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There are some excellent points on that page, but there is also some outdated and misleading stuff.
I find it all a bit difficult to read, as many points appear to be grouped randomly. Because of this, I haven’t (yet) analyzed everything but:
- The purine information still includes advice to avoid some vegetables, which is now generally discounted.
- There is a pointer to acidity of foods that has absolutely no nutritional value – it is only relevant to canners who need to balance the pH of food for packaging purposes.
If there is anything on that page (or other sites) that isn’t better on GoutPal.com, I’d appreciate the heads up so I can improve it.
Completely personal view this time, and so I will precede this with the usual advice that you should discuss this with your doctor.
When starting with allopurinol, you go through a phase of adjusting the dose to get uric acid down to target level. So, in your position, I would adjust allopurinol dose to match normal diet, not the other way round.
I.e. Eat and drink as normal (assuming it isn’t posing other health issues) when you are establishing the dose you need. Because allopurinol should allow you to live your normal life.
roosterwes, please consult your doctor on this.
I’m fairly confident that I can differentiate between good advice and bad advice on gout, but I really do not want this forum to get involved with other conditions (unless they are gout-related)
@Dan – The uric acid tester is covered in the first post of the Uric Acid forum. There are also other discussions dotted around. It is good, but no substitute for proper medical care. I would always recommend the rheumatologist option whenever things are not straightforward. The meter's are great if you want to stay assured between doctor visits, and don't mind the expense.
@Utubelite – good ideas, and nice closing paragraph. A man's gotta know his limitations.
I tried to post the following comment on the black bean broth article, but I couldn't get past the registration process:
A fair summary of the recipe that you have taken from GoutPal.com and the gout forum. It would have been nice for you to acknowledge your source.
I've seen that beer study before – interesting, but only relevant if you do your own experiment.
No direct experience, but I feel that when you have given your body a big change like this, strange sensations and twitches are not unusual.
The most important thing you can do is focus on your uric acid levels for a few months. Make sure that within a month of starting allopurinol you are way below 6mg/dL, and keep it there for at least 6 months. This will help clear all the old crystals.
If you are still having twitches after a few weeks, it merits further investigation, but don’t let it distract you from controlling your uric acid numbers.
There is something seriously missing from this thread.
I've already mentioned elsewhere that it does not make a great song but…..
Allopurinol and uric acid numbers
Aloopurinol and uric acid numbers
Go together like a horse and carriage.Told you it wouldn't work, but I hope the message isn't lost in the tomfoolery.
Allopurinol ONLY helps gout if you use it to lower uric acid levels below 6mg/dL
What are your numbers, algout?
Oops! On second thoughts, this does not quite work.
You can have one without the other.
Uric acid test without allopurinol is perfectly OK, depending on your management plan.
Allopurinol without uric acid test is definitely not OK.
You MUST know your numbers, especially if you are taking meds or making lifestyle changes to reduce uric acid.
nokka said:
Each time we increase dose, don't we also increase the chance of having an attack ?
On the contrary, everything I have seen points to the fact that gout flare risk decreases as uric acid decreases.
Unfortunately, all the studies I've seen compare uric acid levels above 6 mg/dL – nothing to compare 6 with 5 with 4 with 3. E.g “Gout in the UK and Germany: prevalence, comorbidities and management in general practice 2000–2005″.
[Part of]Table 3 Association between serum uric acid (sUA) level and the number of flares
sUA level* Odds ratio
(mg/dl)
6–7 1.33
>7–8 1.49
>8–9 1.71
>9 2.149*Conversion: sUA (mg/dl) ×59.48 = μmol/l.
Something at the back of my mind is suggesting that the trend continues to decrease in the 6 to 3 range, but I cannot find it.
Anyone else seen anything?
It would help to have the uric acid numbers.
Everything you've said indicates gout, but only a proper examination would confirm this or prove otherwise.
If you are not happy, you absolutely must insist on seeing a rheumatologist. Indomethacin will ease the pain, but do absolutely nothing to halt your gout.
