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Utubelite said:
I do not know how it works but I guess some people get gout flares with change in SUA levels much more than others.
I don't think anyone can be certain how it works exactly, as there are lots of factors.
Statistically, several reports show that gout flares decrease rapidly as uric acid falls.
Physically, it is complicated because a lot can happen once you go below saturation point, and this will vary from person to person. Where there are a lot of readily available uric acid crystals to dissoilve, then the very act of them dissoving will raise blood uric acid levels. This might leave half-dissolved crystals, and if there are enough of them, you could get a gout attack. This risk must be much lower with uric acid levels in the 3 to 4 range, compared to the 5 to 6 range.
Many people have deposits that have built up over several years, and become quite inaccessible. In these cases a sharp rise in uric acid level is unlikely, as relatively few crystals dissolve each day, and again the risk of a gout flare is low.
When lowering uric acid, by whatever means, it pays to be prepared for a gout attack, but there is no need to expect one.
It certainly isn't normal in my case, but I can recall a few occasions in knees ankles and elbows when I scan my memory. I cannot recall exact circumstances, but I will keep an eye out for it in future and see if any pattern forms. I guess I've just thought myself lucky that there is no pain.
Does anyone else know if there might be other risks involved here?
There is certainly very little online information about “painless gout”, but what I did find is fairly fascinating (to me). Those of a nervous disposition should look away now, as a picture follows.
The article “A painless, swollen finger (for 20 years)” comes from the LancetMarch 2008 :
A 94-year-old woman was referred to a dermatology clinic with a painless, smooth, hard swelling over the proximal interphalangeal joint of her left little finger (figure). The swelling had been present for 20 years. We could see yellow-white material under the skin. The patient had similar changes over the metatarsal joints of her feet, with overlying ulceration. Skin biopsy and aspiration of joint fluid excluded calciphylaxis, and confirmed that the patient had urate deposits (tophi)-ie, gout. Microscopy with polarised light showed negatively birefringent urate crystals. The serum concentration of urate was 530 mumol / L (normal concentration 60-360 mumol / L). We prescribed allopurinol. Gout mainly affects men, but this predominance is less pronounced among elderly people-in whom gout usually affects more than one joint, often affects the hand, and tends to develop gradually, with fewer acute attacks than in younger people. Nonetheless, painless gout is rare.
The accompanying picture (remember this is painless) has the caption:
Gout
(A) The swollen interphalangeal joint. (B) Negatively birefringent crystals. Birefringence is double refraction, and occurs with materials that are anisotropic: they scatter light unevenly. In pseudogout, joints contain positively birefringent crystals of calcium pyrophosphate dihydrate.
I can also associate many of the points that you mention, but I remain convinced that they are secondary to managing uric acid.
Alcohol, for example makes me much more susceptible to, and aware of, inflammation. We can often cope with high uric acid, and not notice the slow build-up of uric acid. But add alcohol and other inflammatory factors into the mix, and our bodies soon switch from discomfort to full on gout flare.
There are many complicating factors here, but the basic problem is that by associating lifestyle issues with gout pain we lose a significant element of control. We need to associate these things with uric acid levels, as this is ultimately the thing that matters.
As a practical explanation, the factors you list in your next to last paragraph may well have contributed to an increase in uric acid leading to crystals that caused a gout attack. Let us assume for the moment they are the only factors. If you knock them all out, you may still get gout attacks for a few weeks as old uric acid crystals dissolve. The missing measure is uric acid. This is of supreme importance in the real world because there are many other factors besides the ones you list.
To get any meaningful control over gout, you must control uric acid first. Whether you excercise control through drugs, diet or a combination, pain is secondary to uric acid control.
Wise words Richard,
I'm feeling a little guilty that I may have over-emphasized the risk of gout flare from allopurinol (or other urate lowering therapy). I wanted to make the point that allopurinol might not be an immediate solution to gout flares, so (as Richard says), keep taking it because it will work. The biggest reason for allopurinol failure is patients not taking it.
To clarify, on allopurinol, the risk of gout flares is reduced. There is a small risk of gout flares which gets less as weeks go by and disappears when all old crystals dissolve.
Gout flares with allopurinol are not compulsory, but uric acid testing is.
Very interesting!
The calculator on that page doesn't give an ideal weight as such, but if you keep moving the 'actual' weight towards the recommendation, it stabilizes at 189#, so “something like 190#” is definitely ideal. Reviewing the page, and it's accompanying 'Ideal weight' notes, this seems to be what I would term as a 'social ideal weight'.
