[Keith Taylor]

I mentioned 2 parts to the best gout diets – favorite foods and your gout treatment plan.

Without the gout treatment plan, I can only write in general terms. Meal plans need loads more personal info.

I think big salads with animal protein garnish is an excellent strategy. That way, you can include fish and meat (including smoked salmon or anchovies) in healthy ways. As a very rough guide, up to 10% of calorie intake as animal purine should be OK. Definitely a good starting point, then tweak the 10% up or down according to blood or urine test results (best results with careful planning and monitoring). I aim for less than 10% by making the veggies so tasty I can do without meat. Chillies are my friend.

Total calorie intake needs to match daily energy use – over-eating of any food is one of the worst things you can do for gout. That’s because the excesses get turned to body flesh. There’s no point restricting meat in your diet if you create more meat in your body.

I don’t understand why you think oatmeal or spinach should be a problem. OK, I probably do understand – you’ve been reading crap websites. Ignore that rubbish. Life’s hard enough as a gout sufferer without the unsubstantiated rubbish found on many websites.

Any fruit and veg is absolutely fine, as long as you do not overeat a single type. Cranberries are fine, just don’t eat them (or anything else) all day, every day.

It’s a pity you’re not local to me. I absolutely love dark chocolate. I need 80% cocoa now!

Never forget: just like allopurinol and Uloric, lowering uric acid with diet can cause gout flares until all old uric acid crystals have dissolved. Never judge food as good or bad from pain alone – you must measure it against uric acid test results.

[Keith Taylor]

“How long for the Uric Acid levels to normal?”
I hate the term ‘Normal’ for uric acid. When applied to test results, it’s a statistical term that has no medical value. The lab averages include people with gout. It’s a bit like saying the normal range for breasts or testicles is 0.95 to 1.05.

What we want to see is safe uric acid levels. Better still, every gout patient should have a target range that changes during treatment. Long term, safe uric acid is 5mg/dL or lower. Other health conditions such as kidney disease might force a compromise around 6mg/dL, but the important thing is to treat to target, where targets are set based on personal medical history.

In the early stages of treatment, the aim should be to encourage old crystal deposits to dissolve as fast as possible. We can do this by getting uric acid as low as possible. The target during early uric acid lowering treatment is something that you and your medical team are happy with. No higher than 5, as low as you can get it with maximum allopurinol dose, or somewhere in between. It makes for interesting discussions.

Once you have gone 6 months without a gout attack, whilst maintaining safe uric acid levels, you can adjust allopurinol dose to maintain that safe level. But nobody knows how long that will take. It depends how long you have had excess uric acid, how high it was, and how low you get it now.

I was clear in less than six months with uric acid lowered to between 2 and 3, after almost 20 years. Other gout sufferers who don’t get uric acid low enough have struggled for years.

If you have some definite numbers, I can try to guess. The main thing is to be confident that your uric acid is low enough, then you can look forward to an end to gout attacks. Which brings me to…

“when should I ease off of Indomethacin and colchicine?”
First, Colchicine.
I was advised to take for 2 weeks at start of allopurinol, and whenever dose increased. In reality, I reduced this to a week or less after my second increase. I’ve since learned that it is best to take one at night, then take the second next morning if there is any sign of a gout attack. That would be a more scientific approach to easing off colchicine. Go from two a day to one at night, then none. Always be prepared to start again at the first sign of an attack. Colchicine is only useful before the inflammation has set in.

Next, Indomethacin.
I took ibuprofen rather than indomethacin, but the principles apply to all NSAIDs. Ease off as swelling reduces, but be prepared to go back to full strength as required.

doctorrazz, I could write at length on uric acid levels, allopurinol, colchicine, and NSAIDs, but to avoid boring everyone, I will finish for now. If I haven’t been clear on any points, or if you have any other questions, please don’t hesitate to ask.

It’s been far too quiet in these gout forums lately. I need more people who don’t mind spending a few minutes every week to ask questions and comment on other people’s posts. Thanks for your interesting posts.

[Keith Taylor]

Hi Ranji,

I’m also confused! Where is there any suggestion that a HIGH purine diet is good for anybody?

My page about foods high in uric acid is bad. As I’ve said, there is far too much emphasis on low purines. I need to rewrite that page to make it clearer.

