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Few more things to add:
1. My pain during walking has been mostly on the balls under the big toe joint and on the top side of the toe where it bends.
2. The big toe joint still feels pressure when I put my foot down(Load it)
3. When I walk, first few steps, it pains on the lower side of the joint but then after few steps, it becomes better
4. I feel twings in the foot near the big toe area, joint and the balls under the toe.
In summary, not a happy situation yet though much improved. I am puzzled if it is due to injury ( which understandably takes time to recover) or just prolonged gout, which is taking its own time and adding to the agony.
I have no visible tophy anywhere in the body or in the X-rays. The X-rays do not show any bone erosion yet, except for one very small edge(negligible marks). I have no pain in any other joint.
Michael said:
It hurt so bad that I would put ice or frozen towels on it. I have read since that cold is bad since it thickens the blood and causes more crystals to form.
[….] I was told by my Dr. that Allopurinol is good for controlling uric acid but can actually precipitate a gout attack and that it should not be used during a gout attack.
M
Ice is OK for a ten minute application, but get the joint back up to temperature afterwards (warm towel) and keep affected joints warm at all times. Temperature affects the point at which crystals form (the saturation point). The lower the tempearate, the lower the saturation point.
Allopurinol is recommended not to be STARTED during an attack, but if you have started, you should not stop it.
UTubelite said:
Where should I post my details (history) of the case? It is an interesting (and agonizing) case.
I'm looking forward to it.
I think a new topic in Your Gout would be the best place.
First, thanks for the advise to GoutPal Admn. I read the article on need to reduce the Uric Acid level and that is why I have now 200 mg of Allopurinol. Hopefully, it brings it below 6 otherwise I will increase it further. I have no doubt in mind that I have to work on getting it below 6, close to 5 being the target.
And to Zip2Play, you are right. It is really a pain to find that most doctors who treat us are unware of the facts, due to which many of us are suffering.
Mine is a typical example of missed diagnosis, and I have stayed at home for close to 3 months as I was not able to wear a shoe even. Things are getting better now.
Where should I post my details (history) of the case? It is an interesting (and agonizing) case.
Welcome UTubelite,
Firstly, the reference range is meaningless. It's just an average, and one that includes gouty people. Therefore the upper end is real gout country, especially for anyone who has had gout.
Whilst it's OK to maintain uric acid level at 6mg/dL, this is only true if you satisfy BOTH the following conditions:
- sUA readings consistently BELOW 6mg/dL for 6 months (at least 3 consecutive readings).
- No gout flare during that 6 months.
If you do not satisfy these conditions, then please refer your doctor to Hershfield and prior similar research, as mentioned in my Lowering Uric Acid article. You need to get rid of urate buildup in your body tissues as fast as you can, and the lower you can get uric acid, the faster this happens.
Got gout attack on Memorial day weekend after I injured my right big toe hitting it very hard against the bedpost. Will write more details in separate related forum. Got complex due to hairline fracture and inability of doctors to diagnose correctly.
After never ending agony for 2 months, in which gout continued and so the fracture pains( they diagnosed it after 2 months), did uric acid test July end. Got Serum uric acid 9.2. Other kidney and urine tests were normal.
Started 150 mg Allopurinol and Colchcine .6 mg once a day. Retested after a week. Uric acid 7.0( reference range 2.0 to 8.5).
Retested Aug 21, after 3 weeks of Allopurinol 150, Uric acid 6.6.
My foot is still not free, I walk very slowly and getting treated for hairline fracture( which has healed mostly) and gout both.
The walking is still painful and not very balanced. I have increased the dose 200 mg today. The doctor seems to see no need to go Uric Acid under 6 and feels happy with my reading saying my pain was due to residual of the fracture and non-movement of thumb for almost 3 months.
I have not taken any pain killer in last one month and there is no pain when foot is resting.
Will keep posting how things go further.
Change doctor immediately. This one is a menace, and if he cannot understand the basic prescribing routine for allopurinol, what other aspects of your boyfriend's health are at risk?
This is NOT a trivial issue. Many of us who regularly contribute to this forum have spent a lot of time researching how and why allopurinol works. I do not expect a general practice dotor to understand complex issues regarding every disease and medical condition he encounters, but this is basic. The medical equvalent of kindergarten.
Once started, allopurinol should never be stopped, unless it is causing other health problems (which is extremely rare). This is so fundamental, so covered in the labeling and orescribing guidelines, that only a fool can miss it.
Who wants medical advice from a fool?
I'm prepared to be educated on halitosis and gout. I do not know of any direct link. However obesity and alcohol intake are associated with both conditions, so is that relevant?
Wow. English lessons as well! Is there no end to this man's talents?
Shame about the numbers, Zip, but at least now you know.