The calculator also shows the medically recommended weight to be 156 to 205 lbs, which ties in with the gout weight tables I referred to – i.e. the much-maligned BMI tables. BMI has its weaknesses, but it happens to be the basis used for the analysis of the research I mention. That report actually associates BMI below 21 with a lower risk of gout. That is roughly the bottom 25% of the normal BMI range (where my 156 to 168 comes from).
I've mentioned before that my instinct pushes me to shy away from strict interpretation of BMI. In my own case, I simply cannot remember when my own BMI was anywhere near this low figure. Nobody ever accuses me of being skinny!
Much depends on social context. 'Skinny' in the bodybuilder's gym is 'obese' in the supermodel's changing room. Unsurprisingly, I get many more referrals to my gout websites from body-building sites than from catwalk sites.
I can see that my GoutPal.com page on BMI needs some updating to clarify medical recommendations and social acceptability.
Statistically, low BMI is associated with lower risk of gout. A later study in 2008 confirms “Risk of gout was 16-fold greater for BMI > 27.5 than < 20”. However, that clearly underlines the divide between what is medically recommended and what is socially acceptable. A BMI of 20 equates to 164 pounds for our 6'4″ friend, and 148 for myself and my fellow 6-footers. Figures which I am sure zip2play finds as incredible as I do.
It begs the question – should we aim to be skinny (i.e. socially, but not medically, underweight), knowing it gives a lower risk of gout?
I guess the sensible approach is to decide what ones own ideal weight should be. If it is achieved, and no significant change uric acid reduction results, then it's time to abandon the idea that weight loss is part of your gout management plan.
Having said that, weight loss is only one of the lifestyle factors associated with gout, so a personal plan incorporating all the factors might work where a modest uric acid reduction is required.
al_pain said:
I'm on day three of the latest, hopefully Allopurinol induced, attack in my left foot AND right ankle. Apart from the knee attaks of the past, this is the worst it's ever been. I literally can't walk.
In the past I've had great results with Advil but for this attack it's having no effect. So this morning I decided to start Zip4Play's colchicine dosage suggestion. I'm at my wits end and don't know what else to do. My one primary concern is that 1 tablet every hour seems like a lot – is it safe?
I'm in very serious pain and am willing to do through the diarrhea and nausea if I can feel comfortable it will work and is safe.
Can anyone let me know how it's worked for them?
Any help would be appreciated.
Details:
Age 46
Gour for 6 years
Started Allopurinol 6 weeks ago – Doctor started me on 300mg straight off
I'm wondering if 300mg is enough. You really need to get uric acid level checked with some urgency to see if your dose is OK. Ideally get down to 3mg/dL for a few months for the best chance of stopping dissolving crystals reforming.
I'm pleased to see you've promoted zip2play. Long overdue, but I have to confess to schoolboy sniggering.
In addition to Zip's advice, I would add getting the finger checked by a rheumatologist – the lumps may not be uric acid deposits.
Colchicine, or broth of bean.
Might help pain, and keep you sane.
You find out, that won't stop gout.
For that trick, try Uloric
Sorry al_pain for detracting from your story.
I hope the early signs of improvement continue. Looks like you caught it before your upper body got affected. Shoulder and elbow are bad enough, but wrists and hands are a real show-stopper.
Ripper, mate – that deserves a stubby or 3
I think you saved the best 'til last with uric acid.
To beginners – at best, many doctors know that uric acid causes gout, but not how or why. I'll assume that as a beginner, either your doctor does not understand uric acid, or he cannot explain it very well (otherwise, why would you be here?)
If you don't know – and control – your uric acid you are not controlling gout other than by luck and misjudgement. So concentrate on uric acid first and last, then all the other stuff has some relevance. As David says, you need a number – an assessment of “normal” or “slightly high” means absolutely nothing.
We can help beginners train their doctor's to understand uric acid better. You might not even need him for meds if you are around 8mg/dL, but much above that is extremely hard to manage on lifestyle changes alone (0.48 mmol/L according to the new uric acid calculator, but you might as well round that to 0.5).
Even if you rely on lifestyle changes, you must continue to monitor uric acid. The consequences of not doing so are so serious that one wonders why doctors do not make routine uric acid tests more available.
If it is your first uric acid test, chances are it has been done during or immediately after an attack. Uric acid in the blood is usually lower at these times, so your blood test is not representative. Logan, Morison & McGill reported an average fall of 0.12 mmol/L (2mg/dL). Note that this is an average, and individual differences can be higher or lower.
The good news is – if you do control uric acid – you can live a normal, and more enlightened life.