Many doctors give bad advice about purines, and the Internet is full of it. In a very small number of gout sufferers, purines are important. I don’t know enough about you to know if you fall into that category.

I’ll assume that you do not have any special purine needs other than the need to eat a healthy diet. Therefore, it’s best to stop worrying about purines, and start worrying about a proper gout treatment plan. Once you have that plan, we can see if purines are important, then we can manage them.

If you need help with an effective gout treatment plan, just ask.

[Keith Taylor]

Hey, that’s great Sam!

I’m looking for food lovers who want delicious meals as part of a gout-friendly eating plan.

The best gout diet plans are the ones that include your favorite foods and support your gout treatment plan.

To Sam, and every other gouty food lover, I say:

Tell me about your favorite foods, especially those you think you cannot eat. Use your Personal Gout Profile to tell me about your current gout treatment (or also ask for a personal treatment plan). Then we can work together to produce a nutritious, tasty menu that suits your gout.

[Keith Taylor]

Hi Jenine,

Have you got your diagnosis yet? I’d love to help you plan a gout diet that supports your treatment plan.

I’ve lost direction with the diary app. In fact, you are the first to show any interest!

I’d love to work with you, and any other interested people. Perhaps I could tag something onto the Personal Gout Profile to make keeping track of gout meds easier. What sort of information would benefit you?

I hope other visitors show an interest in this. It would be great to add some features that help you all.

[Keith Taylor]

Hi Glen,

I can see that Stevio sent you a note about self-registration. In the past couple of days, I’ve added some notes about different levels of gout help access. I strongly recommend you register as a GoutPal Member, and start posting here regularly.

It’s always a shame when gout doesn’t get diagnosed as early as it should. Whatever the reasons for that, I hope that you can get it under control now that you know you have it.

If you need any help getting your newly diagnosed gout under control, please just ask.

[Keith Taylor]

Hi John,

PRAL is an acronym for Potential Renal Acid Load. It is an estimate of how diet will affect your kidneys. Foods with lower PRAL create more alkaline, which is generally considered to be a good thing for health. For gout, there are strong indications that alkaline urine allows uric acid to be excreted quicker, and will lower uric acid for most gout sufferers. It’s complicated, but there are tests that can confirm if an alkalizing diet will help your gout.

Let me know if you want more details of how to plan an alkalizing diet for gout, and how to monitor it to assess your progress.

[Keith Taylor]

Thanks for that Liz.

Are you now getting proper treatment to get your uric acid safe?

What about pain control until old uric acid crystals have dissolved?

Let me know if I can help you more.

[Keith Taylor]

Hi Melissa,

Thank you for your message. It’s great to see your first post as a Guest. I hope you will consider becoming a GoutPal Member. It costs nothing but a few moments of your time to join, and you will soon save that time when you post more topics and replies. Due to my availability, I always respond to members first.

Who said beans are bad for gout? I don’t think so, but I’m willing to look at the evidence if I’m wrong.

Why take allopurinol then not get blood tested again? The only reason for taking it is to get uric acid safe. It’s really important to get uric acid tests to make sure the dose is right. If the dose is wrong, allopurinol will not help you, and it might give you more pain than is necessary.

I don’t think you need a rheumatologist, unless you have health complications that you haven’t mentioned. The process of controlling uric acid is a simple one. I can give you a step by step guide to what you need to do. It will involve a doctor so you can get the right drugs. Do you have access to a doctor near where you live?

There are lots of other things you can do to minimize gout attacks. Let’s start with the big issue of getting allopurinol right. Then I can give you some advice about avoiding triggers.

Hope to hear from you soon
Keith

[Keith Taylor]

I say: “With gout, it is very important to separate pain and uric acid levels” then I get a garbled confusion of papaya, UA levels, weight loss, gout pain, and more gout pain.

Why does nobody listen? 😕

[Keith Taylor]

Ron, it really does get better as the weeks pass by.

I want to be more encouraging, but I know how useless word are when you are suffering.

All I can suggest is a word with your doctor or pharmacist about your pain relief. I used max strength ibuprofen rather than naproxen as my NSAID, but both should do the job if the dose is right. I did NSAID (800mg ibuprofen) then after two hours, max dose Tylenol. Repeating 4 times a day.

