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Aha, it seems to be working now. For those who missed it, the forum just broke, and Barry’s post went wandering where it shouldn’t have gone. The tech guys mutter bollocks about indexing and stuff. Me and Michael Caine know the real truth. The gout forum is so excited about Barry’s latest uric acid test results, that it went partying. I’m assured it won’t happen again, but who knows. Anyway, sorry for any confusion.
It’s great news Barry. Slow steady progress in the right direction. It’s up to you when you celebrate, but after work, I’ll be raising a glass of cider to you (I’m not keen on Stella). Yes, the old crystals will keep dissolving. Encourage that by avoiding dehydration and prolonged exposure to cold. Encourage it even more, by celebrating with low-fat milk.
As the gout forum explodes, is that Michael Caine we hear?
“Barry, you were only supposed to blow the bloody uric acid down!”Hi Jason, welcome, and thanks for your questions.
1. Uric acid peaks at 2 to 4 hours after a meal rich in animal purines. That uric acid has nothing to do with gout attacks, except that it might create a platform for gout to happen in months or years to come. If you have a gout attack, it’s due to one or more of several triggers affecting crystals that grew earlier:
a) Dehydration
b) Alcohol induced inflammation
c) Free Fatty Acid (FFA) induced immune reaction
d) Emotional stress
e) Physical trauma
f) Low temperature
g) Drop in uric acid below crystallization point2. It makes no difference what time of day you take allopurinol. If you take more than one pill per day, it doesn’t matter if you take them together or separately. The best time is whatever suits you personally. Try at different times relating to meals – i.e. full, empty, or part-filled stomach. Most gout sufferers who start allopurinol, also start colchicine as a short term preventative. Colchicine dose is time dependent, so anyone who is unsure should ask for more personal advice.
Thanks Mike, I didn’t make the Facebook/Forum connection.
Everything you say about spices is very reasonable. So, going back to my first reply here, we have to set the context. Herbs and spices are a part of gout diet, and diet is an optional part of gout treatment. For some gout sufferers, diet changes can be the whole of the gout treatment plan. As I said earlier, to Breanden : Gather facts, consider options, do plan.
The first step in gout treatment is to establish the facts. I turn to your profile and read “My uric acid level: 10mg/dl”
I don’t know how to say this best. There is no way that seasoning your meals differently is going to halve that number and get you safe.
Mike, you remind me so much of myself. I went through years of this type of thinking before I realized I had to take proper control. Basically, it boils down to this: if we are going to fiddle with diet, do it after we get rid of the years of uric acid crystals that are causing gout attacks. The logic for this is:
1. You have a buildup of uric acid crystals.
2. To get rid of them quickly, you need to get uric acid well below 5mg/dL. Let’s say a quarter of your 10.
3. Diet changes will take many months, probably at least 2 years, before they can have significant impact.
4. Every day that uric acid is over 6, your situation is getting worse.
5. Until old crystals are gone, they will confound all your attempts to measure the effects of diet changes.
6. Therefore, reduce the uric acid burden immediately, so you can safely stop meds while you experiment with diet.Having said all that, I’m extremely interested in your ideas. I think the starting point has to be agreeing that two preparations are necessary. One aimed at reducing inflammation. The other aimed at reducing uric acid. Of course, we have to accept that the impact will be tiny compared to the meals we are seasoning.
I have to say, I’m in the middle of some quite intensive reorganization to my GoutPal sites, so my time is limited. However, I’m determined to complete my database of gout treatments and other resources. I’ve always intended to include natural gout medicines in the database. I feel that your ideas fit very neatly with that. As you’ve already done some of the groundwork on individual herbs and spices, that information might make a great start. Would you want to get involved with filling the database? Or, would you prefer to share the information here, so I can start inputting it?
You mention proportions, but to me, the issue is more about taste. I.e. I believe the main objective would be to advise people how to make gout-friendly meals more tasty, and also slightly more gout-friendly.
What would be the next best steps for you? I’m asking both in terms of a gout herbs and spices project, and, more importantly, where do you want to take your own gout treatment plan?
It’s nice and positive, Paul. Just one point.
