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Though gout can be scary, the biggest gout danger comes from doing nothing.
At it’s heart, gout is a very simple disease, and very easy to manage. In practice, it is made complicated by doctors who don’t understand how to treat it properly, by gout sufferers who avoid seeking the right treatment, or a combination of both.
I’m here to overcome those complications, but that can only work with commitment on both sides. I think I can prove my commitment by the thousands of pages that I have written. Many of these are general gout guidelines, but the most effective are my personal gout advice pages here.
Gout management has to be personal. That should be your doctors job, but if you are not getting proper gout advice or treatment, you need my advice. The first thing I’d suggest is to log in every day. That shows a commitment from you. If you are on Facebook, Google or any of the other social networks shown above right, all you have to do is click the appropriate icon. If you don’t want to use the easy social icons, use the username and password boxes.
That will take you to a page where you can enter some gout facts in your Personal Gout Profile. If you are not sure what to put in your profile, just ask.
As far as your fiance is concerned, I can see that he really needs this level of personal guidance. I don’t mean this badly, Elsa, but you are in danger of making his health worse. Scare stories from the Internet are absolutely the worst way to manage gout.
The first problem is trying to understand why he has gout. If reasons are obvious, then they might be changed, but you are probably looking in the wrong place. If it is important to your fiance to avoid medication now, then we have to explore what might be the cause. But he has to understand that prolonged delay is dangerous. There is no point in me pondering the causes – I have to help your fiance build up his Personal Gout Profile so I can focus on the specifics that matter.
If the only reason for avoiding allopurinol is a fear of infertility, then this is exactly the dangerous misguided information that puts his health at risk. These situations are easily manged with a logical controlled approach. Hysteria about uncertain risks will not help!
You are worried about “what longterm damage will occur” and so am I.
You are worried because you’ve read some Internet scare stories and you don’t understand what is happening.
I am worried because I understand what is happening, and I know that the scariest thing your fiance can do is to waste time and not address the problem now. It’s real easy to sort it out now, and you can lead a normal happy life together. Just start asking about your personal gout facts. Or, you can devote your life to caring for a cripple in later life.
I’m happy to work with gout sufferers, or there carers, or both. I can’t give you the help you deserve if you don’t tell me all about your symptoms and concerns. Facts, not hysteria, are what we need now.
Will, I’m sorry that this is continuing, but I’m pleased you have an appointment with a rheumatologist. I can’t prejudge what that outcome might be. I just want to reassure you that if you are not sure what to ask about, or don’t understand any part of what your rheumatologist says, I’m here to help.
It is great for me that you have taken time to record some of your gout facts in your Personal Gout Profile: https://gout-pal.com/users/wpack3/profile/
If I look at this objectively, I say you had uncontrolled gout for at least 2 years, but probably longer. You started getting it under control Aug/Sep 2014, and finally achieved safe uric acid last month. There’s a few unknowns, particularly the length of time that uric acid crystals have been building up. However, from a uric acid control point of view, you are doing everything right. Personally, I went lower with my uric acid levels, but I’d had over 16 years of uncontrolled gout, and I knew I had to act as fast as I could.
You are now in what is usually referred to as the debulking phase. That is where uric acid is low enough to allow old crystals to dissolve. At your current level, I do not think there is any chance that any new crystals will form, but this is not entirely out of the question. The crystallization process is complex, but one major factor is temperature. Prolonged exposure to cold will lower uric acid crystallization point. Therefore, you should take time to explain to your rheumatologist the exact nature of your exposure to cold. Some rheumatologists believe that joint examination for crystal evidence should be accompanied by measuring the temperature of the affected joint.
Fundamentally, there are 2 choices for the pain you are experiencing. Either it is gout-related, or it is something else. If your rheumatologist can detect something else, then that can be treated. If not, the assumption must be that it ought to resolve itself, once the threat of uric acid crystal reaction has gone. If that is the case, I believe your rheumatologist should advise you when to return for a follow-up examination. Or, they might tell you to make an appointment if you are still concerned after so many months.
All I’d add to that is, if gout is still the main suspect, then it makes sense to me to increase allopurinol dose to get uric acid lower. This speeds up the time to dissolve old crystals.
I’m sorry there are no definite answers, Will. However, I think you are doing the best you can to find the best answers you can.
One final thing that might help your rheumatologist is to be as clear as you can about the impact of colchicine and Indocin. I’d recommend adding information to your Profile about when pain occurs, and when you take these pain control drugs.
I hope this helps, but please feel free to ask for clarification if anything is unclear, or if you need more help preparing for your rheumatologist appointment.
Absolutely brilliant questions and observations, Ron! These are exactly the types of issues I’ve struggled with in the past. Sometimes I’ve worried for years about a particular aspect of gout that I didn’t understand. Then, I’ve seen a piece of research that has allowed me to view gout in different ways. Without blowing my trumpet too much, it’s that type of insight that you simply will not get from most places – because most people do not worry about gout at that level.
There is a simple approach – take sufficient allopurinol and stop worrying. This is a necessary approach for many doctors, but has 2 major flaws:
A. They don’t always understand what “sufficient” means. I won’t rant about that again just now.
B. It doesn’t help patients understand their gout in the context of better lifestyle choices.I found point B particularly relevant, as once I knew I could control gout, I didn’t want to die of heart disease.