The best approach is to agree the max dose of each pain-killer with your doctor, then divide that by 4. Then take your normal waking time – let’s say 16 hours for ease of calculation. Divide waking hours by 8 – that gives your dose interval of 2 hours. If you only sleep 6 hours, your dose interval is 2:15 (hh:mm).

When you wake, start with NSAID then after dose interval take Tylenol, and repeat through the day.

Be careful! Measure out your daily doses at the beginning of each day. If you don’t use them all, NEVER carry them forward to the next day.

If gout pain regularly wakes you, make your dose interval 3 hours. Then keep doses for use through the night if you need them.

My only other suggestion is to see your doctor about alternative pain relief. There’s lots to choose from. Don’t go for steroids though (in my humble opinion)!

As long as you keep uric acid down around 300, you won’t need to worry about this in a couple of months 🙂

[Keith Taylor]

If you go for a year without a gout attack, you can definitely consider yourself lucky!

To know if you are “cured” depends on uric acid levels.

I see from your profile, John, you are in Scotland. Your uric acid test results will be in moles. It’s a bit confusing because there are 2 different scales. Fortunately, it is obvious which one you are on. It is either mmol/L or μmol/L. As you can see from the Uric acid levels table in the right hand sidebar, you need to be no higher than 0.30mmol/L or 300μmol/L

If you have maintained that safe level for a year, and had no attacks, then you can consider yourself “cured”

If uric acid has been in the Danger category, then you are probably just lucky, and you can expect more gout attacks in future.

I put “cured” in quotes because most gout can only be truly cured if it is secondary gout, and you cure whatever is causing it. We usually say controlled. That means you can live a life without fear of gout pain, but you must get uric acid tested at least once a year to make sure you stay safe.

[Keith Taylor]

It’s great to see three data points for uric acid levels in your Gout Profile. It’s also great to see three data points for allopurinol dosage. Other gout sufferers take note – record significant gout facts in your personal gout profile. Before I analyze that data, the most significant point is that none of those levels represent safe uric acid.

Your lowest level in your profile is 6.2 on 3/17. This is theoretically good, but has very little safety margin. I’m not sure if the 6.3 in your original question is an extra data point or a typo. Either way, it reinforces the important fact that uric acid is not down to the 5mg/dL that is required.

Moving to the uric acid data analysis. For many years, I have emphasized the need to think in terms of uric acid ranges rather than absolute values. There is natural fluctuation in uric acid levels. Of course, it is impossible to know if an individual test result represents the top or bottom of your daily range, or something in between. To be certain, you would need to test through the day, every two hours. Not very practical.

It is unusual for uric acid to rise when allopurinol dose increases, but we only have limited data to work with. More tests mean better data analysis, though I must repeat that this is all academic, as we are discussing different degrees of unsafe uric acid levels. To get a true comparison between individual test results, we must consider confounding factors. Possible explanations for a rise are:

• Presence of gout flare in early tests
• Recent crystal dissolution in latest test
• Blood drawn at different time of day
• Blood drawn at different time after eating animal purines

My conclusion is that, though this rise from 6.3 to 7.1 is unusual:

1. It is within the bounds of natural fluctuation
2. As a one-off comparison, confounding factors are more likely than cause-effect

My ‘recipe’ for analyzing uric acid test results is to ignore the lowest and highest values, then plot rolling averages to identify trends. In this case, there is insufficient data to draw conclusions, so we must continue to collect data, and switch focus to the treatment plan.

A good uric acid control plan is driven by targets, and tuned by results. The long-term target for uric acid control is 5mg/dL. This might be compromised by other health conditions in a small percentage of cases, where 6mg/dL is the absolute maximum. I describe the first phase of uric acid control as ‘debulking.’ The aim of the debulking phase is to dissolve most of the old uric acid crystals that have formed throughout the body in the years of untreated excess uric acid.

Doctors have a clear mandate from rheumatologists to consider uric acid lower than 5 to resolve visible tophi. My argument is that recent DECT technology proves that pre-visible tophi are rampant in every gout sufferer. These are the uric acid crystals that cause gout flares during uric acid lowering treatment. They are dangerous, destroying joints and compromising organ health. Several studies have proved that old deposits dissolve faster when uric acid is lower than 5. Therefore, I always recommend that patients agree a lower target during the first year of allopurinol, or other uric acid lowering treatment.

