesn't put me on life long medication,” the gouties exclaim.
There is some evidence that uric acid lowering extends the life of kidney patients. The key issue, for most of us though, is quality of life.
Quality of life definitely decreases at an accelerating rate with untreated gout. Left untreated, the consequences of skin-bursting tophi and joint-crumbling urate deposits are much harder to deal with as we get older. Seeing a retired butcher friend in tears, wishing for the tools of his trade to remove his gouty arm, is a real wake up call.
Personally, I have been avoiding the medication for life scenario and fooling myself that weight loss and healthy lifestyle alternatives will provide a better solution. Who am I kidding?
The reality is that anything you do for gout that is not lowering uric acid below 6mg/dL is simply prolonging the agony and ensuring that gout attacks will get worse. My last attack was serious enough to make me see that popping allopurinol everyday is far healthier than popping painkillers so as I said last week, I'm definitely taking the plunge on allopurinol.
Tomorrow
We've all mentioned dose adjustments in some way, but I forgot to emphasize the most significant point – you need to get blood uric acid below 6mg/dL (preferably 5) and keep it there.
If this takes a few weeks, then so be it, but best for your long-term health if it is sooner rather than later. Slight lowering is pointless – it must be below 6.
I'm hoping someone will come along with an answer along the lines of “I had that happen, but I did ….. and the drowsiness went away”. All I can offer is some general advice.
The recommended dosing procedure is to start at 100mg, then increase week by week until blood uric acid levels drop below 6mg/dL – preferably 5. It probably does not pay to mess around with doses without discussing it with your doctor first.
All the references I have seen describe drowsiness as a minor side-effect, so there is no advice about how to treat or avoid it. There are some studies that show that side-effects have been overcome by very gradual dosage increase from a low dose. This is not specific to drowsiness, but it does hold out strong hope that tolerance can be improved over time.
Continuing wth clutching at straws, I notice that dosage recommendations also include advice to:
- Drink sufficient fluid to promote at least 2 liters of urine per day.
- Alkalize urine (or at least make it neutral) – baking soda or dietary alkalizing are options.
- Take allopurinol after meals.
I've no idea if these steps will affect drowsiness or not, but it cannot harm.
If all else fails, it might be necessary to look at alternatives. A 24 hour urine test will determine if you are an overproducer or underexcretor of uric acid. If you are an underexcretor then uricosuric medicines are available to promote extra uric acid excretion. Failing that, febuxostat is becoming available, which reported less side-effects, including drowsiness, in trials.
FritzCat66 said:
Even the Beverages PRAL table on the GoutPal website shows the aspartame drinks as having the highest metabolic acidity of all of them.
I haven’t read anything definitive, however, and would like to know for sure. Also, I cannot find anything about the acidifying effects of other artificial sweeteners besides aspartame, like sucralose.
I've just had a quick look at all the drinks with aspartame in the PRAL beverages table, and it looks pretty inconclusive to me, with some acid producing and others alkaline producing. Irrespective of this, the strategy for an alkalizing diet is to mix acid producing and alkalizing foods with acid producing foods representing about 30% of total calories and a total PRAL in the negative, alkaline range.
I do not believe you will get any extra benefit from continuing with pain relief now the pain has gone. Swelling should abate in a couple of days – in my experience quicker with gentle exercise, but when you are at rest, keep the leg raised.
Now is the time to focus on what caused this, and plan to avoid another attack. If you haven't already done so, I would consider getting the gout diagnosis confirmed by examination of the joint fluid (a painless procedure, usually performed by a rheumatologist).
Whether you do that or not, you must arrange for regular blood tests and maintain your uric acid below 6mg/dL (5 is better).
I've moved this to a separate topic from Gout And Alcohol Expert, because it doesn't really address the issue.
I would really quite like to discuss this topic, but I don't want to muddy the waters in the original topic which is seeking to discuss the issue of a total alcohol ban for gout sufferers.