So on to your points, Ron:
Your description of your lifestyle sounds good to me. I say this in the context of someone who believes that life is for living. I do not think that 4 or 5 weekends of the type you describe will seriously damage your health, or seriously worsen your gout. Sometimes we have to accept that gout has more reasons than diet, focus on the positives, and stop over-analyzing. More than that, it is important to understand the exact nature of how gout pain can and does exist.1) Generally speaking, high uric acid is a result of changeable factors, unchangeable factors, or a mixture of both. Changeable factors include meds for other health problems, environmental or dietary toxins, prolonged bad diet. Unchangeable factors include meds that have no alternative, ingrained bad diet habits that can’t be broken, and most common of all – genetics. It has been proved that a high purine meal will usually produce a uric acid spike, but this will not cause a gout flare. Allopurinol is most effective at lowering uric acid from diet, and about half-effective at lowering uric acid from natural cell turnover. So yes, allopurinol will help prevent a uric acid spike from high purine meals. The latest news is that – if this is just an occasional event, rather than a daily diet problem, then it doesn’t matter.
We now know that a uric acid spike does not trigger a gout attack. Uric acid crystals form very slowly, so a short-lived spike has very little effect. It is the daily average concentration above 6.5mg/dL that leads to extensive uric acid deposits. The startling results of the latest science tells us that uric acid crystals alone cannot produce a gout flare! The inflammation and pain signalling processes are very complex, but they need the presence of Free Fatty Acids(FFAs). By coincidence, FFAs are significantly high in most foods that are also high in animal purines. Thus, we associate a beef dinner with gout attacks, but the truth is far more complicated than simple uric acid spikes.
2)Makes perfect sense, and is not wishful thinking. Some leading-edge gout specialists believe that gout treatment might eventually become a short, annual intense treatment that reduces uric acid to near-zero for a couple of weeks or so. The rapid debulking of crystals in this period removes the risk of gout attacks. Lots of work to be done, but all the latest research supports your theory. On GoutPal, this is now known as Ron’s Plenty Of Room Theory! With more time, I’ll develop a suitable acronym π
3)I hope you can see that temporary additional allopurinol is not necessary. By adopting a strategy that lowers uric acid to 5mg/dL, you have a built in safeguard against uric acid fluctuation. The real issue, shortterm, is how best to manage the debulking period. Once you get that right, you can kiss gout worries goodbye forever.
Alcohol-related inflammation in my context, is about prolonged heavy drinking. I’ve not studied it in depth, as once I realized I might be a victim, I adopted an alcohol intake pattern similar to yours. I’ve read some reports about this, and i can best describe it as a sort of pre-cirrhosis condition. My symptoms were stiff legs, with low-level inflammation in knees and feet. Immediately I thought gout, yet this isn’t really the same, as gout tends to only affect one or two joints. A chance discussion with a fellow heavy drinker revealed that he had similar problems, but was definitely not a gout sufferer. A little self observation and restraint confirmed to me that prolonged excess alcohol consumption can definitely make inflammation more likely – at least for me. However, because this is bound to vary from person to person, I believe it has to be viewed in the light of personal history. It’s a factor that might be considered, but can be discounted for many people. Can I suggest it falls into the category: “Be aware of, but don’t worry unnecessarily.”
Of course, if anyone reading this is seriously worried about alcohol affecting there gout, then feel free to start your own personal discussion about it.
If you are worried about it, Ron, a monthly appointment is a good thing. Dedicate a year to the experiment, and alternate months of abstinence with months of normal drinking. Don’t feel obliged to do this. I hope you can see that it is probably a red herring in your case. I’m just trying to consider all possibilities, based on your “I also enjoy my alcohol & beer” reference.
I’m really pleased that your knees are feeling better. Doubly so, because you are pushing yourself to stay mobile rather than wallowing in a pit of self-destructive inactivity. Chin up! Boots On! Walk it off, and celebrate with a pint π
Thanks, Ron π
Exercise generally is good for gout, but you do need to be careful about over-stressing joints that might be weakened by the presence of uric acid crystals. Maybe swimming or walking to keep up the fitness levels for when you do feel like squash again. Also, somebody at the gym might be able to advise you better on this – maybe an exercise plan that avoids joint stress. There’s evidence that tendons etc recover once uric acid is under control, so the future looks bright.
There’s an awful lot of stuff written about gout diet, but I’m moving towards a simple view.
If you eat a diet that is generally considered to be healthy by modern nutrition standards, it is almost the best you can do for gout. There might be some tweaks you can introduce to lower the reliance on allopurinol, but attention to basic health is more important than purine control.
My reasons for saying this is that a modern healthy diet is very low in animal purines. Despite widespread repetition of vegetable purine information, we now know that vegetable purines do not affect gout. My simple basic diet approach ticks almost all the right boxes for a good gout diet. Beyond that, personal tweaks for individual diet management need to recognize what that person likes (or hates) to eat.