JohnnyBrew said:
I just wanted to let everyone know that my Dr just called and my uric acid level was 4.5!!!!!!!!!!!! and just over 8 months of painful flare ups and changes in Alli of 100 to 200 and now at 300mgs. I am hoping that I'm in the clear. It's been one hell of a ride and my uric acid level when I started this whole thing was 10.9 Its looking up for ol' JohnnyBrew.
Wish me luck and thanks for everyones advice
Best to all of you in '10
Bonza mate!
(I think I've caught something
)modogg said:
I am 6'4″ and 215 lbs.
Target weight from the gout weight tables is 156 to 168 lbs.
I exercise regularly as well. I am just getting over the longest attack (almost 2 weeks) in my ankle and foot. I have been to my doctor and he has prescribed Allopurinol. I will be doing the 24 hour urine test as well to determine if my kidneys are not efficient or if I am producing too much uric acid. Then my doctor will determine the dosage. So on to my questions. Again, I am new and am sure these topics have been discussed in great detail many times over. I would appreciate any and all help! Thanks and have a great 2010!
1) Do the home meter tests work if done correclty? Any particular recommendations?
Yes, they are accurate, but the weak link is taking consistent, good blood sample. Practice finger pricking to get a droplet size that matches (by eye) the size of the test strip before wasting strips. Be extremely methodical in the way you do the test.
2) If my doctor starts with 300mg, can I request a lower dosage and work my way up? I am relcutant to start too high as to not endure the harsh side affects right away. I have read a lower dosage combined with a proper diet is a good combination instead of a higher dosage and a slight change in diet.
- Start with 100mg to ensure you are not allergic.
- After a week increase to 300 or 400 depending on your uric acid level.
- Test every 2 weeks and adjust dose to get uric acid to around 3mg/dL.
- Test every month, extending to 3 months if stable.
- Continue until you have had no gout attack for 6 months and no visible signs of tophi.
- Optionally get joint fluid analyzed to ensure no crystals.
- Relax allopurinol dose to maintain uric acid around 6mg/dL for rest of your life.
If you have changed your diet effectively enough during the above procedure, you might be able to adjust dose to zero, but do not be surprised if you cannot get low enough with diet alone.
3) From reading the UDRP cylce, if I get my levels under 6 by natural means (proper diet), will it begin to dissolve the deposits in my joints as well? Or will I have to go on Allopuinal to dissolve these deposits.
Urate crystals dissolve when you get uric acid to around 6mg/dL. This happens however you do it – medication or lifestyle. The problem with dietary changes is that it is often hard to make enough difference, but this will depend on personal circumstances. It is impossible to get down to the 3mg/dL I mention in the allopurinol procedure, but that just means, as long as you can get to 6, that the crystal dissolving phase takes much longer.
3) If I have to go on Allopurinol, my thoughts were to take the Allopurinol until all deposits have dissolved and my levels are below 6. I want to eliminate any long term effects from leftover depostis (tophi). At which time I will cease the Allopurinol and monitor with proper dieting. Has anyone tried this plan and is it safe to stop the drug once the uric acid level has reached the intended goal?
See allopurinol procedure above. Once you are sure that all crystals are dissolved, you slowly reduce the allopurinol dosage, and test at each reduction. If you are very lucky, you might be able to reduce to zero. You must be extremely careful to never allow uric acid to rise above 6. It is not safe to simply drop allopurinol without careful monitoring.
4) I have also read Allopurinal is a short term drug and has to be taken daily. I have read where people take it when they binge into high purine foods and beer to reduce their levels during those days. I know this is not a recommended way to do it, but has anyone tried this as well to manage their condition?
Allopurinol has a short life, but it's active by-product, oxypurinol, lasts much longer. Dose cannot be adjusted on a daily basis. You need at least one week (which is why I say 2 weeks) between dose changing and measuring uric acid
Again, excuse any ignorance on these topics. I just want to get my facts straight before I get on the drug. If I can lower my UA to 6 without the drug and also benefit from the deposits dissolving, that would be my preferred route. Thanks for the advise and answers in advance!
Mohit (Mo) Mohindru
It's always a good idea to get your facts straight first. The non-drug route might be possible, but we do not know the biggest factor – your current uric acid number. Lifestyle changes generally only account for a couple of points, though I guess you might push this higher with a really restrictive diet and regular blood donation.
You have to get uric acid down to 6mg/dL – even lower for a couple of years to get rid of old crystals.
Without knowing what your current level is, it is difficult to be specific about what you can do, or even if it is realistic to try.
Some of the measures are:
- Lose weight gradually (the gout and weight loss tables indicate you have a good potential to reduce gout attacks)
- Increase daily exercise gradually
- Drink tea, coffee and skim milk
- Get more vitamin c (best from fruit or juice, but 500mg per day tablets have been shown to be good)
As this topic is a little old, please respond in al_pain's new topic Allopurinol, Headaches & Mild Heart Burn.