Now, I have been a little scathing about the reliance on statistical studies. Having had some training in statistics, I am aware that statistical analysis is useful in identifying trends, but great care must be taken in drawing conclusions from those trends.
The study referred to is a worthy reference for finding associations, but that in itself does not explain the link. Yes there is a link, but what is the nature of that link?
Clearly there is an overarching association that shows an increased risk of gout amongst alcohol drinkers. Equally clearly, as the different types of alcohol give different values, the link cannot simply be alcohol. If it were, then there would be a distinct correlation between the strength of alcohol and the amount of alcohol consumed. This is not the case. As stated: “moderate wine drinking does not increase the risk”.
This raises other questions.
Would further sub-analysis of the data reveal that some alcohol is actually good for gout?
Or is it the case that alcohol is irrelevant, and some other substances are the real link between these drinking habits and gout?
So the report proves that there is no statistical justification for banning all alcohol. It gives pointers to suggest that beer is bad, spirits less so, and wine has no effect.
Does experience bear this out? Has anyone seen any evidence of the direct efffect of alcohol on uric acid readings (which is probably all that matters).
trev said:
Can't see it somehow JuNe? !
A first timer could be a professor of Gout and be ignored and a revered 'old timer' might go a bit potty [they do , you know
] and post a really dodgy bit of opinion that has no relevance in reality.Any how it makes a lot more work for our benevolent, if sometimes opinionated GP .
I reckon a new, humorous name every 100 up would keep the interest high !
Actually, it is very little work to administer – it's just coming up with the names that take the time and effort.
I'm all for some humorous names – any suggestions? Something with a gout theme would be good.
Then I'll update the forum guidelines to clarify how it works (everybody reads those don't they?).
I agree with zip2play – unless there is something particularly unhealthy with tap water, it is far more important to keep hydrated when you have gout than it is to worry about the quality. If you prefer distilled, then that is the way to go.
I also agree that controlling uric acid is the most important thing that you should focus on.
Also, this item about gout diagnosis is relevant. How was your gout diagnosed?
Have you had fluid from the joint tested to confirm this is gout? If not, then treatment is going to be very difficult as you may be treating the wrong condition (and all our advice will probably change)
I'd be very wary of anyone claiming a better long term safety record for NSAIDs (which carry FDA warnings against long term use) against colchicine, a well proven gout pain relief, which has had some bad press because people cannot (or will not) read labels.
I share your frustration, but I'm sure we can move things along. Let's start with a confirmed gout diagnosis.
By coincidence, I've just learned a new phrase to describe this type of activity – bear shaving:
Seth Godin: Let's define “bear shaving” as the efforts we go to do deal with the symptoms of a problem instead of addressing the cause of the problem.
Very interesting – yes, Gout without Hyperuricemia by Daniel McCarthy in JAMA.
And very surprising: –
At 30°C, however, the solubility of uric acid is only 268 µmol/L (4.5mg/dL).
Can I suggest you contact [email protected]
You should be able to send payment from PayPal direct to them using an email address, and ask Arctic Medical to complete the order when that payment goes through.
If you get no joy, send me a private message, and I will chase it with my contact.
mathman said:
Hi – I've been having gout issues for about 6 weeks now. I had a SUA test during an attack and it was 4.6 mg/dl. After the attack improved a bit (but was still ongoing), I had it retested and it was 5.9 mg/dl. My doctor said that this is definitely gout because of its clinical presentation. He is hesitant to put me on allopurinol, though. Couple questions:
1. Can stiffness and mild pain persist after a gout attack? If so, for how long? My foot is still a little swollen and hot, and the joint is painful to bend. But I walk fine …
Ever noticed how some people get a wound and it seems to heal in days, whereas other people take longer? Inflammation from a gout attack is the same. Gentle exercise to keep the blood flowing seems to wor best for me.