I’m trying to find time to expand the best simple diet into some practical guidelines. The foundation is:
Eat Food. Sufficient. Especially Plants. (EFSEP)It’s my take on a similar theory about nutritionism:
Eat Food – not food-like substances. Essentially, it is much healthier to eat whole, natural foods, compared to highly processed meals that sound like food. If you look at labels, focus on the ingredients. If you wouldn’t order a plateful of an ingredient, don’t buy the product that contains it. There are some gout specifics that have been highlighted, such as High Fructose Corn Syrup. More generally, we know that toxins can increase uric acid, and many food additives are toxic to a degree. Added iron is significantly associated with gout.Sufficient – overeating is bad for general health, and terrible for gout. It is usually worse than excess animal purine intake. Why? Because our own flesh produces uric acid as it metabolizes, just the same as purines that we eat. Overweight people have a significantly higher source of uric acid, and a significantly higher risk of gout.
Especially Plants – most of your food intake should come from plants in the form of fruits, vegetables, grains, nuts, etc. This is true of diets that have shown to be associated with better health, such as alkaline diets and Mediterranean style diets. The beauty of this is that there are loads of free resources to help you plan tasty meals. Also, you can change gradually. I’m now at a point where I rarely cook with meat, and when I do, it is as a flavoring, not a main ingredient. Traditional Chinese food is very strong on this idea. It can be hard to change the habits of a lifetime, but new discoveries with simple healthy eating goals are much easier to follow than boring low-purine diets. I eat more meat when eating out, but even then, I’m finding myself drawn more to vegetarian options. I’m aware that it can be quite hard to be totally vegetarian, as missing important nutrients might be unhealthy. However, with occasional meat, and mainly plants, I know I’m doing my gout good. This type of diet produces alkaline urine, which is much better for excreting uric acid.
The alcohol issue is fraught with difficulties, and debate. The science is confusing and occasionally contradictory, and this reinforces my belief that you have to take a personal approach. Commonsense certainly plays a part. If you drink heavily every day, that’s not good for gout, but also not good for general health. If you drink moderately every day, or heavily occasionally, this is less likely to have an impact. If you suspect alcohol is impacting your gout, it is important to analyze your situation carefully.
You need to distinguish between inflammation and uric acid levels. Alcohol might affect both, but you need to be certain. This involves carefully recording uric acid levels and any signs or symptoms of gout. You do this during a period of normal drinking, then during a period of abstinence, and keep repeating the pattern. In order to reach a fair conclusion, you have to do this many times. Personally, I find life is too short, as you say. Anyway, I always found that my gout felt better after a few pints, and I prefer to live my normal life, and accept whatever allopurinol dose is best to keep me safe.
As an aside, I find some of the official alcohol guidelines very restrictive. I’m ‘guilty’ of my own interpretation – e.g. 1 Unit = 1 Pint. The most useful part, for me, is at least 2 alcohol-free days per week. For me, I keep this as at least 3 alcohol-free days, and usually 4. I find that without that, I tend towards low-level inflammation, which may or may not be gout related. Also, I now find that drinking on more than 2 consecutive days induces depression – a personal observation, and nothing to do with gout.
I hope this helps, Ron. I’ve covered quite a lot of ground here, but feel free to ask about any of the detail.
Not sure if I answered you completely, Ron.
I always felt that the best approach was minimum pain control consistent with mobility. I.e. if I can walk with a little discomfort, then I don’t need more drugs. This is something you get a feel for if you try to be aware what your body is telling you.
Until allopurinol has got rid of the bulk of old crystals, you might experience some discomfort. Naproxen will help, but might not remove it completely. If the pain stops you from doing something, then best to treat it. However, try avoid being fixated by pain. A good walk, or other ways of getting out and enjoying yourself will take your mind of residual pain.
The most important thing is to get uric acid down to 5mg/dL, or lower. Then you know that any pain will be short-lived, which gives you more confidence to get on with your life.
If I’m not making myself clear, please keep returning to ask questions. I’ll give you all the support I can to make sure you get complete control of your gout.
Colchicine stops inflammation spreading, but does not reduce it. If inflammation is significant or unbearable, take naproxen.
Never ever take more than two colchicine per day. It poisons your immune system. That’s good if it it just enough to slow inflammation (2 per day), but bad if it kills you 9more than 2 per day). Also avoid colchicine if you have an infection, or are exposed to infectious people.
Naproxen can reduce inflammation by itself, but it is more effective for severe gout pain if taken alongside colchicine.
The 3-pronged approach is always effective:
Colchicine to stop inflammation spreading
Naproxen to reduce inflammation
Tylenol to block pain.If attacks are not severe, then not all three are required. For most people, preventative colchicine during the early days of allopurinol treatment prevents gout flares. If they do happen, the other 2 elements of your pain control package allow you to stay mobile.
For other readers, please note that your choice of anti-inflammatory and pain-blocker can be different from naproxen and Tylenol. Discuss your options with your doctor, but always insist on the maximum dose, as gout is not something to treat lightly.
Don’t even think about an impact sport that might stress damaged joints until you get uric acid safe.
Post your uric acid test result history, and I’ll give further advice on how you can avoid serious joint damage.
Of course they can.
Never forget though, that excess purines are only one of the 5 bad gout foods: http://www.goutpal.com/7616/what-are-your-5-bad-gout-foods/
Hi Ron, you are doing everything right!