“I?m still steering clear of high purine rich food wherever possible”
I tried to explain purine consumption and gout to Dan, yesterday. As it’s Facebook, you have to keep clicking ‘Read More’ to get the full picture, but it’s very relevant. Gout pain has nothing to do with today’s purines. It’s a coincidence that most high-purine food is high in Free Fatty Acids (FFAs), and FFAs are the most likely candidate for gout flares after meals. The role of alcohol is unclear, but it is recognized as an inflammatory trigger in some studies, so that could be significant. But, avoiding those 2 potential triggers doesn’t free you from risk of a gout flare. In my conversation with Dan, we also identified emotional stress, physical trauma, low temperatures, and falling uric acid levels. There may be others that spring to mind, but the last one is the killer.Anyone on a uric acid lowering plan has to be aware of the risk of a gout flare. You can ruin your life trying to dream up ways to combat all triggers. Or you can be vigilant, and swing into action at the first sign of a twinge. There is no reason to stop colchicine if the idea of a flare frightens you. If you do stop it, set an hourly reminder to be aware of your body. Take a tour in your mind from head to toe, flexing joints. Carefully feel around your joints. Any unexpected swelling or twinges? Take a colchicine and naproxen dose. Fight it. Text me, if you must.
I agree with every word you write about colchicine, Breanden. In medicine, there’s almost a trade-off between risks of treatment and benefits to patients. Most meds are toxic to some extent – it’s all about balancing the risks. Frontline doctors get blunted by the amount of advice that gets ignored, so they stop giving it. That’s unfortunate for people like you and I who would listen.
As well as all the personal factors that make gout an individual disease, we have different levels of gout understanding with doctors. My default setting is to try and bring doctor and patient together so that gout patients get an effective treatment plan. I can gauge that plan against expert recommendations. Your doctor can gauge it against medical safety and personal history.
In the end, all that matters is that your immediate and longterm needs are met. Only you know what they are. Or, only you can find your aims and objectives, if you’re unsure now.
If colchicine isn’t right for you, their are lots of alternatives. First, you have to set the framework. Are you looking for pain relief as a short term measure to support you during the early months of uric acid lowering. Or are you looking for pain relief as a long term alternative to uric acid lowering. The choice might seem obvious, but it has to be made clearly, and with commitment.
NSAIDs are often best for most people, but not everyone can tolerate them, and all come with a warning against long term use. They include diclofenac, indomethacin, ibuprofen, and naproxen. Some appear to work better than others for different people. It’s essential that your doctor advises the maximum safe dose. You do not have to take maximum every day. But, on the days you can’t move, you have to take enough to get mobile. Staying in bed just makes the pain last longer. The best pain relief usually involves more than one drug.
I have an inkling that steroids would be safer than NSAIDs longterm. Personally, I hate them, but my best advice is to discuss with your doctor. The main reason I don’t like steroids for gout is that they knock out your natural inflammation fighters. But, if those fighters are not performing, you might have nothing to lose.
It’s good to get second opinion. But, if you get treatment advice from a podiatrist, be sure to discuss it here. I’m sure there are some good ones, but I never heard of one yet that understands uric acid.
X-ray, or other scan, is ideal to rule out (or rule in) any physical impairment. There’s been some fantastic advances in ultrasound and MRI for gout recently. I don’t know how much of that has reached local facilities yet, but physical examination is always good.Gather the facts.
Consider the options.
Do the plan.It’s the only way for personal gout management.
As for uric acid control, your test results are encouraging. I’d love to see how they compare to a lab test result. If a heavy meat diet is leaving you in the 6-7 range, then just getting a little more healthy might be all you need. We’ve grown up in post-war years, when the measure of success is overcoming austerity, and consuming the hell out of everything. These days, I see a new study every week about the appalling consequences of too much meat consumption. As well as gout, there’s a whole host of diseases that improve when you see meat as a treat. Most people won’t believe the amount of meat I used to eat in a week. Now, I can’t believe how little I eat every month. It just get’s easier each day, especially if you change slowly.
Thanks for responding Paul.
Because gout is personal, I’m very interested in what you want to achieve. It sounds obvious, but everyone really does have a different view. Some want immediate pain to go. Some want gout to never return. Some (like me) just want to understand more. This is important, because if we start a plan, we need to know if it’s working or not. So…
Allopurinol – Why do you take it? What do you hope it will do for you? I’m going to link this with uric acid levels because they are related to each other. We could start a project called something like “Paul’s plan for uric acid levels with allopurinol.” This would involve us agreeing some immediate and long-term targets, then reviewing them at least once a month. I’ll start this as soon as you tell me to. Please just let me know:
1. What do you hope to achieve by taking allopurinol that you wouldn’t get if you didn’t take it?
2. Can you think of a better title than the one I suggested?Diet – what does it mean to you? I’m going to include alcohol in this, as it’s part of diet. They say we are what we eat, so this is very personal. So, what do you want from your diet? People often say, just tell me what I can and can’t eat, but gout is not that simple. However, if you want to make it simple, I could just give you a set of eating plans that would not make your gout worse. I hope you can understand that isn’t what I’m really here to do, but I don’t mind doing it. Another way is for you to tell me exactly what you eat and drink, then I’ll analyse it and make suggestions on how you can make it better. That’s a much better option for me, especially if you tell me about things that you wanted to eat, but you avoided them because you thought they might make gout worse. Finally, we could just do one or more projects on specific aspects of food and gout, such as “How alcohol affects Paul’s Gout.” As you can see, there are lots of ways to approach this, so I’m going to need more input from you before I can start a project. Do you want a simple “tell me what to eat” plan, or a more involved “help me understand” project?