Also, you cannot discount a second, perhaps milder, attack. As your uric acid level has dropped (common when uric acid leaves the blood to form crystals), it might be that some uric acid crystals are dissolving again and triggering more inflammation.
I know that doctors are hesitant to use allopurinol on first attack, but you still need to get blood tested regularly to monitor uric acid levels.
2. Has anybody here ever had repeated attacks of gout but has a low SUA level repeatedly? My doctor says it's possible, but not common.
Thanks!
MM
It's only possible if there have been periods with blood uric acid levels above 6.8 – the crystals have to come from somewhere.
If you are still experiencing pain, your attack is not completely over.
Gout is very sneaky. When it starts you will convince yourself that it could be from a possible injury, maybe stubbing your toe. Dont be fooled. Start some kind of therapy immediatly. If it sets in, your in for some painful days.
Dont stop your preferred thereapy until you are back to 100%. It can sneak right back.
I'm sure your scanning technique cannot be any worse than the contributor to arthritistrust.org – http://www.arthritistrust.org/…../index.htm
It is also available (similar quality) in a pdf file.
Knew I'd get a good doctor-patient response
zip2play [also] said:
Trouble is that awful effect that once you have gout, a uric acid level that is completely tolerable for a normal person becomes crystallizable. Perhaps it is because urates, once formed in a joint will NEVER leave completely…and thus always present a site for easy crystallization of a saturated uric acid solution. Another possibility iis that the immune system LEARNS its enemies…and thus once an attack is made on uric acid, subsequent attacks become quicker, easier, and more viscious.
This is hard to phrase: But what I am saying is that GOUT makes gout incurable and once gout strikes and is treated you can never get back to a goutless state…and a goutless state is one that can do without allopurinol.
Did that make sense?
This makes perfect sense to me. There are a few recent articles that seem to suggest that gout immune system reactions are extremely complicated, i.e. more than just white blood cells trying to kill the undead uric acid crystal. The possibility of the immune system learning swifter responses makes the situation quite perilous – gout makes gout incurable, indeed.
Your explanation is the best I've seen to date, especially the point about permanent urate deposits.
There are hints of a fuller explanation in some recent research. However I have extreme difficulty getting my head round statements like:
Monosodium urate (MSU) crystals are potent inducers of inflammation. Within the joint, they trigger a local inflammatory reaction, neutrophil recruitment, and the production of pro-inflammatory cytokines as well as other inflammatory mediators. Experimentally, the uptake of MSU crystals by monocytes involves interactions with components of the innate immune system, namely Toll-like receptor (TLR)-2, TLR-4, and CD14. Intracellularly, MSU crystals activate multiple processes that lead to the formation of the NALP-3 (NACHT, LRR, and pyrin domain-containing-3) inflammasome complex that in turn processes pro-interleukin (IL)-1 to yield mature IL-1β, which is then secreted. The inflammatory effects of MSU are IL-1-dependent and can be blocked by IL-1 inhibitors. These advances in the understanding of hyperuricemia and gout provide new therapeutic targets for the future.
Does it say “We can relieve some pain and inflammation by blocking IL-1, but gout makes gout incurable?”
With the hips and knees pain, pseudo-gout is a possibility.
The best option, as with any difficult-to-diagnose joint problems is a thorough examination by a rheumatologist.
Your definitions seem OK to me, but in practice they seem to get confused. I've seen secondary gout quoted when it is identified after another disease, but no link established.
Logically, if gout is secondary to some other condition, then treating that condition will cure the gout. If the other condition cannot be treated, then uric acid lowering (usually allopurinol) is the answer.
One significant point is that treating the primary condition may not be a complete answer. We've discussed elsewhere how gout attacks are much more likely to happen once you get uric acid crystals in your body.