The bad news is, if the genes say so, you are never too young for gout.
The good news is, if you see a sensible doctor, it is very easy to manage.
You must get your uric acid level below 6mg/dL. My latest article – Uric Acid Numbers – tells you exactly how to do it.
headusher said:
He also told me that Allopurinol shouldn't be used until all the gout symptoms are gone for 2-3 weeks otherwise Allopurinol can start a new attack.
This is against everything I've ever read about allopurinol. There are many accounts of allopurinol triggering a gout attack, as with any uric acid lowering therapy. This can happen in 2 days, 2 weeks, 2 months, or (if you really don't get your uric acid numbers right) 2 years.
It is not the medication that does it, it is the fact that uric acid is lower, therefore old crystals start to dissolve, therefore they shed the coating that the immune system tried to kill them with, therefore the immune system sees them again, therefore you may get a gout flare.
You need to refer your doctor to Allopurinol Medication: Why It Hurts To Get Rid Of Gout.
The only explanation that I have ever seen for delaying allopurinol is that the patient is unlikely to continue with it if it does not improve their gout pain. A good explanation and some appropriate pain relief would forestall such a patient reaction.
zip2play said:
It's so tough when you have to suffer without a proper diagnosis. I guess I was lucky that my 4th attack was the dreaded podagra that a BLIND doctor would have clearly “seen” to be gout. Seems with regard to gout there are MANY blind doctors out there.
Perhaps they are just number blind.
This has prompted me to look more closely at uric acid numbers, with a new gout topic to discuss your uric acid number.
There are doubts about the exact nature of the link between IgA nephropathy and gout. Some suggest that IgA nephropathy, where you get Iga protein deposits in the kidney, affects the way the kidney handles uric acid, leading to raised uric acid levels in the blood. Others believe that uric acid crystal deposits in the kidney cause Iga protein to build-up.
In practical terms, management requires the skills of both the nephrologist, and rheumatologist. The goal is to reduce your uric acid level below 6mg/dL. If you are not on any other medication, allopurinol is the obvious choice, and as that situation is quite straightforward, I would expect the nephrologist to be able to manage this. If you are on other medications, or if there are other complications, the nephrologist and rheumatologist may need to work together to ennsure that treatments do not conflict.
Whatever happens, I repeat, you must get your uric acid below 6mg/dL and get regular tests to keep it there. Some pain relief may be necessary for a few months until all uric acid crystals have dissolved.
I have IGA nephropethy and have just been diagnosed with the Gout. I want to know how this is related to my kidney disease. My nephrologist hasn't called me back yet this am to tell me to come in or what he thinks but I think this is related to my kidney disease. I had gastric bypass to reduce my weight from 330 and I'm 6'5″…I now weigh 193 after 7 months out from the surgery. I lost too fast because I had a gastric ulcer and didn't know it…I was in ICU in March because I fell out from the loss of blood and my wife rushed me to the hospital and I had already lost 4 units of blood and received 2 emergency surgeries and a full transfusion before finally recovering. I had thought the gastric bypass would help my kidney's more and it has cured my high blood pressure problem caused by the kidney disease…I don't even have to take high blood pressure meds or the kidney meds they had me taking…but this gout is very painful and I know my kidney's are acting up because of the odor and color of the urine. Just wanted to know the relation between IGA and GOUT
From your descriotion, it is clear that you have gout. The 2 big questions are:
- Is the gout under control?
- Do you have a co-existing condition?
The first, as there is doubt, requires frequent uric acid tests, and confirmation that uric acid is staying below 6mg/dL. I think every 6 months is not enough until you are without attacks for six months. Maybe every month or two, then gradually relax if the level stays low. If it creeps above 6, you may need to increase the dosage and temporarily increase test frequency until you get back to a stable state.
Remember, even though your hyperuricemia has been described as asymptomatic, the reality is often that you have experienced a long slow build-up of uric acid crystals. It sounds like these are now making there presence felt, and may take some time to dissolve completely.
Other conditions are not uncommon with gout. The only way to be sure is to examine fluid from the joint, usually by a rheumatologist. This might reveal pseudo-gout or perhaps an infection, or perhaps something else. It will also confirm if there are still uric acid crystals in the joint.
zip2play said:
Too bad if they didn't analyze any of the residue from those stones. Maybe we can PRESUME they were urate?
Why no allopurinol?
Heh, heh.
This reminds me of a Siemens presentation that I watched online recently. A technical presentation / sales pitch of the DECT technology we have spoken of here before, that allows visual imagery of uric acid crystals in the body. This particular pitch was for an earlier version that could use a non-invasive scan to differentiate between urate stones and others. The pitch was the cost and time savings that could be made by identifying urate stones (reliably dissolved with allopurinol, water, and maybe a pinch of bicarb.) from others that might need surgery.