Treatment Time-scales
I think this falls in with the allopurinol and uric acid topic. If you’re thinking of something different, please let me know.@throbingtoe1 wrote: “I have stopped drinking anything alcohol related weeks ago”
Let me know when that wears off, Phil. A few pints around Liverpool is well overdue π
A podiatrist will tease you for years until the gout gets tophaceous and he can charge you for surgery.
Sorry Breanden, that’s been building up for years, and I had to let it out. If any podiatrists want a serious discussion about whether that is true or not, please start a new topic.
Now, despite me qualifying everything I write by saying I’m not a doctor, and I can’t be expected to diagnose gout, I’m prepared to bet one of my limbs that you do have gout. Every word you have written matches the gout experience. Also, a very small number of people can carry a 10mg/dL uric acid load for years without gout symptoms. But, it will ruin their lives later. Best deal with it when you’re young and fit, rather than giving your older self a crippled retirement.
Home uric acid meters are useful as a guide in some circumstances. But, an individual result is not reliable. The meter itself is not an issue, unless it’s faulty. The problem lies with the sample. With a lab test, they use a syringe of blood from a vein. It’s representative of what’s happening throughout your body. Not perfect, but a realistic alternative to taking a pint. With a home test, you use a tiny droplet of capillary blood. 10 tests will give 10 different results on the same day, so you can only rely on averages and trends.
OK, that’s how uric acid tests work, but here’s the rub…
Uric acid test results have got nothing to do with gout attacks!
Long term, you obviously can’t have a gout attack unless uric acid has been high enough to leave crystal deposits. But, it’s the crystals that create the attack. This has nothing to do with the level of uric acid that is dissolved in your blood.
Breanden, I hope I’ve explained why I think you have gout. Now, I have to think about what you do next. There are two issues. One is a long-term plan to get uric acid safe. I’ll leave that for now, as I believe managing gout pain is more immediate.
Colchicine is a great friend to gout sufferers. But it’s a friend that needs to be understood. It’s a poison that stops inflammation spreading. It’s great as a preventative during the early weeks of uric acid lowering treatment. It is not 100% effective, so it often needs the help of anti-inflammatories like your ibuprofen and Aleve(naproxen). It has no effect on pain, so it often needs the help of pain-killers like Tylenol or codeine. A good pharmacist can help with a package of pain control for gout. In the UK, hospital nurses are very good at pain control advice. I’ve not yet had experience of American hospitals, so I’ll leave it to other GoutPal members to have their say. Who knows pain control best? Here’s my view:
The best gout pain control has to be personal, based on what works for you. It’s a 3-pronged attack:
1. Colchicine at the first twinge, plus gout strength anti-inflammatory (gout strength = max dose advised by doctor). Colchicine dose should be one or two according to your tolerance.
2. After 2 hours: Tylenol or other compatible pain blocker at gout strength.
3. After 4 hours: Repeat anti-inflammatory if necessary. If swelling not improved, take second and final colchicine.
Repeat pain-blocker and anti-inflammatory steps as long as necessary up to maximum daily dose.Some people prefer a 3 hour cycle instead of 2 hours. Choose what suits your daily routines best.
I’m recommending max colchicine dose of 2 per day. Studies suggest that it isn’t effective after that. It has to be individual, so if 3 improves your control of swelling, then take 3 if that’s what your doctor prescribes. Understand that gout pain is essentially an immune system reaction to the presence of uric acid crystals. Colchicine works by poisoning your immune system. Good for agony control, but not so good for general health. It’s a personal risk/reward assessment. I’m with you, Breanden, on “I asked what he would prescribe. He said colchicine, I said no thanks, ibuprofen worked fine…”It boils down to this:
You’ve had uric acid crystals building up for years, and now they are causing trouble. It is not going to go away until your uric acid is consistently below 6. 5 is a better long term target. Crystals will dissolve faster at lower uric acid levels. Gout attacks will occur at random until most uric acid crystals are dissolved.Those are the facts that apply to all gout sufferers.
How you control it depends on your personal preferences.
I’m here to help.Hi Phil,
I hope you don’t mind, but I moved your last post here from the Beers and Cider discussion. I know beer is something we can discuss, but there’s a much bigger issue that I think we need to sort out first.
People sometimes accuse me of pushing allopurinol too much. I don’t like to do that, but for many gout sufferers there is no alternative for lowering uric acid.