I feel it’s important that patient and doctor are both very clear about dose during different phases. They need to manage a high allopurinol dose during debulking, and a suitable lifetime dose to maintain uric acid no higher than 5. There are transition (aka titration) phases before debulking is achieved, and between debulking and maintenance doses. The transition phases need blood test control and dose adjustment every 2 to 4 weeks. Maintenance testing must be at least once a year, with debulking testing somewhere in between.

So, concluding with:

2) assuming liver and kidney levels are unchanged ? I?m guessing you would increase Allo and continue search for correct dosage

You are right to mention liver function and kidney function tests. These are recommended for every gout sufferer whenever uric acid is tested. They are vital for every gout patient undergoing any form of uric acid lowering treatment.

I would first set a target uric acid level for 2015. Personally, I would go for “as low as I can get,” but you and your doctor should agree what is best for you. Clearly, 300mg allopurinol is insufficient and so you need to agree an action plan with your doctor. Beyond 2015, you can reassess your allopurinol dose to maintain gout freedom for life.

We can discuss your maintenance dose specifically at the time. In my opinion, the end of the debulking period is marked by no gout flares for 6 months during a period when uric acid is never higher than 5mg/dL. In that regard, you haven’t actually started the debulking period yet.

In simple terms: Yes! increase the allopurinol as soon as you are sure that blood tests indicate that is safe.

[Keith Taylor]

Sorry Robert, you haven’t given me enough information to advise how long your prescription will take to work.

I strongly advise you to see your doctor about this. If you are not sure what to ask, then please reply here, and I will try and help. If you get responses from your doctor about gout that you don’t understand, I might be able to help with that.

[Keith Taylor]

my uric acid levels were 7.5 ?which based on my research I though was not high enough to be gout

I wonder where you were looking for that piece of misinformation. Please let me know so I can start a new list of “Websites to avoid if you want to beat gout.” 😉

I don’t know enough about you to have an opinion on whether you should take Uloric or not. You could log in to GoutPal, add some facts to your Personal Gout Profile, and post more details abut why you are considering Uloric for your gout. Better still, discuss it with your doctor. If you are not sure what to ask your doctor, then reply here, and I’ll try to help. I can also help if you need to understand what your doctor says to you.

If you and your doctor decide that Uloric is the best way forward, then indomethacin must certainly be considered as part of a pain control package. You may need pain control for a few months after starting any uric acid lowering treatment. I say “part of a package” because ideally, you need medication to:

1. Limit spread of inflammation (usually colchicine)
2. Reduce inflammation (e.g. indomethacin)
3. Block residual pain (e.g. paracetamol or compatible narcotic analgesic)

You might not need all of those at the same time, but it is important to understand your personal approach to those 3 aspects of gout pain control. That will allow you to control any temporary pain until you can remove the risk of gout pain by making your uric acid safe.

Good luck Alan. Let’s make 2015 your only year of gout troubles.

[Keith Taylor]

Hi John,

It aint about luck. It’s all about dedication to getting a good plan, following it carefully, and monitoring regularly. It does not matter if you choose drugs, herbal medicine, or non-medical treatments. You might even choose a combination of 2 or all 3.

The reason why natural treatment rarely works for gout is because people treat it like a lottery.

You might get better. You probably won’t.

[Keith Taylor]

I agree Olan, it probably isn’t gout. Good job really, because some of the advice you’ve been getting is poor (apart from the very excellent advice from Ron, above).

The only way dried fruit is going to cause gout is if substantially more than 25% of your daily calorie intake comes from it. Nothing to do with fructose or fruit. Any diet that is not nutritionally balanced can lead to gout, but the circumstances vary.

“Normal uric acid” is a phrase used by medical staff who are incompetent, or patients who have been misled. Don’t use it, unless you are a statistician.

Olan. your 194 (presumably μmol/L) is perfectly safe. It can only ever be gout-related if it has been significantly higher in the past. I do wish that doctors who suspect gout would keep their opinions to themselves until the test results come back. Pity really, as I got 3 posts off you in a day. I wish the real gout sufferers were so prolific.