I agree 100%. Allopurinol has done wonders for my symptoms – which have been very similar to yours. Get a good rheumatologist, visit regularly and have your uric acid measured (lab) prior to each visit. Good luck!
nokka said:
I see. I think
Makes you wonder all this. If you're a bit high and your crystals don't get disturbed too often, well maybe you'll not have an attack for some time. If you get your figures down to 6 – 6.5 you have a bigger chance. Food for thought !
This is also my view. I know my levels are high (not currently monitoring so don't know exactly), and I have several coping strategies for when new crystals form. I cannot be certain, but prior measurements suggest, that I experienced old crystals dissolving, and I found this much worse. I know this isn't very scientific, but it is logical that reaction to new crystals forming will be less painful than reaction to crystals dissolving and reforming. “bigger chance” is key – there are few certainties.
Clearly below 6 at all times is the place to be. I'm averaging 6.0 at present and have only been on the drug for a week and a bit. It may be sensible to move to 200mg per day, though would like to see where I stabilise with the 100mg first. I've read it can take a couple of weeks before the drug takes full effect.
2 weeks is probably a maximum. Most effect of a change is the first 4 days, with effects diminishing day by day. Incremental changes in the second week are not significant.
I'm not particularly averse to moving to a higher dose; if that's what's needed, that's what's needed. But I am mindful of increasing dose when overseas and I especially do not want to cause a major flare while away.
Thanks again for all your inputs.
I think it wise to adopt a plan you are comfortable with. As we are dealing with chance, you will never be certain, so stick with your plan, and avoid worrying about different options.
There is no way to avoid the risk, though I hope you avoid the actual. Be sure to have the pain relief on hand. Early action seems to be the key, in my experience, so if a twinge comes, pop the pills with copious water, and keep warm and active.
Great issues nokka,
On the first point, the issue of 300mg v 100mg is separate from the comparison between allopurinol-taker, and diet-manager. Once you have made the decision to take allopurinol it is a question of how best to take it, and zip2play's advice is spot on.
On your second point, you are absolutely right to say that between 6.0 and 6.8, nothing much happens. Natural fluctuations mean that either of these readings could mean that new crystals are forming, old crystals dissolving, or no change. No number can be interpreted precisely because many other factors come in to play. What is certain is that, the nearer you get to 6.8, the higher your chances of uric acid crystals forming. This risk reduces as your uric acid level reduces until, at 6mg/dl, the risk of new crystals forming is very, very slight unless you are very, very cold.
Moving on from that generalization, you need to consider your own situation. On allopurinol, once you have proved it is safe for you, your plan is to stabilize uric acid around the 6 mark. This is easy if you've only had gout for a short time, as the pool of existing crystals is too small to have much effect. Where you have substantial deposits, these will affect the early months of allopurinol significantly. Dissolving crystals can push the levels up again, and there is a hellish place around the 6-6.5 mark where you are almost perpetually dissolving and recreating crystals.
That is why it pays to aim for 5mg/dL. If you want to get rid of old crystals as fast as possible, aim for 3.
On allopurinol, you have that choice. A diet-manager can only aim as low as possible and accept that it might take years, if ever, to get rid of old crystals.
The 24 hour urine test measures your total uric acid clearance in a day. As far as I know, there are no varieties of this test – just a standard test.
It is normally done prior to treatment as part of your uric acid metabolism assessment. It is by no means common, and most doctors opt for the simplest and best solution of allopurinol if there are no confounding factors.
Unless you are having problems with allopurinol, or are not getting your uric acid level below 6, I wouldn’t worry about it.
The 24 hour test will be pretty meaningless unless you take a second test after so allopurinol for 2 weeks.
sirlimpsalot, I'd recommend you talk to your doctor about moving to 400mg allopurinol for a few months.
This will speed the period for getting rid of old crystals. After 6 months without a flare, you can then move to a maintenance dose to keep you round the 6 mark
Uncomplicated gout can be treated by some general doctors, but your husband must see a rheumatologist.
Even the rheumatologist might have to consult with a neprologist (kidney specialist) to get the right medication package.
Controlling uric acid is absolutely vital, but only an expert can conduct the right tests and interpret the results correctly to make sure the right treatment is prescribed.