Hi Leon,
Your symptoms started alot like mine did. Pain in the heel, it would go away and then the exact same pain in the other heal. I heard from more then one doctor that it is not Gout and I continued to suffer for a few more years. I get attacks in my heel, ankles, mid outside of foot and the classic big toe. Odd how all the doctors dismissed it so fast til I saw a doctor that listened to what I had been going through and took the time to understand my families history with Gout. Once I started making adjustments for Gout all of those pains went away but do come back if I mis behave. I exercise alot and drink plenty of water. My diet is more balanced but alcohol is pretty much out of my diet all together. I also have issues with specific foods that I would typically eat. For instance I cannot have chicken products from Jack in the Box or Burger King, if I do I will have an attack everytime. My mom has the same issue but with different food chains so if you are eating out a lot be careful of what you have because a typical food that is not known to affect Gout suffers could very well trigger one in you.
Good Luck
Ron
Arline Applegate said:
The Dr.[2 of them] just adjust Allopurinol dosage.
What are your uric acid level test results? The dosage should be adjusted to get you below 6mg/dL, preferably below 5mg/dL. This will definitely bring the gout flares to an end, but it will take a while (not too long if you have only had gout for 4 months).
Are you making sure you take the allopurinol every day? If you stop and start, this is almost guaranteed to make gout flares almost continuous.
How much colchicine do you take, and how often?
Uric acid in the blood can drop after a gout attack as some uric acid leaves the blood to form crystals in the joints and other tissue. However, it must have been above 6.8 at some other time for crystals to form in the first place. Do you have the numbers from your earlier tests? (numbers, not grades – normal means nothing in uric acid level tests.)
I haven’t used colchicine, but I doubt that one every 8 hours is going to have much effect. Zip2play has recommended one an hour up to a maximum of 16, or diarrhea becomes unbearable. I do not like to put words in his mouth, but I’m sure that he would say that if this doesn’t stop the pain, then it aint gout.
Gout often presents in different ways, and can strike in any joint. An uncommon multi-joint first attack makes me uncertain about gout, but does not rule it out. The fact that the attack has lasted so long also makes me suspicious of gout – yes gout attacks can last a long time, but in my experience this also involves uric acid levels above 7mg/dL (at some point, if not continuously).
One thing is certain – if it is gout then it will become much easier to diagnose soon, because it will spread to other joints. In fact, if it is gout, there is probably enough evidence in larger joints such as the knee even now. The only other diagnostic tool is the DECT scanner, though finding one could be difficult.
went back do doctor, uric acid level was normal. she gave me 30 doses of cochicine .6mg. I took 2 then 1 every hour for 8 straight hours (until midnight). Read somewhere at 10 should be the max. Not much relief at all no nausea or diarrhea when I fell asleep. BUT this morning aroun 7am I came down with both, toe feels much better but still stiff. I've had the nausea and diarrhea for the last 8hrs. Does this last more than a day? Thanks all for the advise.
The first pain treatment for gout should be colchicine.
For most gout sufferers, you do not need anything else.
If that doesn’t work, first insist on a thorough investigation by a gout specialist (rheumatologist), because there is a strong chance that you might have something other than gout – bursitis, pseudo-gout and septic arthritis all have gout-like symptoms.
Next in line is one of the many NSAIDs such as indomethacin (Indocin) or ibuprofen. There is a lot of research going on at the moment for medication normally used for other forms of arthritis, such as rilonacept.
Prednisone should be last on the list. I do not have enough information on your case, but it is often lazy prescribing for gout that does more harm than good.
Keep on with the water, and keep the affected joints warm (though you can try an ice pack for 10 minutes – just keep warm at all other times).
cjeezy said:
Thanks for the quick response. I guess the problem with me (and any new gout sufferer) is that it is too early too tell exactly what the ?triggers? will be.
Be very careful about your attitude to gout triggers.
The most important thing you can do is to monitor uric acid levels. Lowering uric acid might trigger gout attacks for a short period of time, but it is the only way to avoid the long-term debilitating effects of gout.
(and, probably fast eroding knees )