Gout sufferers take note! Olan cured his “gout” with 3 posts in this gout forum. Just think what you can do if you really have gout, and choose to control it properly. Log in, and get posting!

[Keith Taylor]

Leku asked:

Can you give me your opinion of that recommendation

Uloric is manufactured and distributed by Takeda.

From Japan (needs login)

Takeda Tops Physician Honoraria Payment List in FY2013

We surveyed 19 companies that had disclosed their funding as of September 24 and for which comparable data were available for the previous year. Takeda Pharmaceutical paid over 1.9 billion yen under this category, the largest among the 19, followed by Daiichi Sankyo and Novartis Pharma. The closely watched category consists of three subcategories of ?lecture fees,? ?manuscript writing fees or supervising fees,? and ?consulting or commissioning fees?

From USA:

Dollars for Docs: Who?s On Pharma?s Top-Paid List?

Psychiatrist Jon W. Draud […] speaks or consults not only for those companies, but also for Forest Laboratories, Sanofi-Aventis, Takeda Pharmaceuticals and Wyeth Pharmaceuticals (Pfizer acquired Wyeth in October 2009)

and How Much Money Does Your Doctor Get From Medical Companies? has a search tool for doctor payments and links to the database of payments. There are hundreds of Uloric related payments from Takeda in the database. I didn’t find any for allopurinol, but I was struggling with the search tool, so there might be some.

These people might be starving, or otherwise financially challenged. Buy as much Uloric as you can to prevent further suffering. On the other hand, a significant part of my advertising revenue comes directly, or indirectly from Uloric. Stop buying it so they advertise more!

I’m conflicted. 😕

[Keith Taylor]

Keith thanks for running the worlds? top gout site, longtime fan.

Ha ha! That’s put a big 🙂 on my face.

I think the Colcrys license has run out now, so generic colchicine should be available again. At least, that is the theory. Can any of my wonderful friends in America confirm this has reached the pharmacy shelves yet?

Just because I feel like trying to start an interesting discussion, I’m going to match you point for point, goutken. I’m not trying to start a fight – just trying to liven things up a bit:

• Purines are tasty, especially from dead animals. Too many are evil, but whose fault is that?
• Many foods and drinks can reduce inflammation. Turmeric in hot curry sauce is my fave.
• Sufficient fluid is vital, and I love water. I love 5 pints of cider more, and pain always seems less after that.
• Elevate your gouty parts, but also wrap to keep warm
• Gout can also get worse on 5-6 months of lettuce if you’re not controlling uric acid and the 5 bad gout foods
• Agreed! Life’s too short to spend hours at the stove. Wife’s left, so can’t delegate.

Anyone with allopurinol issues should get a 24 hour urine test at least 2 weeks after last allopurinol dose. My only allopurinol issue is spell checker wanted to change it to walloping.

The best uric acid lowering diet?
Eat food
Sufficient
Especially plants

Really good if you include the occasional rabbit stew.

If that doesn’t spark some responses, I’m taking a month off 😀

[Keith Taylor]

As I told you previously I was on 600mg of allopurinol

I can’t see that fact anywhere, so I’m worrying that I might be missing important information that will allow me to respond better. Best to keep this type of important gout information in your profile. Your profile is displayed every time you log in. The best advice I can give about controlling gout is to get into the habit of logging into this forum a few times a week. When anything significant happens, record the facts in your profile. Your profile has 2 powerful properties to help control gout:

1. It prompts you to focus on gout issues that are important to you
2. It helps other people who are responding to you. We can make sure our responses are relevant

I can’t get a proper handle on how many years your uric acid crystals have been building up, or how long you have been actively dissolving them. These are the crucial facts to assess if you should increase your allopurinol or not.

It’s very frustrating. Your doctor has the facts about your gout history, blood test results and allopurinol dose. Unfortunately, it looks like your doctor does not have sufficient gout knowledge to advise you properly. I have the knowledge, but insufficient facts to advise properly.

In my opinion, diet is not very important until the allopurinol dosage issue is sorted out. Diet changes have different effects depending on your uric acid levels. I like discussing these effects, but without the context of a uric acid plan, such discussions tend to be too random.

My worst fear is that I am making this too difficult, but nobody is telling me. Lots of people do complete their profiles here, then never start discussions. Others discuss general aspects of gout, without sufficient personal gout facts in their profiles to help make responses relevant.