Experience from other contributors suggests that you should ask the rheumatologist about their experience with treating gout / nephrotic syndrome patients before you consult. These complications are beyond some specialists, and way beyond most family doctors (though some good ones have consulted properly to learn correct procedure).
It is definitely beyond online advice, though we will try to explain procedures and terminology where we can.
Please book that appointment now.
J. Barleyworn said:
Do any of you think I'm overreacting? Could I have possibly stumbled onto a cluster of bad information about Niacin?
I certainly do not think you are overreacting, nor do I think you are chasing your tail online.
There are clear issues with niacin (aka nicotinic acid or vitamin B3) and gout. That is not to say that niacin should never be given to gout patients – simply that any medication plan should consider all known conditions, therefore it is wholly inappropriate to prescribe niacin without co-prescribing something for the uric acid.
I believe your immediate course of action should be to write to your doctor outlining your concerns and asking for an immediate response.
I also think you should consider seeing a rheumatologist.
If you are seeking information online, it pays to stick to sites like Google Scholar and PubMed – merely relying on standard search engines reveals far too much sensationalism, myths or even downright lies. Other sites can give clues, but always check scientific references back to PubMed. Often they either do not exist, or have been quoted out of context. Wikipedia is poor in this respect, but is often a good source of reference material (i.e. start with Wikipedia, but checkout the references and share good sources, not crappy wiki summaries).
Even using good scientific research sites you need to be careful. As I looked for information about niacin and gout I found “Drug-induced gout” by J T Scott. It starts off well enough:
A number of pharmacological agents can induce hyperuricaemia, and sometimes gout, usually by interfering with the renal tubular excretion of urate but also in some instances by increasing the formation of uric acid. Alcohol is well known to have this property and in recent years diuretic-induced hyperuricaemia has become a global phenomenon. Other drugs which can cause hyperuricaemia are salicylates, pyrazinamide, ethambutol, nicotinic acid, cyclosporin, 2-ethylamino-1,3,4-thiadiazole, fructose and cytotoxic agents
Fair enough, but it then goes on to say:
A special type of 'drug-induced gout' can follow the rapid lowering of serum uric acid by allopurinol or uricosuric drugs.
That is not 'drug-induced gout'. It is part of the treatment of the disease – the early stages of uric acid lowering treatment can cause a gout flare. Gout is already there – it is not being induced by treatment, but immune response induced pain can be a temporary side-effect of correct gout treatment.
rucyrius said:
.. anyone else have this sort of movement to different parts of the foot..
Yes, and not just to the foot, but different joints in the hand, shoulder, etc, etc
I've not experienced diclofenac, but there are enough reported studies of taste masking experiments to suggest that it has quite widespread taste effects.
It is unfortunate that uric acid deposits weaken ligaments and may well have contributed to the damage. I hope it heals well.
As zip2play says you need to increase the allopurinol dose as soon as you can. The last thing you want is more crystals forming around the surgery site. Aim for uric acid level below 6mg/dL, and if you can hold it around 3 for a few months you should see significant improvement.
Good points. And I fear we are wandering way off topic now, but looking at uric acid from the urine point of view seems very different, and I'm fascinated to learn more.
These large values, especially the 220, are very much of the test tube than in vivo healthy humans. However, they do emphasize the importance of pH when considering the kidney and beyond.
To maximize uric acid clearance, the practical implications of the effect of pH on solubility underline the importance of alkalizing the urine. Flushing through with plenty of fluids should ensure the dreaded supersaturation disaster never gets near.
This is also making me think about blood uric acid. I know that our bodies keep blood pH very tightly controlled between 7.35 and 7.45. A very narrow range, but it is a logarithmic scale, so the difference could be significant. Now, I somehow need to find the solubility of uric acid at the extremes of this range at normal blood temperatures.
Anybody know where to look?
How lovely
Thanks for the video (I edited it to get the right code in – you need to click the HTML button to paste this type of link).
Much learning for me today – I now know what multinucleated giant cells are.