Your description of gout symptoms is quite common, but other people reading this should note that symptoms do vary from person to person. Anything from dull ache to raging hot pain is ‘normal’ for gout. The fever comes because your immune system is fighting invading uric acid crystals.
I’d recommend one colchicine before bed, and the other in the morning. When you support that with Naproxen and Tylenol, I’m certain that you will enjoy your Vegas trip. March temperatures might be a bit low, so make sure you avoid prolonged exposure to cold. Also, stay hydrated. Any fluid is fine – just drink until your pee is pale straw color.
Ron, you’ve made life easy for yourself! π
Enjoy Vegas and send us a photo of your winnings!Peter, it’s very important to track uric acid levels. once you are stable, an annual test is sufficient.
If you have maintained uric acid at, or below, 5mg/dL for a year, and not had any gout attacks, then it is OK to take a break from allopurinol. However, you should get tested every 3 months or so, and restart allopurinol if levels rise above 6.5mg/dL.
Never forget that your Personal Gout Profile is there to help you. All you need to do is login, and make a note whenever anything significant occurs with your gout. It’s something you can refer to in future, and it can be very useful if you experience any more problems.
The only reason for taking allopurinol is to lower uric acid to safe levels.
I do not know what your uric acid level is now, or how it has changed.
Please can you login Peter, and add your uric acid test results history to your profile. The format is entirely up to you, but I find it easiest to follow if you type something like:
Feb 1st 2015 UA 5mg/dl other bloods OK
Nov 27th 2014 UA 6mg/dL other bloods OK
Aug 15th 2014 UA 6.5mg/dL kidney functions now all OK
Jul 15th 2014 UA 6.3mg/dL kidney function slightly high, retest next month
etcTest results might not be in mg/dL, but please use your own local values. I.e. do not convert, just write whatever it says on the results.
It is also good to use your Profile to record dates and dosages of all medications, and any other significant events.
Armed with the right information, I can say if your doctors advice is sensible, or if you have to ask more questions.
300mg is far from the maximum dose. There are several studies that show that this is the most common dose. However, that is simply because most doctors do not understand gout, and do not appreciate the dangers of under-dosing. In the States, 800 is the maximum recommended, and 900 in UK. I don’t know about other countries, but these are only recommendations anyway. Doctors can prescribe off-label if their professional judgment tells them that is best for the patient.
I recall some studies showing that allopurinol was safe at much higher levels, but I can’t remember where.
That brings me to your point about the ridiculous contradictions on the Internet.
But, is it ridiculous? If you get a group of people chatting about gout anywhere, you will always get differences of opinion. Those who tend to shout loudest are frequently the ones who have least worth saying. Never stops them though, does it. The Internet is just a bunch of people sharing their opinions. There is very little professional medical or nutrition advice available. Doctors and other professionals do not want to be associated with free advice. Besides which, they would be professionally compromised if they offered such advice without examination and personal consultation.
Internet pages are often worse than social chitchat because the written word lends an air of authority. However, greedy charlatans make a point of trying to seem credible in order to sell things.
You have to learn to be selective, and take the time to build up trust. Good things to look for are links to properly conducted studies. Be wary of people who make scientific claims, but then fail to refer to exact sources. I know that I have done exactly that here, but the context is different. On GoutPal.com I give references whenever they are available and relevant. Here in the forums, I write less formally, and give references when I’m asked.
One very significant point is that advice that suits one person, might not suit another. I’m not being helpful if I do not consider personal issues. That is why I now focus on this forum. As I have time, I’m amending pages on my main website to try and emphasize the personal nature of gout management.
This personal support extends to discussing things you have read elsewhere. You can learn a lot about gout from analyzing where people get it wrong. Please feel free to share any information you find. If you want to discuss a particular issue, it’s usually best to start a separate topic, otherwise threads get intertwined, and lost.
How did the allopurinol affect your kidney function and liver function test results? What dose were you on?
Same questions for Uloric.
Have you ever had a 24-hour urine test to assess your uric acid excretion rate? If not, that’s the best thing to do now, but wait at least two weeks since you last took Uloric. I assume that you are not taking any other medications or herbal remedies. If you are, I retract what I just wrote, and advise you to see a rheumatologist immediately.
A couple of apologies first @halfwayline15 :
1. Sorry for delay – it’s been a very hectic 3 days for me, and today I’ve got lots of catching up to do.
2. I got distracted by your excellent gout info find on Medscape, and I never noticed your question about colchicine.Many medicines are poisonous, but the good effects outweigh side effects if the dose is right.
If you are new to allopurinol, or increase the dose, preventative colchicine is very good. Take one at bedtime. If any sign of inflammation when you wake up, take another. Maximum two per day, but avoid colchicine if you have any infection, or are likely to come into contact with people who have any infectious disease.
As I said, colchicine does nothing to reduce inflammation or pain, but it should stop it getting worse.
For the inflammation, you need maximum strength ibuprofen, or other anti-inflammatory. See doctor or pharmacist about the maximum dose. Whilst you are there, ask about a compatible max strength pain blocker. I used paracetamol (aka Tylenol or acetaminophen), but there are lots of other choices. You alternate the anti-inflammatory and pain-blocker every 2 to 3 hours, and get on with your life. The pain package will allow you to stay mobile, which is also good at reducing inflammation, so long as you do not overdo the exercise.