You seem to be saying that you need to lower your uric acid so that you can start taking allopurinol. I’m sorry if I’ve misunderstood this.
Now, it’s a great thing if you can lower your uric acid by diet changes. Some can, but most can’t. I tried and failed miserably. Here’s what I don’t understand:
If you can lower uric acid without allopurinol, why would you need to take it?
Ron, it’s good to read your thoughts. So much of what you write aligns well with my experiences. I guess we’ve both been ‘through the wringer’ and can enjoy the benefits of life without fear of the next gout attack. It’s fantastic that you take time to encourage other gouties.
I well remember the doubtful days when, like Paul, you just don’t know what to do for the best. Sometimes I get ahead of myself and forget to listen properly. Paul, let me try and address the points that you’ve raised now.
Uric Acid Target
The rheumatologists are clear on the long term target. 5mg/dL. Outside USA, that’s 300 μmol/L or 0.3mmol/L. Different scales in different countries make this slightly more complicated than it should be. But, scale issues aside, and leaving out complications of kidney disease, and prolonged exposure to cold, it’s a simple message. 5 is safe.The guidelines on the early months of treatment are not so clear. There are hints that going lower is better, but no definite objectives, other than to treat the patient as an individual. In my case, I believe that the lowest possible level is the best target until I’ve gone 6 months without a gout flare. Every gout study I’ve read about uric acid crystals supports that objective, but it is not spelled out in the guidelines.
Paul, I hope that explains why I say zero is the best target short term, but 0.3 mmol/L is usually a good target for life. I’m hedging my bets with a ‘usually’ there, because it should be set by personal circumstances. If you’re regularly out on the Channel with Hove Deep Sea Anglers, you need a lower target, especially during the winter months.
I think the second biggest weakness with professional guidelines on both side of the Pond, is they don’t distinguish clearly enough between maintenance treatment once gout is controlled, and intervention treatment when years of excess uric acid must be reversed. During intervention, I cannot understand any reason for not aiming for zero, yet the professionals have not yet thought this through.
The first weakness of the guidelines is that most front-line healthcare professionals have never heard of them.Allopurinol Dose
Paul, you ask why you weren’t started on less than 300mg allopurinol. It’s another symptom of not keeping up with best current advice. I don’t like to be critical of doctors who have to know about thousands of diseases. I’m only keeping up with one, and I still miss new developments. Anyway, it’s a safety issue, and one that clearly does not affect you, so best to forget it, and focus on what to do now you know that allopurinol is safe for you.Foods To Avoid
Moving on to your next point. Individual food items are not important. Balanced diet is essential. Avoid chemicals (seriously – read the labels). If you do want to consider individual foods, you can only do it sensibly if you know whether you are an under-excreter or an over-producer of uric acid. It’s an interesting subject, but most of us simply need to eat a healthy balanced diet. If it’s balanced, individual foods don’t contribute enough to worry about.You’ve got me thinking about offal and seafood. I am now developing a theory. What really matters for those people who need to limit purines, is not the purine count, but the ratio of purines to protein. I think that should be a separate discussion, so if anyone wants to start it, I’ll be happy to join in.
Uric Acid Lowering Treatment
Next, I think 3 months is far too long between appointments during the first stages of gout treatment. It just prolongs the agony, and anyone who truly understands the debilitating effects of excess uric acid would see that. The most effective schedule is two weeks, because you need that time for accurate assessment of blood test results. Realistically, 4 weeks is probably best. An important part of this is kidney and liver function test results. For most people, 900mg allopurinol per day is perfectly safe. However, it makes sense to phase this. So, you should get the tests, and increase the dose every 4 weeks, in the safe knowledge that blood test results confirm that everything is proceeding as it should.Gout Doctor Relationship
Paul, you are absolutely right not to go against your doctor’s advice. It’s essential for me to encourage doctor and patient to work together on their own personal gout treatment plan. My role is to provide evidence of better methods, if I can. I don’t like to give lots of research links to back up my thoughts, because doctors have far better facilities than I have. They can check the facts if they need to, but I will always provide specific references if you ask me to. The most important thing for me, is that you have a good relationship with your doctor, where you both understand why the action you are taking is the best in your situation. For example, you mentioned a target of 0.34. You don’t understand that. I don’t understand that. If your doctor explains why that is the target, we can either accept it, or present arguments why a lower target is better.What Next For Paul’s Gout
I’ve got some catching up to do with other posts, then I’m going to take a serious look at your personal response in https://gout-pal.com/gout-pal-forum/please-help-my-gout/gout-is-personal/#post-21958To Paul, and anyone else who is juggling several gout issues at once, will Gout Is Personal help?
Hi Paul, I’m going to start with your paragraph about alcohol and diet.