Imagine the audience looking askance: “What is he on about? We just blast the buggers and hope for the best.”
Just taking this a step further, the allopurinol study is cited in Canadian Cardiovascular Society Consensus Conference recommendations on heart failure update 2007: Prevention, management during intercurrent illness or acute decompensation, and use of biomarkers
Those recommendations include:
Patients with heart failure are at increased risk of gout due to low cardiac output, reduced renal function, chronic loop diuretic use and possibly increased total body water fluctuation. The standard therapy treatment for gouty arthritis, NSAIDs or cyclooxygenase 2 inhibitors, have known adverse renal effects and are associated with increased hospitalizations (and possibly death) in patients with heart failure (88,129–132). They should, therefore, be avoided when other adequate treatments are available. Oral colchicine is an effective therapy and is generally safe to use in heart failure patients. Alternatively, a short-term oral steroid for one to two weeks or an intra-articular steroid (when feasible, such as with a certain single joint involvement) may be used for a lower level of fluid retention and other side effects (133). Allopurinol may be started approximately two weeks after the acute episode is completed. Small studies have hypothesized that allopurinol may be beneficial in chronic heart failure, possibly due to its antioxidant properties, although this is has not been proven (84,129–131,134).
The numbers in brackets are references to further studies that may be of interest to anyone researching links between gout and heart disease. I wonder why they recommend the 2 week delay before starting allopurinol?
An excellent find – the full study is online as “Effect of allopurinol on mortality and hospitalisations in chronic heart failure: a retrospective cohort study”.
As Jon(*) notes it is right to be wary of statistical analysis, but it is a clear pointer that allopurinol saves lives. That should not be interpreted to mean that all gout sufferers are at risk, or all gout sufferers will be saved. However, those gout sufferers also at risk of cardiovascular problems should certainly be alert to the dangers. Perhaps their inflated uric acid is due to underlying inflammatory problems that also increase cardiovascular risks.
One thing that does rankle me about the study is the complete lack of any uric acid data. I can understand this not being available for all cases, but anyone who is taking allopurinol should be having uric acid tests.
The authors note:
It also raises the hypothesis that patients with CHF who have gout ought to receive ≥ 300 mg allopurinol/day even if a lower dose keeps the gout under clinical control.
To me, the conclusion is that there is no reason to believe that gout was properly under control in this group. It points for the need for more studies to correlate uric acid levels with mortality and morbidity.
A typical gout patient who is under-dosed on allopurinol is unlikely to question the fact. More importantly, how many doctors are going to recognise the continuing risk if the lab test comes back “normal?”
(*)I've traced Jon to CHFpatients.com, a site for Congestive Heart Failure sufferers. I haven't studied his site in depth, but his story has some echoes to my own – couldn't find a decent website about his condition, so he created one.
Allopurinol inhibits uric acid production, by suppressing an enzyme called xanthine oxidase. Useful for over-producers, but still effective for under-excretors.
Uricosurics, of which Probenecid is one, along with Sulfinpyrazone and others, help under-excreters. You can identify if you are an under-excreter by taking a 24-hour urine test. You collect all your urine over a 24 hour period, and some lucky bastard get's to test it.
Absolutely, absolutely, absolutely.
There are some of us round here who believe that the medical profession has not quite got a grasp on uric acid management. This seems to be a global problem, presumably because the ACR and EULAR work closely together, and everyone else follows their lead.
It starts with 8.2mg/dL uric acid being classed as “normal”, and ends with unnecessary cripples.
This is the front line cjeezy. Good to have you with us. You've come up with a Gout Cure Gem.
cjeezy said:
Just heard back from Arctic Medical. They said that they have had no claims about that particular batch being defective, but they would send me another box of test stripts to try…so at least they have very good customer service! Has anyone else had any issues with the control readings?
There is an extensive topic on uric acid monitor results.
I really need to summarize it sometime, but yes – there are good and bad points.
The main point for me seems to be that it takes a while to get used to taking consistent tests.
It is a long thread, but we finally got to an acceptable uric acid test result. You really need to read it all.
You can only realistically lower uric acid through diet if bad diet is the cause of your gout. If your gout is due to other factors – e.g. hereditary or kidney problems, then it is almost impossible to have any significant affect with diet.
Obviously, a healthy diet is good for you generally, so I'm not suggesting bad habits, but you need to do more to tackle the uric acid issue.
If you are overweight, it will certainly help lower uric acid if you can lower BMI to the low end of normal. This is a long-term project, as you need to lose weight gradually – say one pound per week. I now recommend that you support this with allopurinol until you reach your weight goal. This will protect you from the bad effects of uric acid during your weight loss program. You may be able to reduce the dosage or drop it all together.