Stay hydrated, and avoid prolonged exposure to cold.
Mike, you are not getting gout attacks because of your allopurinol dose. You are getting gout attacks because your body is packed with uric acid crystals. You have to get rid of them, and allopurinol is your saviour – at the right dose.
Clearly. 300mg allopurinol is not enough, because it puts you firmly in Gout Hell Zone.
In that zone, around 6.5 to 7.5 give or take, gout crystals are partially dissolving and reforming. This is pretty constant, and it makes absolutely no sense in delaying treatment. There is nothing wrong with starting allopurinol, or increasing the dose during a gout attack. It makes no difference.
You need your own personal gout-strength pain package now, so stop messing about with low dose over the counter stuff.
You need allopurinol dose increased to get uric acid safe. Personally, I’d go for the max dose for a year, but that’s something you can discuss with your doctor.Pain control now! Uric acid control soon! You’ll be out of Gout Hell Zone before you know it, and soon on your way to Gout Freedom π
No, you are not ignorant, joe, but I am very stupid.
I changed the name of the website from GoutPal Interactive to Your Gout Friend, but I forgot to change the security question.
Sorry. Please try now.
Yes, you definitely need to give the allopurinol more time to work. It can take several months for allopurinol to get rid of old uric acid crystals. Until most of them have gone, you might experience gout flares, but they should get less intense and less frequent.
Be sure you keep returning to your doctor for blood tests. You need to get uric acid down to at most 5mg/dL – lower if possible for a year. Also, blood tests should include liver function and kidney function.
Please let us know how you get on.
I like the sound of that, Graham. That’s 2 good news posts today π
Dehydration and prolonged exposure to cold are two things bad for gout, so it’s great that you’ve got them covered.
Gout is bad because it comes and goes. I’m not saying this to prick your bubble! It’s great that you are more comfortable now. I’m just saying that were here for you to help through any future bad times, as well as celebrating the good times.
Hey, @hawkeyez really good to hear from you again. π
I’m so pleased that Uloric is giving you your Gout Freedom! You are absolutely right to point out that what works for one person, might not work for another. We all have to find our own way of controlling gout.
A massive thank you from me, for visiting again and encouraging other gout sufferers. You are living proof that perseverance and a positive attitude are the best cure for gout!
To everyone else:
Uloric might be what you need.
Allopurinol might be what you need.
Something else might be right for you.
Doing nothing means disaster! π₯That’s a great question R. O?Hara. I’m going to need more information to answer it properly
First, let’s start with your Personal Gout Profile.
It’s great that you’ve started to put some information in your profile. Can I make a suggestion?
You say: “I’m now on gout medicine”
That’s good because it tells me you have been diagnosed with gout and you are actively getting treatment. So I can help you better, I need to know what you have been prescribed. Also dates are quite important in making your profile useful as time goes by. Can you amend that to say exactly what medicine you are taking, the daily dose, and when you started? Something like a single line that says:8th Feb 2015 started 100mg allopurinol daily.
In future, if your meds change, you can add another line such as:
6th March 2015 allopurinol increased to 200mg daily.As far as the alcohol goes, red wine is generally better than beer. But I don’t want to leave it there. This forum is all about you, not general principles that might or might not apply to you. Some gout patients find wine is better than beer. Some find that complete abstinence helps (poor beggars π !). I believe that alcohol has very little to do with gout. I’ve got gout under control now, with allopurinol. Before that, I never noticed any particular drink triggering a gout attack, and I often felt much better after drinking beer. Different people have different reactions, but there is always a way to deal with gout problems – if we have enough information. Can you can describe the problems you have had with beer? Sometimes it isn’t the type of alcohol that’s the issue. For instance, alcohol can lead to dehydration, which is very bad for gout. By remembering to drink non-alcoholic beverages after alcohol, you might reduce the problems.
Sorry I can’t be more specific, but there is no single rule that applies to all gout sufferers.
I’d like to turn your question round, and say: which do you prefer – red wine or beer? Then we can work together to make sure you can enjoy what you like, without making your gout worse. π
Oops! That was long-winded as I kept getting broken off with work. Who do these people think they are, just because I’m being paid to do something else.
Anyway, more, succinctly Luke:
once I land on a dose of allo that gets me to the sub 5 UA reading continue colchcine for two weeks and then suspend ? realizing that I need to begin at first sign of flare.
Sounds perfect to me! π
You can’t really align uric acid level with gout pain or, at least, not in a short-term, cause and effect way.
Gout pain comes as uric acid forms crystals, but not always.
Some days, your immune system deals with them. Maybe with some low-level symptoms, but not a gout flare.
Other days, your immune system get’s overwhelmed and calls in reinforcements. That intense inflammation process is the familiar agony of gout.
The flashpoint varies from person to person. I strongly suspect that it also varies for individuals at different times. In fact, this is almost certain, as the latest science tells us that exposure to uric acid crystals alone will not cause gout. Our pain pathways seem to require the presence of fatty acids in order to produce the acute gout attack. This is fairly cutting-edge, and the processes are not fully understood yet. The important point is:
You can do everything right for long term uric acid control, and still get an unexpected gout flare.