Those words are amazing. You got it right with your take on “what suits me (Paul).” Your doctor got it right with his take on “why would you?” Anyway, you have all the advice you need to go forward in the right way. Probably something like a real and lasting improvement in your diet, and your health, for now. Then when that pint needs to be murdered, enjoy it! But don’t go on a killing spree!
On the veggie stuff, I made similar changes to you. I started slowly finding favourite veggie recipes, and gradually reduced meat intake. Hardest was stopping processed meats, but I find it easier once I’ve read the labels (Anyone for a Potassium Nitrate And Sodium Ascorbate sandwich?). I now enjoy cooking with veg. I hardly buy any animal flesh these days, and mostly fish. I’m not vegetarian, but I save my meat treats for visits to daughter/sister or anyone else who wants to treat me π
On colchicine, the advice given to me was colchicine for 2 weeks when allopurinol dose started or changed. Then keep on hand for the first hint of a flare. That “first hint” is very important. Once an attack takes hold, colchicine is next door to useless, though it might limit a 5 day flare to 4 days if you’re lucky.
Just for the sake of completeness, my pain control method is:
1. One colchicine at first sign of a flare, with gout strength NSAID.
2. 2 hours later, if pain limits mobility, prevents sleep, or lowers quality of life beneath the endurable, take paracetamol, as directed by your doctor.
3. 2 hours later, if swelling persists, 1 more colchicine plus NSAID. That’s the last colchicine of the day, because any more than 2 per day is foolish.
4. Repeat cycle of paracetamol and NSAID as long as you need it up to the maximum dose.Clearly, that’s something personal, so best to run it by your doctor.
Finally, the allopurinol. I’ll try and stick to the facts, but I’m sure my opinions will sneak in somewhere π
The finest gout brains in the world came up with “British Society for Rheumatology and British Health Professional in Rheumatology Guideline for the Management of Gout” in 2007. Bear in mind that this was state-of-the art 8 years ago based on research that had been published up to that date. In my opinion, it’s the starting point for great gout management, not the Holy Grail (told you π ).
I just noticed that they recommend the preventative colchicine for up to 12 months. I’m guessing they have to consider unresponsive patients and slow doctors π
Fact 1: “A long-term treatment plan is needed for each individual patient,
taking into account the rather limited amount of good data
available.”That is an important break from the concept that there are set ways to treat gout. It has to be individual.
Fact 2: ” One rather strict goal has been to reduce plasma urate
concentrations to, or below, the median concentration for men
[32]. In the UK today this is <300 μmol/l (using a specific uricase
assay; non-specific colorimetric methods give higher values). The
goal of this is to prevent acute gout, tophus formation and tissue
damage. Reduction in plasma urate to this degree, has been shown
to be associated with reduction or elimination of intra-articular
microcrystals of monosodium urate that otherwise persist even in
symptomless patients”300 μmol/L is the same as 0.30 mmol/L (and 5mg/dL). And I can’t resist, but in my opinion, I think doctors should avoid being rather strict with gout, and go all out for being downright mean with it. Since these guidelines were written, they’ve absolutely proved that going for zero controls gout in weeks, if not days. Why settle for less π
Fact 3: “Initial long-term treatment of recurrent uncomplicated gout normally
should be with allopurinol, starting in a dose of 50?100 mg and
increasing by 50?100mg increments every few weeks, adjusted if
necessary for renal function (see further), until the therapeutic target
(SUA <300 μmol/l) is reached (maximum dose 900 mg).”Now, if .34 is your target because you have kidney problems, then I’m truly sorry about that, and the tone of some of my responses. In my defence: “nobody said” [brief pause for profile check]
No, I’m pretty sure I’m on safe grounds here. In my opinion, 0.34 mmol/L has been plucked out of the air based on a spurious lab result, or some other bollocks that has nothing to do with good gout management. πSometimes it beggars belief. “Yes sir, we can cure your gout in a few weeks with just three of these lovely 300mg allopurinol pills each day. But I’m only letting you have one, cos I’m a bastard” π
I’ll finish with a serious note, Paul. I really hope that nothing I’ve written here has caused any offence, or confusion. I’m truly committed to help you find the quickest, least stressful way to manage your gout. I’ve raised a few points, and you can probably see that I have strong feelings about some of them. I promise to respond to any of your concerns the best way I can.
I agree, Paul, that getting on allopurinol is the priority. I just don’t understand why Phil isn’t taking it anyway.