You've hit the nail on the head there, JohnnyBrew.
It's interesting to note that allopurinol is much more effective against purines from diet than it is against purines from our own body metabolism. It makes me wonder if there is any link between body weight and effective allopurinol dose.
The medicine choice is a difficult one. We've had discussions here before on the difficulties of getting nephrologist and rheumatologist to agree on what will control uric acid without compromising kidney function. At least you've got to stage 1, which is recognizing the need to lower uric acid – lets see what the medics recommend.
On the non-medical front, there is a host of things you can do. Lowering by 3 points without medication is hard, but depends where you are starting from. Weight loss and exercise, if applicable, can bring tremendous benefits if taken gradually. Tea, coffee and skim milk have been shown to reduce uric acid, as has 500mg per day vitamin C.
I can't buy into the herbal thing. I do believe that natural sources of uric acid reducing compounds exist, but getting them to a stage where they have any significant effect is another matter. The most effective part of the goutcure remedy is their advice on fluid intake and diet – do that without the goutcure, and you are likely to get the same results. The fact is that the product is only any good if it lowers uric acid, and this needs to be measured and monitored. Gout flares are absolutely no use as a measure – they can happen whatever you do until all uric acid deposits are dissolved and your blood uric acid stays at 6.
Medical or lifestyle – it all comes down to keeping uric acid levels in the safe zone.
Hi clayover,
All I can add to the excellent advice already given is to ask for a 24 hour urine test. This will determine if your high uric acid is due to under-excretion or over-production. Allopurinol or febuxostat work for both, but if you are an underexcreter, probenecid is another choice.
The gout/injury relationships can be hard to work out.
On the one hand, gout attacks can be induced by trauma – presumably resulting from blood flow restrictions at the injury site.
On the other hand, urate crystals weaken tendons, cartilage and bone – that weakness can raise the risk of injury if joints are stressed.
bb1vince said:
hey i was the one that made this post can someone link it somehow? or how doe sit work fror me?
Sorry, Vince, but old posts submitted as guests remain separate. Due to all the problems with guest posts, I have had to stop that feature.
Thanks for registering.
I experienced sciatica pains on a few occasions. I put this down to straining my back/pelvis from limping with gout in the knee and/or foot. Maximum effort to walk properly cleared it up, so I assume my assessment was correct. In advanced gout cases it is possible for the sciatic nerve to be compressed by uric acid deposits, but I'm pretty certain that by that stage gout would be very obvious.
I've been missing the antipodean language lab
. Chooks = chickens.Juicing has always looked like a good idea to me to get the best out of the veg, but I have yet to get into the habit. Those who know, advise me that it does take some experience to get used to taking vagetables this way, so your practical advice is very welcome.
When you could not take allopurinol, you had 2 options.
- Get 24 hour urine test to assess suitability for probenecid or other uricosuric.
- Start an allopurinol desensitization schedule.
There is now the third option of febuxostat (Uloric, Adenuric).
The unspoken option of ignoring uric acid is what leads to tophi and crippling joint damage, with possible kidney disease, heart disease, stroke and diabetes thrown in. Colchicine and other painkillers without attention to uric acid levels only serve to make matters worse, as they mask the danger until it is too late.
From what you have written, I would assess your situation as critical, and no amount of herbal or kitchen cupboard cures are going to save you.
A serious session with a good, gout specializing, rheumatologist is your best way forward.
Gout is simply not that simple.
You might be able to use gout diet as part of a gout management strategy, but you have to start with assessing uric acid level.
Your BMI, typical current diet, exercise levels and iron load are also important in dietary terms. Gout history is also crucial (how many attacks, when was the first, how frequent now???)
Any quick and easy measures are bound to be quick and easy failures, so spend some more time assessing your current status. We need more information here to help you develop a plan.
theres are the symptoms i get for sure sure, It hurts when i sneeze or cough and when its cold.
- After standing or sitting
- At night
- When sneezing, coughing, or laughing
I do recall having back pain before like real bad ones. I googled sciatica and that looks really legitimate to where my pain is.
Though your uric acid level puts you at high risk of gout, it is not proof.
Sometimes gout diagnosis is obvious, but often it can be misdiagnosed because there are a bunch of other conditions that give similar symptoms.
The true test, where there is suspicion of gout, is to analyze joint fluid. This really should be done by an experienced rheumatologist with local testing facilities. You do not want someone incompetent drawing joint fluid, and you need to get results tested fast, as uric acid crystals can be unstable.