The reason for this lies in my emphasis above. Our immune system only responds when it sees the threat. It only signals the emergency as a gout flare when enough uric acid crystals are exposed.
But, uric acid crystals are exposed when they form, and might be exposed again when they start to dissolve. In the first instance, our immune cells sacrifice themselves, and engulf uric acid crystals. This is the same process that kills an infection. Unfortunately, uric acid crystals cannot be killed. They become hidden by a coating of dead white blood cells. Those hidden uric acid crystals are the timebomb that all gout patients face when they start lowering uric acid. In sufficient numbers, with sufficient fatty acids around to complete the pain signal, dissolving uric acid crystals might cause a gout attack.
Somebody recently in the forum has been complaining of gout flares several months after starting allopurinol. It is a very complex situation, but with some common sense, it can be managed. The first milestone is to get uric acid down to 5mg/dL. That removes any doubt as to where the pain is coming from – it must be from dissolving uric acid crystals.
That is why I emphasize the importance of a personal gout pain relief package that works for you. It gives you the confidence to ride out a gout flare. Then you soon realize that each successive gout flare is less frequent, and less intense. That pain package helps you through the hard times. After a few months, you never need it again. Leastways, not for gout. I feel much more confident now about pain management, and that helps me through other of life’s troubles.
I know that is a long explanation, and I could probably make it more succinct. My main reason for it is so that you can understand that gout attacks might appear, somewhat randomly, until you get most of your uric acid crystals dissolved. There is no complete answer to the question of how long this lasts. The two major factors are how much uric acid has formed crystals in your body, and how low is your uric acid level. It’s hard to measure the first, and it’s historic, so you can’t do much about it. There are no hard and fast rules, so you’ve got to analyze your situation as it changes.
If you are happy to take colchicine daily, then I do not believe six months should pose any serious side effects. Colchicine side effects are almost always stomach-related, and obvious. If you want to take as little as possible, my doctor told me that the most likely time for attacks was the two week period following an allopurinol dose increase. It’s precisely because attacks cannot really be predicted, that I believe the best approach is whatever suits you. Six months of daily colchicine, with sufficient allopurinol to make uric acid safe, gives many gout patients complete freedom from any more gout attacks. But, there are no guarantees, so I prefer to say “do what you think is best, but ask questions if you don’t understand what is happening”
I should finish by saying that you can also minimize problems during allopurinol treatment by avoiding both dehydration, and prolonged exposure to cold. When allopurinol has done it’s job, you want to do as much as possible to help your kidneys excrete it’s by-products, along with any dissolved uric acid. Some people might suggest avoiding alcohol, as it gives your kidneys more work to do. I believe I can counter this with extra water, coffee, and other gout-friendly fluids. Again, make your own mind up based on your preferences and gout facts that are relevant to you.
I’m working now (*), but in my mind, I’m raising a glass to celebrate the start of Luke’s allopurinol journey. I want you to become the latest member of the “I found Gout Freedom” club π
(*) My life is 8 hours ahead of the posting time shown here – I am not considering celebrations mid-morning!
Yes Luke, if you haven’t had problems with colchicine in the past, one at bed time for a week or two is a good pre-emptive strike. Just be aware that it might not be the complete answer, but it’s a great advantage tomorrow morning.
If you get a twinge, it won’t be as bad as if you hadn’t taken the colchicine pill, so take another first thing in the morning, and indomethacin if necessary. A bit of preemptive pain treatment will help you enjoy your day.
If you don’t get a twinge, just enjoy your day π
Point 2 in a moment, just in case I get distracted.
First off, Luke, I’m really sorry for not responding earlier. I’m having a busy week, but that is no excuse. I’ve had my focus in the wrong place. I get a notification when new members post their first message. As you know, this goes into a moderation queue, so I get a big red warning. I have now changed my daily routine to look for existing members posts first.
I hope my delay doesn’t put you off posting more messages. I’m convinced that regular posting, to your own, and other people’s threads, makes a positive contribution to fast gout recovery.
I think you are in a perfect position to successfully control your gout. It’s good to have a long view of your treatment, but also good to take one step at a time. Your description of the first six weeks is ideal. My answer to your colchicine question is: “whatever feels right for you.” Now I’m going to expand those short answers to aim specifically at you, Luke.
100mg allopurinol is definitely the best first step for anyone who is not of Han Chinese, Vietnamese, or Korean origin. For those people, a simple genetic screening test will identify suitability for allopurinol. I’m going to assume you are not in those groups, so if you haven’t already done so, start the allopurinol now!
I am also assuming that your doctor has been vigilant and taken appropriate blood tests besides uric acid. For gout patients, every blood test should include uric acid, liver function, and kidney function. Before allopurinol, these additional tests establish your personal benchmark for liver function and kidney function. Then, during treatment, abnormal results are the best early indication that specialist intervention is required.
Whenever any GoutPal member has a blood test, I urge you to include the results on your Personal Gout Profile (the page that appears when you login). Be sure to include date, uric acid level, and uric acid scale. There is no need to include other results, unless you wish to, but you should always ask your doctor if these other tests were OK, and if not, make a note of the response.