J. Barleyworn said:
The whole experience since the day I was diagnosed has thrown me into a state of depression that is really testing me. I really feel for you folks who have experienced years of multiple flare ups. I guess I'm still awfully new to this and shouldn't assume that won't be my experience. Actually that's part of what is fueling the depression: I feel like the sword of Damocles is constantly dangling over my head. I know how much worse things could possibly get.
I feel that this aspect of gout (in fact, most health problems) is greatly increased by anxiety caused by fear of the unknown.
Pain is a strong stimulus, and fear of pain is often worse than pain itself. Living in this constant state of anxiety is not good for your health, and my view is that you need to take control.
The good news is that your uric acid levels are not massively high, but I believe you need to take regular tests to make sure they do not continue to rise. You are not at the point where most doctors would consider urate lowering treatments.
Your uric acid levels do not need to come down by much to get to a safe zone, so it might be possible to do this through lifestyle changes.
The most important thing is to lose weight, as various studies have shown that this can lower uric acid. Do this gradually, and combine it with increased exercise – but not to the point of exhaustion. Regular exercise reduces your baseline uric acid level, though levels will rise during exercise.
Ensure good fluid intake which prevents increased uric acid concentration from dehydration, and also helps the kidneys excrete uric acid. Alcohol is a complex beast, as it raises uric acid production, but it also raises excretion. Ending a night out with plenty of water is a hard habit to form, but a good one for the gout. Milk is another good choice, and I have a report that I will summarize soon that indicates good effects from orange juice.
Your diet seems good, though it might be good to monitor iron content, as excess iron encourages our bodies to increase uric acid production.
If you can lose a pound a week and improve exercise whilst maintaining good hydration, you should see results in 2 or 3 months. I recommend that you keep a weight and exercise log, and then get your uric acid tested again. There is nothing like getting back in control to ease the black mood.
zip2play said:
Yu cites a normal range between 16 and 100 mg/dL.
YOI, can anything approaching 100 mg./dL come out as anything besides solid chunks of urate?
I'm still very much the learner on this topic, and today I learned from “Solubility of uric acid and supersaturation of monosodium urate: why is uric acid so highly soluble in urine?” (Journal of Urology):
the increasing solubility of uric acid with the rise in pH depended solely on the increase of urate anion. As much as 220 mg./dl. of uric acid could be dissolved for 24 hours at pH 7.0. But following seven-day incubation the total dissolved urate concentration decreased to 16 mg./dl. due to NaU crystallization. The stability of NaU supersaturation depended not only on the concentration of sodium and urate anion but also on time and pH
220??!! are they taking the piss?
Traditionally, juniper is a diuretic, and this has been confirmed by a recent Russian study, who also note anti-inflammatory properties. As with all natural products, active elements vary widely between species, climate, and especially preparation methods.
One reference that I can read confuses diuretic with uricosuric, which may be where the “good for gout” myth started. Diuretics increase urine output which can result in higher blood uric acid. Uricosurics increase the uric acid concentration of urine, thus lowering blood uric acid.
Of course, the diuretic effect is probably so weak that it will be offset by the fluid content of the tea, so it probably has very little effect either way. Like so many of these things, as a flavoring (tea or gin) it really has no significance for gout.
I agree with zip2play's assessment that your continuing discomfort is most likely to be from existing uric acid deposits. I think you are correct with “My hope is that all the pain now is really gain because the stuff is dissolving.”
I'm encouraged by your current blood uric acid results. You will probably need a few more weeks to clear the old crystals, and some, as in zip2play's experience, may remain long after they cease to cause pain.
Urinary uric acid is interesting. I've only had time to look in-depth at one study (Intermittent elevation of serum urate and 24-hour urinary uric acid excretion — Yu et al.), but that has some interesting data, and references to similar studies.
Most analysis is done on 24-hour excretion rates, as this is the best indication of how good your kidneys are from a gout point of view. Your first reading appears to be above normal, but Yu points out that there are large changes from day-to-day and argues for an upper normal limit of 1000. My interpretation of your clearance results is that the first test showed you were capable of normal uric acid excretion – i.e. an overproducer rather than underexcreter, and therefore a good candidate for allopurinol or febuxostat. Your later results are lower, I believe, because you are now producing much less uric acid thanks to the febuxostat.
