Should I Increase My Allopurinol Dosage?

[goutbgone]

I am 37 years old. ?I had my first gout flare in February 2011. ?Nobody in my family history ever had gout (or at least nobody ever knew they had gout). ?During my first gout flare, my UA was 8.0. ?At that time, I believed that I could treat my UA through diet. ?Wrong. ?By August 2012, I had a UA of 10.1. ?I really focused on healthy eating, but my UA # in October 2012 was 8.8. ?Beginning in November, I had another flare up (my flare up has always been on the instep of my right foot). ?It lingered and lingered, despite my treating it Indocin and Colchicine. ?Finally, in January 2013, I stumbled across this website and became determined to lower my UA to a safe level. ?I consulted my doctor, and he prescribed me on 100 mg per day of Allopurinol.

Not wanting to screw around with a low dosage, I scheduled and obtained a blood test on February 8, 2013. ?My UA was just 8.6. ?I immediately asked my doctor to increase my dosage to 300 mg per day. ?He agreed and I started on 300 a day on February 13. ?I again went in for a blood test March 6, and my UA had dropped to 5.8.

My question is, should I try to persuade my doctor to increase my dosage to 400 mg of Allopurinol a day to try to get my UA below 5? ?I have an appointment with him on Monday, but my guess is that he will balk at that, in that my UA is now in the “normal” range according to general standards. ?One final caveat…I am starting to have a flare up today in my usual right instep spot. ?Continuing the 300 mg/day, and just wondering 1) if I should try to go up to 400, 2) if so, suggestions on how to convince my doctor, and 3) whether I should ignore my doctor and go up to 400 if he says no, in that I have almost all of the 100 mg pills leftover from the ones he prescribed in January (just take 1 300 and 1 100 pill per day). ?Thanks!

[KeithTaylor]

Welcome @goutbgone,

First, on diet, I respect your view that diet alone will not make you safe if uric acid levels are over 10. Even at 8, it can be a struggle, though it depends on how bad your eating habits are to start with. I’m glad you’ve gone to allopurinol, and I would urge anyone else to do the same if uric acid is above 7.

I like your attitude to uric acid control. Strictly speaking, there is an important stage missing. Prior to starting allopurinol, you and your doctor should have agreed a target uric acid level. Professional rheumatologists are crying out for the medical profession to “treat to target” for gout.

The standard target, as directed by the American College of Rheumatology in 2012 is 5 mg/dL. They allow that this might have to be relaxed to 6 if there is kidney disease or other medical reasons why 5 is not achievable. This is a clear directive, also recognized in other countries. For anyone who has gout, the target is 5, with 6 allowed for complications. “Normal” is a statistical nonsense – as irrelevant as the statistic that half the population have a normal range of 0.8 to 1.2 breasts.

There is a refinement to the lifetime target which is not spelled out in the directives, but hinted at in the background notes. It is made very clear by various studies. This has to do with the first few months of uric acid lowering treatment. Gout is a progressive disease, so all the time you have had it, uric acid crystals have been building up in your joints and soft tissues. These will dissolve faster if you get uric acid lower. As I had visible tophi at the time of my allopurinol initiation, I persuaded my doctor to go for maximum allopurinol for six months. This got me down to around 2, which is good, as my target was anywhere below 3. We later extended this for another year. I totally believe in this aggressive approach to uric acid lowering treatment, but the choice is yours.

The important thing is to agree a target at your next appointment. Forget dosing – that is just a process that gets to your target. There has been a belief that 300 mg allopurinol is a standard dose, but this is outmoded. If your doctor signs prescriptions with a quill, you might have problems persuading him of modern best practice But, if you arm yourself with the facts, and be clear about what you want to achieve, no tight-minded doctor is going to ignore a patient who is serious about his health.

The only way I would agree with a decision to ignore the prescribed dose is as a temporary plan if you are moving to a new doctor and don’t have immediate access to a prescription upgrade. It is never wise to break the doctor-patient trust. I believe in working to strengthen that trust, and your trust will be lost as soon as you need a repeat prescription.

Two other points:
1. You mention a flare. These are likely whilst uric acid crystals remain in your body. My aggressive approach shortens the length of time you are exposed. Whichever target you decide, you should consider preventative daily colchicine for a few weeks / months, and have anti-inflammatories on hand to take at the first sign of an attack.
2. As we have touched on uric acid testing, I must add my usual recommendation about blood tests. Gout patients on (or considering) allopurinol or Uloric should always get liver function and kidney function tests whenever they have a uric acid blood test. Uric acid should be tested at least once a year, with frequency increased up to once a month where results are unstable, or medications are changed.

Good luck @goutbgone. Please let us know how you get on.

[goutbgone]

Thanks for your thorough response. ?I really do appreciate it. ?It is extremely comforting to know that there are people who genuinely care about helping people who suffer from gout and providing them with objective advice.

Yesterday, I met with my doctor, and I talked with him about the research that I had done and my desire for us to come up with a target uric acid number. ?He indicated that he thinks I am already at a healthy level, so I am “already below any target he would have advised”. ?He said that dropping from 8.6 on February 8 to 5.8 on March 6 is a significant and rapid drop for UA. He says that it is likely to go even lower than 5.8 at my current dosage (is that true, btw? ?Does UA continue to drop after 1 month at a particular dosage? How long does it continue to impact UA before the dosage “levels off”, so to speak?). ?He recommended that I continue with my current 300 mg/day Allopurinol dosage, then get another blood test in 4 months to monitor my UA (and kidney/liver function too).

Also, my kidney/liver function have been checked with each blood test since I started Allopurinol as well. ?Everything is fine, and, in fact, there was a huge drop in my ALT level from a range of 22-26 over the past few years, down to 6 on March 8 (all are healthy).

[KeithTaylor]

Your first paragraph is heartwarming, and exactly why I do this, so thank you for your support and encouragement.

My overall assessment is that you are probably getting better treatment than most, but it could be better. For a long time, 6 was regarded as the best target, but research over the last decade has made it quite clear that 5 is preferable. The reason is all to do with safety margins. Uric acid levels fluctuate naturally. Another significant factor is temperature. One day I will have to find a chart that tells me uric acid crystallization point at different temperatures. For now, I accept that uric acid is less soluble at lower temperatures. Joints in the limbs are often exposed to lower temperatures. I like to be safe, and accept professional recommendations to aim for 5. More importantly, I want to get rid of old uric acid as fast as I can, so I am aiming for less than 3 for now.

I’m lucky to belong to a group practice where I can make appointments with different doctors. The 4th one agreed with me.

5.8 ought to be safe, but if you want to go lower I believe the choice should be yours.

Though I have no data to support it, there is some logic that supports the notion that uric acid level may fall. Some of that number is made up of old crystals dissolving, so as that value shrinks, the concentration that is measured in a blood test should fall. I do not know how significant that drop will be, if any.

I’m happy that your uric acid test results are in the safe zone, and your other blood work is good. I guess it boils down to how aggressive you want to be. Maybe you could ask for another test in two months, just to make sure everything is going OK.

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