Whilst I’m talking about your Personal Gout Profile, it’s the perfect place to record any visits to your doctor, and any gout episodes, but always better to date your entries.
Before I return to the ideal allopurinol dosing schedule, I’ll cover colchicine during uric acid lowering treatment.
Personally, I was advised to take one colchicine pill per day for two weeks after an allopurinol dose change, and then as required – at the first sign of an attack. If not resolved after two to four hours, I took a second colchicine, within my one or two per day prescription. I now know that a slight improvement on that advice would have been to take the first colchicine last thing at night, with an optional second in the morning if inflammation present.
For you, Luke, and for any other gout patient reading this, you must realize that my personal pain treatment package might not suit you. Colchicine has been prescribed badly in the past, causing stomach disorders by taking more than 2 pills per day, which has no additional benefit. If you’ve had bad colchicine experiences with more than two per day, then that is normal, so restrict to two in future. Colchicine is not for everyone so avoid if:
- You’ve had bad experiences with one colchicine
- Your immune system is compromised due to infection, or potential exposure to infection
- You simply don’t want it
Colchicine is a great way to stop inflammation spreading, especially when taken at the first sign. It does not reduce inflammation, so if swelling has already started, take an anti-inflammatory with your colchicine, then at recommended intervals. If pain remains unbearable after two hours, take a compatible painkiller such as Tylenol (paracetamol/acetaminophen). Always check with your pharmacist that your personal pain package is safe.
You need that confidence in a personal pain package that suits you. With any uric acid lowering treatment, you might have a gout flare during treatment. The risk period continues until most of the old uric acid crystals, that are deposited round your body, have dissolved. The lower you get your uric acid level during the first year of treatment, the shorter period of time you are at risk. Those are gout facts that affect everyone, but personal factors might affect your allopurinol schedule.
The biggest influence is your doctor. They often have their own agenda for allopurinol dosing, and it is often wrong. My answer to that is, it’s your body, so it should be you that decides what to do with it.
Going back to Luke’s (and mine) ideal allopurinol schedule, the 100mg start is perfect. The minimum period after a dose change, before retesting is 2 weeks. In most cases, you might have to wait a few days for results prior to increasing allopurinol to 200mg, so let’s say the ideal is actually 2-3 weeks. 4 weeks/1 month is OK. 2 months is showing signs of lack of commitment. Waiting more than two months is a sure sign that either you or your doctor wants you to suffer gout forever (or at least doesn’t care).
That establishes the starting dose, and testing interval, but what happens next? Some doctors might suggest 300mg, if blood tests show that uric acid level is not decreasing rapidly enough, and liver and kidney function remains OK. That is perfectly fine. 200mg or 300mg are valid choices. They are both right if they have been selected as an option based on a patients latest blood test results, and medical history. They are both wrong if they have been selected because “that’s what we always do.”
The same goes for subsequent tests, and increases. At some point, patient and doctor must decide on a suitable target uric acid level for the first year. I was able to persuade my doctor that “low as possible” was my best option, and so I quickly escalated to maximum dose. A more cautious approach might be “4 to 5 mg/dL.” The target is only wrong if it is above 5 without consideration for other disease (e.g. kidney disease, where the maximum is deemed to be 6mg/dL).
So, if I haven’t bored the hell out of you Luke, with my long-winded explanations, let’s continue to refine your personal gout treatment plan. You’re off to a great start. π
I recently got a response from Terise, via my support ticket system:
Thanks for the response but I recently found out that I do not have gout after all. My primary care doctor was the one who dx’d gout but I finally was able to see a rheumatologist who said I did not have gout (as I suspected) but tendinitis.
I appreciate your help though.
So, this shows us all how important it is to see a rheumatologist if your gout is not straightforward. Rheumatologists are best if your gout symptoms are not clear, as in this case. Though gout symptoms are often obvious, there are many cases where symptoms of other diseases can mimic gout. Most often, this is pseudogout, but we can see in this case, it is tendinitis. As discussed elsewhere, rheumatologists are also very useful when treatment becomes complicated by intolerance or other health issues.
Speaking of complications…
If you have problems posting to this forum, you might find my new support system useful. Just click the orange Support tab on the left. I put it there so you can get help with technical problems. If you are having difficulty posting in this gout forum, you can also post via that support button. I will post your gout questions or opinions in the appropriate forum for you.Oh, this is bad news indeed. I can see that dry eyes/mouth are an acknowledged side effect of both allopurinol and febuxostat (Uloric) for a few people. Unfortunately, I can’t find any info on how this might be combated specifically. Generally, there have been several successful cases reported, at least for allopurinol, of overcoming some side-effects. The method is to start with very low dose, then very gradually increase it by tiny amounts. The low doses are achieved by using allopurinol solutions.
This is definitely a case for a rheumatologist, but must be one who has experience of managing allopurinol / Uloric intolerance.
There are good search tools at healthgrades.com and rheumatology.org
First step is to contact them, and ask specifically what intolerance experience they have for uric acid lowering meds.Getting uric acid down from 8 or 9 without meds is a tall order, but that depends how bad your lifestyle is. If it’s something you want to consider, then I’d be happy to work with you to at least give it a go.