Please somebody! Tell me what I’m doing wrong.

[Keith Taylor]

Great feedback Jason,

I think it’s time for me to nag you to log in before you post. Just click the Google icon near the top right (or Facebook, YouTube, Twitter, etc if you prefer). As a guest poster, you have to wait each time for posts to be approved. Logged in members only need the first post to be approved, then it’s automatic. Also gives you access to your Personal Gout Profile. That’s a very useful tool if you use it properly.

Here’s a great pain management plan for you:

1. Take one Colcrys at night
2. If any sign of painful inflammation when you wake, one more Colcrys and max strength Aleve dose.
3. If pain uncomfortable after two hours, max strength Tylenol dose
4. If painful inflammation after two more hours, max strength Aleve dose.
5. Repeat 3 and 4 until maximum daily dose reached (usually 4 times)

Never take more than 2 Colcrys in 24 hours.
See your doctor for max strength prescriptions of Aleve and Tylenol. Also discuss other possible combinations if you wish. It’s important to get gout strength doses, but also important not to risk overdose.
Personally, I often extended the two hour interval to three hours (or 2.5 hours) if I found pain was waking me through the night. The principles are the same for everyone, but each individual finds the best combination and interval.
The principles are:
Colcrys (colchicine) helps stop inflammation spreading, but does nothing for existing swelling or pain.
Non-Steroidal Anti-Inflammatories (NSAIDs) such as Aleve (naproxen) reduce swelling. Ibuprofen is also very useful and common, but many others are available.
Tylenol (acetaminophen/paracetamol) blocks pain. Other pain blockers such as codeine or tramadol can be effective, but acetaminophen is usually preferred as it is compatible with NSAIDs and also has an anti-inflammatory effect.
You must discuss this with your doctor who can provide gout-strength combinations that are safe with respect to your medical history. OTC doses simple tickle gout – you need gout-strength to snuff it.

Daily discussion here of your gout, your pain control package, your uric acid levels, your hopes, and your dreams will definitely make 2015 the last year you ever have gout. Beyond that, we can discuss the best lifetime strategy for easy gout control.

Life is fun.

Speaking of fun, Jason, I suspect a common IT background (please accept my apologies for a little harmless stalking). Let’s play at turning my 5 point pain control plan into common programming languages. Everybody is welcome to join in.

[Keith Taylor]

It’s good to know we’re getting somewhere, Lennon

If you test during a gout attack, uric acid levels are often artificially low. This is because some uric acid in the blood has turned to crystals, so the dissolved uric acid falls slightly. I’m not sure exactly how much, but probably around half to one point. So if you tested at 6 during a gout attack, the result a week or so later might be around 7. Anyway, it’s always best to think of a range, as uric acid fluctuates naturally during the day. That’s why gout professionals say the safe upper maximum is 5 because it might actually go to 6 at some point in the day (or 4 if you’re lucky the other way).

It’d be great to get your dad on here. If he’s not an Internet user, you could always set up an account for him, and type his messages. Lennon Roberts – worlds first Gout Secretary! I look forward to that 🙂

[Keith Taylor]

healeyguy, the answer lies in your uric acid levels and your attitude to gout pain.

Physically, what is happening to you is exactly what you describe in:

Is it possible that I have UA crystals in my hands that are not being diluted away? Should I increase the Allopurinol dosage and put up with the pain while my body get?s cleansed?

So, yes, you should increase the allopurinol dose, but please do it right.

Get uric acid test, with liver function and kidney function tests. Every time you get uric acid test results, log the date and value in your gout profile under “Other personal gout facts” and change “My uric acid level to the latest value.”

Increase from 100 to 200 for 2 to 4 weeks, then retest. Then we can review, but it might be good to go for another increase. My reason for suggesting that is because you’ve had gout for years. That’s a lot of old uric acid deposits hanging around, and the lower you get uric acid for a few months, the quicker you get rid of them.

In my experience, which includes gout pain in my hands, knowing your current uric acid level is below 300 gives you the confidence to tackle the pain.

Once you start to see every painful episode as some more crystals gone, it’s easier to cope psychologically. But, you also need to cope with the pain physically.