Similarly if your diet has led you to excess iron, a low iron diet with appropriate iron chelation (and perhaps blood donating to help gout), then addressing this might help. This is also a fairly long-term endeavour, so again I would recommend the protection of allopurinol.
Most drugs have a risk, but one patient with complications is hardly a reason to not even try a well-tolerated appropriate treatment. If you want to wait for the second attack, then you are probably in the majority. Just remember that not all attacks are the full blown crippling variety – unexplained stiffness in the joints is a sign that crystals are forming.
Just don't wait for a third attack. If your doctor is still reluctant to prescribe allopurinol in future, I'm sure I can find 10 pages of benefits of allopurinol for every page of problems that he can find.
Hi headusher. I've moved this to a separate topic (was lingering symptom question) as you have some special requirements.
I think it is important, whenever gout is complicated by another disease, to seek the advice of a gout specialist. This would usually be a rheumatologist. In your case, it is important to find one who has good experience with gout in kidney patients.
I do not think colchicine can be effective at such low doses, so I would think an alternative would be more use. 2 to 4 days is the usual period for most gout attacks. Yes, they can last longer, especially some residual pain and swelling, but it sounds to me like the worst is over, for now.
I wonder if the nature of the kidney stone has been identified. If it is a uric acid stone, then allopurinol is the thing to get rid of it. And that is what you need to get uric acid down to manage your gout. You need a 4mg/dL reduction in your uric acid and home remedies just won't cut it.
Thank you Phoenix for your kind comments. These are not due to me, but to all the people who contribute to this forum. Especially the top posters, pulled from todays stats:
zip2play – 388
trev – 140
vegetarianGuy – 66
metamorph – 63
cjeezy – 59
Tavery – 41
The numbers show each time they have given something to all of us. Thanks are due not just to the top posters, but everyone who contributes. Even good questions often motivate us to find out more. And please note that all contributors are just regular guys and gals who seek to make gout life easier for themselves or a gouty friend or family member. You are all inspiriational.
Gout flares with allopurinol are not a certainty, but happen often enough to be prepared. Colchicine is usually the best as it is so effective. 2 pills at the first twinge are often enough.
Indomethacin, and other NSAIDs like ibuprofen and naproxen, are also very good. They should not be necessary for lengthy periods, where most of their risks lie. New studies are ongoing about IL-1 blockers, comonly used in osteoarthritis and rheumatoid arthritis. Some doctors seem to prefer steroids like prednisolone, but these should be avoided at all costs.
Gout Pal,
I would like to thank you and this web site, a few days ago I was lost and frustrated, because this theme was an unknown. Even when reading all the web sites, was not good, they all said the same thing which is basically a big site's of defintiion. Gout Pal .com not only give relaiable advice, but there are so many stories that resemble what each of us is going through one way or another.
Last night I read a part in the achillies section and the person explain almost exactly what I amgoing through,
So most importantly, I do not feel Alone.
Thank You
I had my blood check done today and the UA was 8.2, which has gone down from last weeks 9.4.
I aslo have the Allopurinol perscriprion already and will begin taking it on Sunday. The Doc did not proscribe that colchicine, I know I will get a flare up once I start taking the Allorpurinol.
Do I really need the colchicine, and can the indomicne help as well?
I know I have to buckle down
good Luck everyone
Phoenix
Phoenix Rises said:
Here goes another question, if I lower the weight and show a consistancy in my diet, can I slowing ween myself off the allopurinol as long as i maintain UA levels?
Yes. But you need to keep up the uric acid testing. Of course if your gout is due to other factors, eg genetics, then the weight loss might not help – but you will be generally healthier.
There is a very slight risk of kidney stones with allopurinol and dehydration, due to precipitation of xanthine, oxypurinol and hypoxanthine. All the reports I've seen cite other health issues besides gout, and high allopurinol doses (e.g. 600mg per day).
In normal cases, I would say the risk is very low indeed.
thanks guys for your advice, I am going to take my blood test tommorrow mornig and it will be ready in the after noon, that will tell me where I am compared to last weeks 9.4. I will take the results to the doctor. Last week he said he wanted me to wait a week, because I had high level indicators that my liver was bang up. Proably, because previously I was taking some other anti ingfflamatory medicine and not eating when I took the pill or drinking enough water.
The pain seems to get a little better, but I still cannot walk i am sure you all have been there.
tommorrow, I will ask the Doc to put me on the allopurinol, like you say I can at least lower my uric acid immediatly. See I am 5 foot 6 and 230 pound, 37 year old person so there is a lot of room for improvement. So I need to make adjustments to my lifestyle.
Here goes another question, if I lower the weight and show a consistancy in my diet, can I slowing ween myself off the allopurinol as long as i maintain UA levels?
Phoenix