I really hope we can find something that works for you.
Sorry you are having problems logging in. It’s because you used your email rather than your user name. Your username is mcarey1 and I’m pleased to see you’ve started your Gout Profile at @mcarey1. I notice you use a Google email address, so you should be able to login by clicking the Google icon instead of typing in username and password. I’m really sorry to you and anyone else who is having trouble with logging in. I’ve added a little Support tab which I hope will help anyone who is stuck with technical issues, though I’m still perfecting it.
Thanks for the extra information.
The main thing about gout pain, is it’s different for everybody. Sure, there are some common symptoms, but they might not affect you. For instance, I’ve never had gout in my big toe.
Gout pain is a reaction to uric acid crystals. These have built up over many years. They were growing before you had your first attack last year, but it takes a while to notice them. Some people go for many years without noticing gout. Eventually, huge lumps of uric acid crystals make their presence felt in other ways. I’ve referred to this as painless gout, and it can get quite horrific.
You have your own reaction to the crystals. Because you are active, it is likely that the dead immune cells that mask uric acid crystals are constantly shedding. Coupled with new crystals growing, you’ve probably got enough inflammation to maintain continuous low-level residual pain.
I hope this explanation is clear? If it isn’t, please ask.
If it sounds like a reasonable explanation, the next question is what do you want to do about it?
If you want lifestyle changes, I need to know much more detail about your height, weight, and food intake, as well as the alcohol. Managing gout through lifestyle changes is all about healthy balance of everything you eat and drink, compared to your activity levels. Just like gout pain, diet is personal. There are a few common rules, but your plan has to be built around you.
If you want meds, then I can help you get the right treatment plan from your doctor. Again, it has to be what suits you, within the rules.
Whatever questions you have, please feel free to post them anytime. Once your first post as a logged in member is approved, all your posts will get accepted immediately. Contributing to other threads, with questions, opinions, or experiences, is a great way to learn what is most important to you – then we can start putting it right. π
It’s not really important why vegetarians get gout, Premilla Devi Naidoo. It’s important that you understand your own gout. Yes, that involves what you eat, but gout diet is the last subject that should concern you. Your symptoms and treatment are most important.
From your second question, can I assume that you have noticed lumps in soft tissues? Uric acid crystals affect joints first, probably due to temperature, though other factors could be important. Eventually, they will spread into all tissues, leading to serious damage, which can be fatal.
I need much more personal information about your gout history before I can advise you better. Please login before you post. The welcome page after you login includes your Personal Gout Profile. Use that to record your gout facts, and any important questions.
With your gout facts, and some more discussions here, we’ll soon be able to control your gout so you can live a happy life free from the fear of more gout attacks. You will also be able to stop worrying about being vegetarian. As I say, gout diet comes last, but if you have some immediate concerns about your diet, I can help.
I need to know what you eat in a typical day. Better still, a typical week. Also your height and weight. That will give me a start towards explaining why vegetarians get gout. More importantly, I can give you personal advice about the important aspects of your diet that need to change. I can also allay your fears if you are worried about certain vegetables. All fruits and vegetables are good for gout if you eat them properly.
My first reaction is: Why do you think it’s gout?
Have you definitely had a gout diagnosis? If so, your uric acid level is vital to understanding if gout is the cause of your recent pain.
I strongly recommend you login before you post. If you have difficulty doing so, please drop me a line in the Using GoutPal forum – https://gout-pal.com/gout-pal-forum/gouty/tech-stuff/#new-post – or open a support ticket at https://goutpal.freshdesk.com/support/tickets/new
When you login, you get a welcome page that contains your Personal Gout Profile. That’s the place to store all your personal gout facts, and important questions. Use it to record your uric acid test results. They are vital to understanding your gout symptoms before, during, and after treatment.I’ve put complete explanations of all aspects of gout pain in my Gout Guidelines. The trouble is, there are hundreds of different factors that affect gout pain. If you can explain more about your gout history, including any treatment, I’ll be able to give you the personal help you need.
This might take a bit of effort, as we have 2 other things to consider here.
I’ve noticed that when I drink too much, I get stiff and sore. This also happens to a friend who doesn’t have gout. We worked out that it is frequency related. If we drank too much every day, we got sore. However, if we had days off, the pain and stiffness went. I’ve now applied this to my life, and I never drink on more than 2 consecutive days.
Your other potential complication is exercise. Exercise is good for gout, but stress is bad for joints and ligaments that have been weakened by uric acid crystals. We really need that uric acid test result history to assess how likely it is that the stress of basketball might be causing your current discomfort.
Please keep logging in and posting, M. franklin. Together, we will get to the bottom of this.
Hey @rob-pharazyn I just realized I missed a point on Facebook.
You asked:
just posted a question on the forum but forgot to tick the “notify me of emails” box..it’s still in moderation so is it possible for you to tick the box
I replied:
Just tick it when you respond
What I should have said was:
Just click the Subscribe link at the top of the post.It works for all posts, and is conveniently located next to the Favorite link. It’s good to mark favorite topics, so please can everyone do it at least once a week! Clicking Favorite in the gout forum is similar to clicking Like in Facebook, only much nicer. π
Post by Rob Pharazyn.