Consider daily colchicine for at least 2 weeks around every dose increase, then as required.

That can stop most gout pain starting, or stop it getting worse, but it often needs help. For that, I recommend ibuprofen, naproxen, or other NSAID, and you should discuss this with your doctor to get the maximum strength prescription for gout pain. At the same time, discuss with him a compatible pain blocker.

There are options in your gout pain control package, and we can discuss those in detail whenever you like. The important goal is confidence to know you can control the pain and get on with your life whilst allopurinol saves it.

That combination of confident pain control and confident uric acid control is magic. You take control of your gout, and life gets better every day.

Because your hands are a specific problem, treat them with more care. Try to avoid prolonged exposure to cold. If you flex them as you wake, you can take emergency action first thing at the first sign of a twinge. The specifics depend on which pain control package you choose, so let me know what you decide on, and I’ll give more specific advice on what to take, and when to take it, for maximum relief as you dissolve those old crystals.

[Keith Taylor]

I?m sure Keith will elaborate as he so eloquently does

Thanks Ron. Your response to Jason is masterful. I’m not gilding the lily.

Jason, I don’t want you to think I don’t care, so please write again if you still feel despondent. Your older self is going to love you for helping him enjoy life. I’ve no idea how old you are, so let’s say you’re in your 40s. That was my age when I knew I should take daily allopurinol, but avoided it. You are not avoiding daily meds – you’re avoiding future pain. I’m not happy with my 45 year-old self, but I celebrate my 53 year-old self every day. I smile at my 80 year-old self, knowing he is gout-free. You’ve done an even better job of loving your older self.

If that doesn’t help, let’s talk about the breaks from daily meds that you can look forward to, if it matters that much. Post here daily, so I can get to know you better. I don’t know if ‘hang tough’ or ‘love yourself’ is the strongest motivator to you. I do know that you have a good gout treatment plan. If you still can’t feel positive about that, let me know, and I’ll try and help more with making plans and living life. If you do feel more positive, let’s talk about making your good plan even better for you.

[Keith Taylor]

Lennon, I think I’ve got the picture now, but I’m a little bit vague on the exact date you stopped allopurinol, and the exact date of the blood draw for your uric acid test. Anyway, I’m going to proceed with my theory, and you can shoot me down in flames if I’m wrong.

300mg allopurinol twice a day is a great dose, in my opinion. 800-900 is the usual maximum. 600mg per day will have a significant effect for most gout suffers. It will get usually uric acid nice and low, which is what you need to get rid of old uric acid crystals quickly.

Allopurinol lasts a long time in your system. The usual advice is to wait 2 weeks after stopping or starting to get an accurate blood test. I’m going with the theory that you still had allopurinol in your system when the blood was taken. If this is right, then your uric acid level was low enough to allow crystals to dissolve.

As they are dissolving, old crystals can sometimes cause gout attacks. This can happen even if uric acid is low. However, the attacks tend to be shorter and less painful than gout attacks when uric acid is high. Also, because the volume of old crystals is reducing, such attacks become less frequent. There is no fixed time for this process. It depends how long you had gout, and how high levels were before allopurinol.

Earlier, you asked:

What lvl of uric acid do u have to be at to get gouty symtoms..was i misdiagnosed?

If you have had untreated gout for many years, when you start allopurinol, you can still get gouty symptoms for a few weeks, even though uric acid is low. Therefore, I don’t think you were misdiagnosed, but I would need to know your blood test results at the time of your gout diagnosis to be more sure.

Anyway, I’m proceeding as if it is gout, and you are experiencing the common problem of gout attacks during the early days of uric acid lowering treatment. That’s why most doctors recommend pain control. Personally, I don’t think your steroids are the best option for this type of pain relief. You are looking at more like 5 weeks rather than 5 days. For gout patients who don’t get uric acid as low as you did, they might be looking at 5 months.

What really matters is that you understand that these symptoms happen because old crystals are dissolving. That is a good thing. The pain will not last forever.

Latest science has shown that uric acid crystals don’t cause pain by themselves. They need other chemicals to stimulate the inflammation. It’s new research, so I don’t have all the answers yet. The best estimate is that Free Fatty Acids (FFAs) are to blame. As these are common in meat, this fits in well with your experience of less symptoms on a vegetarian diet.