Very interesting, Paul. You’re absolutely right that all cases are individual. There is one ‘rule’ however, that I think applies to everyone. We should all eat a healthy balanced diet. That means either vegetarian or Mediterranean style, where meat consumption is limited. That’s not just a gout consideration. It applies to disease risks for heart, stroke, diabetes, cancer, and more. There’s overwhelming evidence for this, neatly summed up in Unhappy Meals. My interpretation of his slogan is Eat Food. Sufficient. Especially Plants. For no other reason than it makes a nice acronym. π
I became aware of this after I took control of my gout. I was happy that I’d beaten one disease, but didn’t want to succumb to another, especially as there’s a history of heart disease on my Dad’s side. So, in my world, alcohol is just another item in the diet. As such, too much is definitely not balanced. However, I think the choice of whether you drink or not is exactly the same as meat. Too much is definitely unhealthy, but that does not imply that none at all is best. For every report that suggests alcohol abstention is bad for gout, there’s another that suggests moderate drinking has little effect. That’s especially true of moderate red wine intake. This might be explained by the different types of gout, and their genetic roots. We know that some gene defects cause uric acid over-production. Different genes affect uric acid excretion. I’ve yet to read a gout study about alcohol that makes this distinction, and categorizes subjects accordingly. Maybe it’s wrong to speculate, but I can’t help wondering if this is linked to variations in results between gout studies in different countries.
Irrespective of my waffling, it always comes back to the individual. If anyone is concerned about their alcohol consumption, I recommend alternating months with normal consumption and abstention. You should get uric acid tests at the end of each test period, and repeat this several months. You should also make a note each day of your gout pain, from none to screaming agony. Science says to repeat for 50 months to be confident in the results, but most people would get a clear picture much earlier. A less scientific way would be to simply keep a diary of gout pain and alcohol consumption. This misses the important uric acid element, but might still be useful. Personally, from my own experiences, I found that drinking had little or no effect on my gout. It has to be an individual decision based on your own reactions, and that is true of all aspects of gout diet.
Paul, I’m concerned about your final paragraph. I strongly suspect that your numbers are for the millimole scale, which is most common in the UK. In that case, 0.34 mmol/L falls within the acceptable range of 0.3-0.35. However, I strongly believe that whilst this is acceptable once gout is under control, it is not low enough for the early months of uric acid lowering. My logic is backed by some rheumatologists recommendations, but I don’t think they are clear enough. This forum is full of tales of woe during early uric acid lowering. That period of uric acid crystal dissolving is something we all have to go through. The pain can be minimized if treatment is managed properly – like with your preventative colchicine. The single most useful thing is to increase the dose of allopurinol, which reduces the time period we are at risk of a gout attack. It’s blindingly obvious to those who examine the facts, but inescapably hidden to those who rely on 20th century custom and practice.
I strongly recommend that people consider maximum allopurinol for a few months at the start of their uric acid lowering treatment. I had to visit 4 different doctors at my group practice until I found one who appreciated my logic. That 4th doctor is now my medical hero. I noticed he’s also very good with other health issues, and always seems to start with his patient, not his medical school notes.
There’s 2 issues, Phil. One is treating uric acid. The other is treating gout pain.
Uric acid treatment is long term. There are times when a drop in uric acid can trigger an attack, but the answer to that is to treat the attack. Get uric acid below 3mg/dL and you turn the tables, because most crystals dissolve so fast they don’t get time to trigger an attack. You have to help this with sufficient hydration, and avoiding prolonged exposure to cold.
As Paul says, colchicine and naproxen are good combinations for gout. I’d also add paracetamol in extreme attacks, alternated with the naproxen (or other NSAID). Personally, I think steroids should always be a last resort for gout sufferers, because they destroy your body’s natural ability to fight inflammation.
Remember, with allopurinol, there are 2 things guaranteed to make gout worse:
- Starting and stopping it
- Insufficient dose
Well, Paul, that’s one point of view. Another point of view is to control uric acid, so you can make choices about your lifestyle rather than being dictated to by gout.
Phil, it seems to me that you have similar reactions to Barry, so the best way is to go with what works for you. That’s the main thing about managing gout. We are all different, so finding what works best for each individual is always the best way to manage gout. Whether it’s diagnosis, treatment, or diet, I hate the “one size fits all” approach.
Hi Paul, it’s nice to read your gout story. I hope we can agree to differ on our approach to alcohol.
You said “I?ll expand if anyone wants me to.” I’d love to know more about your uric acid levels. Have you and your doctor agreed a target?
Ron, I’m blown away by your comments. It’s great of you to take time to let us all know about your progress.
It’s a wonderful feeling for all gout sufferers to know that our gout is improving. It’s a wonderful feeling for me to be part of that.
Barry, the apparent randomness of gout attacks can be confusing and confounding. I can’t tell you the number of bad days I’ve had in the past, wondering what I’ve done to deserve another gout flare. I’m certain you’ll soon be looking back on recent months as the time you found Gout Freedom. I know that’s an optimistic hope at the moment. But, I can’t wait for your test results to confirm that you’re continuing to control uric acid.