The concentration of urinary uric acid is a much wider range than for blood. Our bodies have many control systems for blood to maintain temperature, pH level etc, but urine can vary enormously. Yu cites a normal range between 16 and 100 mg/dL, so your first result was normal, and your later ones again support the view that febuxostat is doing it's job. I can only assume that with these numbers, your risk for urate stones in the kidneys is very low. However, I'm only basing this on a very small amount of research, so the general advice of plenty of fluids and alkaline urine still applies.
Thank you, John, for your fascinating question and interesting facts. Now do me a favor, and login before your next post so that others can see your great contribution without waiting for admin approval
Yes, there was more to the diagnosis.
I had my hand aspirated (fluid taken from the swollen joint with a needle) a couple different times. First time there was no crystals. the second time MSU crystals were identified in the fluid.
I also have the tophi on the helix of my ear – not terrible, but there are about 6 or 7 small hard bumps – like shot pellets on the edge of my ear. I have never had any break through the skin. But, they look like classic gout tophi on the ear.
I have had my doubts about the diagnosis over the years, but with the tophi on the ear, the crystals in the hand…it seems accurate.
In my 20s and 30s, I drank plenty of beer – pale ale.
My mom tells me that my grandfather (who died before I was born) couldn't make fists – the belief has been from working his farm so hard. My uncles worked the farm too (with more modern equipment), but still a lot of hands on labor and they can may fists. I work a computer keyboard and can't make fists. I suspect my grandfather may have had gout.
I never had any RA factors show up in my blood – so that was ruled out.
Your right about the blood level uric acid – mine has never been above 6. Strange….
Thanks for the reply and the information on the site. I really appreciate it.
Hi John, I've moved your message here from a topic in gout cures, as it really deserves a new discussion.
I'll be back later with a view on urine uric acid levels.
What concerns me for now is your starting blood uric acid level. Not the number of a gout sufferer that I recognize. Was there more to the gout diagnosis?
I would have thought might make it worse, more accurate than will make it worse.
Be sure to get uric acid tests 2 weeks after you start allopurinol, to adjust the dose if necessary to lower uric acid to a good target – you don't want to be on that cocktail of pain-relief long (some might say ever).
rucyrius said:
i have such an aversion to taking one of these drugs as i have heard they both can cause kidney or liver problems…
I thought the medical view these days was that the lowering uric acid was massively beneficial to kidney health.
The liver situation is more complex. I have seen concerns about the effects of febuxostat (Uloric/Adenuric) on the liver, but there does not seem to be a conclusion yet.
There have been reports of liver problems with allopurinol, however these vary greatly between individuals. Some people have reactions agains allopurinol and others do not. Where the reactions do happen, they appear to be reversible once allopurinol is stopped, except in those cases that prove fatal. On the other side of the coin, a recent report (Allopurinol, an inhibitor of uric acid synthesis–can it be used for the treatment of metabolic syndrome and related disorders?) states:
This article presents a review of reports, mainly of recent studies, on the efficacy of allopurinol in various diseases and explores novel potential uses of the drug. Important novel and potential uses of great interest include metabolic syndrome (MetS) and related disorders, chronic kidney disease (CKD), nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH). Ischemia-reperfusion injury and mucositis, encountered as adverse effects of cancer treatment, have also been under investigation as potential targets for allopurinol
Like many things in life, there are risks on both sides – risks if you take action, and risks if you leave the problem untreated.
Much will depend on what your uric acid levels are, and if you have other alternatives for reducing uric acid.
I just got back from the doctor to get some help with my gout. He gave me prescription to te following:
- Prednisone 4mg – to reduce the flare up
- Allopurinol 100mg – instructed not to take until the flare up is gone, or it will make it worse
- Vicodin – For Pain Relief
I was taking indomethacin 50mg, and he told me to stop because it's going to give me ulcers if I am not careful. Coming into the house, I accidentally bent my foot while taking my shoes off. I swear I thought I was going to keel over and faint from the pain.
Let's hope the prednisone works.