This leaves me wondering what you want to do next. I don’t want to suggest options at this stage, because I’m not absolutely sure if my theories fit with your exact timeline. I’ll wait and see what you think about my ideas, and then we can discuss what you want to do next.

If it’s gout, I can help. If it’s not, you need to see a rheumatologist.

[Keith Taylor]

I’m getting closer to an explanation and a plan, but still need more info.

After being on the vege diet for a week i tested my uric acid blood level five days ago and it was 2.4mg/dl

A self test or a lab test? i.e. tested with a home test meter and a finger prick, or a lab test with blood drawn from the arm, or something else?

Also, 100mg allopurinol or 300mg allopurinol?

Less important is the name and dosage of the anti-inflammatory?

Sorry for being so nosy, but if I assume the wrong facts, I won’t give good advice.

[Keith Taylor]

Hi Lennon,

This is really interesting, but I’m surprised by that test result. What does your doctor say about it?

If it’s really 2.4 mg/dL then there are some explanations I can suggest, and we can soon work this out.

Can you give me a bit more history about when your symptoms started, when you went on allopurinol, and how much a day were you taking before you stopped.

The more information I have, the better. I’m looking forward to some more information so I can answer your questions properly. There are different explanations depending on your history, so I don’t want to confuse this by speculating until I get more facts.

[Keith Taylor]

Hi Kathy,

I notice you say you’ve joined here. You will get faster responses, and better information if you log in to GoutPal before you post. If you are experiencing difficulty with that, please click the orange Support button, and let my support team fix your technical problem.

I don’t know how long you’ve had gout, but it always gets worse as time goes by. I was just thinking about that earlier today in response to people (like me!) who leave it too long before treating high uric acid. We suffer in so many unnecessary ways. Delays to treatment mean gout attacks get more frequent, more intense, and last longer. Once we start uric acid lowering treatment, it takes longer to get rid of old crystal deposits.

Kathy, all I can suggest is to stop delaying, and start your allopurinol now. It takes several weeks, even months, to get rid of old uric acid crystals and remove the risk of more gout flares.

Colchicine never stops gout pain – it just stops it getting worse. But, nothing stops flares becoming continuous, so you end up with your lingering pain and inflammation. Colchicine won’t get rid of inflammation either, so you need to support it with anti-inflammatories in all but the mildest of attacks.

Colchicine is a potent poison, and it will upset most people’s stomachs to varying degrees. If it is too bad, your doctor might be able to prescribe additional medicine to help. Whatever pain treatment you end up with, the best way forward is to get uric acid as low as you can, as quickly as you can. After a few weeks, you don’t need anything for gout pain.

[Keith Taylor]

That’s a great question about febuxostat and allopurinol, Ralf. I’m left wondering why you ask, but the short answer is Yes!

Though the exact mechanisms are different, allopurinol and febuxostat both work by inhibiting our natural production of Xanthine Oxidase (XO). XO is the hormone responsible for producing uric acid. Therefore, even if one is an under-excreter, rather than an over-producer of uric acid, XO inhibitors will reduce uric acid.

Normally, unless genetic screening for high-risk groups suggests otherwise, allopurinol is the first choice. This is because it is cheaper and has a long safety record. Conscientious prescribing dictates that doctors test for kidney function and liver function, as well as uric acid, withing 2 to 4 weeks of starting any uric acid lowering treatment. They should also test whenever dose is changed, and always at least once per year. If physical adverse effects, or those blood test results show that the patient might suffer side effects, then the doctor can switch at will.

One related topic that I’ve never seen mentioned is whether you can take both at the same time. I think the circumstances that would involve such a choice would mean that the patient was a very special case.

[Keith Taylor]

Hi Rick, I like your interesting views on residual soreness after your gout flare.

I’m always interested when gout sufferers tell me that they want to avoid allopurinol in favor of healthier diet. To help you properly with this, I need you to log in to GoutPal, and start recording some gout facts in your Personal Gout Profile. I appreciate that you have given important information about your uric acid levels in February and March. Unfortunately, these facts become difficult to find after a few days, so it is much better to add them to your profile.

I look forward to creating some gout-friendly healthy eating plans with you. Please tell me more about your experiences with celery seed.

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