Thanks guys for a really optimistic start to October π
Great update Barry. I was going to take you to task for not supplying latest uric acid test results. But, who cares – an update is an update π
You are a fine example of a good gout patient. Find your own way to deal with the gout pain. And never take your eye off safe uric acid numbers.
It’s 3 and a half months since you started here, and we’ve had some great discussions. Is that over six months on the allopurinol now? I always see six months as a milestone in gout. In my opinion, once you’ve gone six months with uric acid under 300 μmol/L, and not had a gout flare, you’re pretty much ‘cured’. You say 5 weeks without an attack, and I’m hoping it’s the first 5 weeks of your Gout Freedom!
Anyway, Wednesday is my weekend, so it’s off to the pub to meet my Mum for lunch. I’ll be raising a glass to your continuing improvement, Barry. I’ll also be toasting all the other gout sufferers who make my GoutPal project so fulfilling for me.
Cheers!
“Could it be the meds just helped inflammation and not the gout, so maybe it?s been there the whole time and the meds were just masking it?”
I couldn’t put it better myself.Post your uric acid test results, and let’s get ourselves a plan to make your uric acid safe, Mike.
On the face of it, it sounds like you have a great plan Mike. It’s good to know you are planning a uric acid blood test in a month or so. I’d be really interested to see if you can see significant improvement.
Try to sustain the weight loss. It doesn’t have to be 4lbs a week – one or two is good. I like how you’ve combined diet and exercise.
The problem with advice is that it needs the right context.
Generally speaking, it’s good advice not to carry sharp knives. But that’s poor advice for a surgeon or butcher.
So, that’s why I always say, start with your gout facts, and what worries you most. Then we can create a plan together that removes those worries. In the process, we might uncover other worries so we deal with them. Ultimately, the biggest worry for all sufferers is “how do I maintain my uric acid at a safe level?”
So, Mike, we’re doing well so far, as you have a great plan to switch diuretics and lose weight. It’s a brilliant plan, so we have to measure it properly. Please record your weight in your Personal Gout Profile so that we can compare that in six months. Also, try arrange a blood uric acid test every month or so, and post the results here.
To help you on the plan, let’s get rid of some of the other minor worries.
1) Allopurinol: no need to think about that for now. We’ll try to manage gout without it. We can consider it in six months if you don’t reach safe uric acid levels on your current plan.2) Confusing diets: it’s all about context. Individual foods don’t matter. Your total food intake and your body mass are what creates uric acid. Cabbage and oatmeal won’t affect uric acid unless you gorge on them. I’d like to know which of my articles said not to worry about diet, so I can understand the context better. Some people should definitely worry about diet. But most who already eat a healthy balanced diet should stop worrying about every single thing they eat.
3) Exercise: though this can raise uric acid during strenuous activity, it lowers uric acid in the long run. Best to avoid exercise designed to build muscle mass. That’s because muscle mass is a source of uric acid – and why gout is a common topic among body builders.
Good luck with the plan, Mike. If I can help with the weight loss, or any more worries, just ask. I really hope you can post your weight and uric acid each month. It will really help you to achieve your goals if you post those results here.
George, I think it’s right to be very careful, and think hard before you decide. In my own life, I spent years deciding what to do.
I was nervous about any form of medication, but I finally realized that my failure to act was far worse than most potential allopurinol side-effects. When I considered my situation, I learned that all potential risks could be minimized with careful planning.
So it is with colchicine.
To be blunt, colchicine is a poison, so it’s good to be wary. I found it very tolerable and effective. It is important not to exceed 2 colchicine pills in 24 hours. It is also important to be aware that your immune system is compromised by colchicine. That means avoiding exposure to infections, or stopping colchicine if you are exposed. I suggest that the perfect plan would be to try colchicine 2 days before the planned start of allopurinol. If you can tolerate it, proceed with allopurinol. If not, think again.
In my view, it’s always best to go as low as possible with uric acid during the first few months. That gets rid of old crystals quicker, thus reducing the gout attack risk period, and minimizing the time you need to take preventative colchicine.
I’d normally recommend starting allopurinol, or other uric acid lowering treatment. But your’s is a special case. I understand why you want to wait before starting allopurinol. Lowering uric acid to 300 μmol or lower is the best thing lomg-term, as it causes old uric acid crystals to dissolve. Once thy are gone, you can’t get gout attacks. But that takes a few months, so you are at risk. There are still a couple of points to consider though:
1. You might get gout attacks anyway, and the chances of this increase as uric acid remains high.
2. Taking colchicine alongside allopurinol usually prevents gout attacks.Now, nobody knows if you will get more attacks or not, so you have to weigh things up, discuss them with your doctor, then decide if it’s right to try allopurinol soon, or after you get the blood clot sorted out. There’s no right or wrong answer – just whatever suits you best.
You are right that colchicine isn’t much good once a gout attack has become established. It’s best to think of it as a way to reduce your risk of a gout attack in future.
Even with colchicine, I usually recommend to keep other pain killers on hand, just in case colchicine isn’t enough. There has been a suggestion that salsalate is compatible with warfarin. However, it’s not a good choice for gout patients, as it interferes with uric acid excretion. The other option is to consider pain blockers that have no anti-inflammatory component, but are compatible with warfarin. It could well be that a combination of colchicine and a pain blocker will keep pain tolerable without compromising your warfarin.
George, it’s probably best to discuss these options with your doctor. Anyway, whatever you decide, I hope you’ll keep us all updated with your progress.
Diclofenac isn’t a specialist gout medicine. It’s just an anti-inflammatory that can help your gout pain until you get uric acid under control.
I’ve got lots of suggestions, but I don’t want to waste your time with alternatives to diclofenac that are not relevant to your particular situation. How about a bit more information so I can help you better? Your profile is a good place to start, as it’s completely empty at the moment.
Also, it’s important to consider other health issues that can complicate gout treatment. I’m worried that whatever you need to take warfarin for will impact your best gout treatment.
I look forward to getting some more facts about your gout and your health in general. Then we can get together a plan to stop gout ever coming back. It’s very important to do this, as gout will only get worse if it’s not treated properly.
OK, Susan.
I’m looking forward to your updates. Please let us all know what happens next with your Primary Care Physician and your rheumatologist.
Hi Susan,
I’m amazed that 10 specialists have not suggested that the best option would be to reduce uric acid. This might not be your complete answer. However, I think it’s the best way to know if gout is really your problem. Once you get uric acid safe, you can review your symptoms.
Permanent low uric acid will solve your problem, if it is gout. The only other way to be 100% sure about gout, is to get a DECT scan. These are not widely available, but they are the perfect diagnostic tool for gout, if you can find one.
I can only advise on gout, so I’m going to continue as if that is what you have.
All gout sufferers fear gout attacks. But, there is very little you can do to avoid them until allopurinol, or other uric acid lowering treatment, has done it’s job. It is impossible to predict if an attack will happen or not whilst old uric acid crystals exist in your body. Therefore, your treatment should include pain control.
I follow my doctor’s recommendation, and always advise preventative pain relief for at least two weeks when you change allopurinol dose. After that, it’s a doctor-patient choice that is dictated by personal history and preferences. The point of that is: given the wide range of pain control medicines and devices, there is no need in this day and age to suffer immobilizing gout pain. Yes, you might get some discomfort, but this should be controllable.
Now, back to your allopurinol dose. There is no need to lower uric acid below 4.6mg/dL, unless your joints are particularly cold. The only reason I suggest it is that it will get rid of old crystals quicker. That reduces the number of months that you remain at risk of further attacks.
Your pain control choices do not seem ideal to me. I’ve used tramadol, and it is effective, though it made it hard to concentrate for me. From a gout point of view, if it blocks the pain, that is good. However, I do not think it reduces inflammation. It would be good to ask your doctor or pharmacist for recommendations about inflammation reducing meds that are compatible with tramadol.
I worry about using ice with gout. Yes, it can help with pain, but it also reduces joint temperature, making uric acid crystallization more likely. There is some controversy about whether ice or warmth is best as a non-medical pain control device for gout. Some people find relief using TENS machines. I’d say if ice is your best pain relief, keep the affected area at comfortable body heat when you’re not applying the cold-pack.
I’m hoping that your allopurinol will stop more gout attacks, Susan. If it doesn’t do that fast enough for you, I’ll try to help more.
Beer and gout discussion continues after this update notice…
Beer and Gout Update
This is an old discussion about beer and gout. But it still contains many relevant and interesting points. But, for the latest gout discussions, you should read:
However, before you join those discussions, it is wise to read the facts about gout and beer:
I’m reviewing all my beer and gout articles. So, please share your questions, opinions, and experiences at Beer and Gout review.
Why worry about gout when you’re drinking beer?
Thanks Ron,
I think you are right in saying “one more piece of the puzzle”
There are so many things that can trigger an attack, and I believe they are often very individual. For instance, @susan-lewis-suselew wrote recently about lack of common redness with and only minor swelling with her gout. Her immune response might be different from most, but I’ve no idea how we can measure that.
It seems that, as soon as we learn something new about gout, we uncover more mysteries.
Many doctors are still stuck with “one size fits all” gout treatment plans. But leading rheumatologists emphasize individual treatment plans for each gout patient.
