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Hi Mark,
Don’t feel the need to apologise – I just found a message that I missed 2 months ago, so what’s a few days? 🙂
I’ll start with your last point about uric acid test meters.
I have used one myself – the UASure model. I did this when I was trying to learn all I could about gout. I don’t use one any more, for several reasons:
1. The testing routine needs to be meticulous. This is not a major issue for me, as I seem to have mild OCD tendencies (can you hear the ex-wives and partners shouting MILD???). I did find myself beating myself up occasionally about the occasional departure from what must be a very strict routine.
2. I came to realise that it is my doctors job to monitor my uric acid, and other important health indicators. I don’t keep blood pressure equipment or a stethoscope. I don’t even keep a thermometer. Why should I bother with a uric acid meter?
3. Now the real reason. I’m a tight Tyke who won’t pay for test strips when I can get a blood test free of charge!Overall, I found the data insufficient to help me manage my gout. I realised that playing around with diet was not going to get my uric acid safe. This was a gradual realisation that developed as I learned more and more about gout. I also realised that, if you are interested in the science, a uric acid test meter can help you understand your gout better. As far as buying one, please let me refer you to my response to https://gout-pal.com/gout-pal-forum/please-help-my-gout/blood-tests-are-in/#post-19271
If you do get one, be sure to share your results, opinions, and experiences here. With the benefit of hindsight, I’d say daily allopurinol is far easier than daily finger pricking. But sometimes you have to go through the process to fully understand it. I’m here to help, either way.Moving on to daily pill fears.
There are at least a couple of years comments in old threads about me recommending allopurinol, yet not taking it myself. The pill-a-day-for-life fear was strong in me, and I’ve not fully overcome it yet. I like to fool myself that, as long as there’s no pain, I’m OK. Please don’t tell anyone else, but I’ve become complacent about my daily allopurinol. I know it’s wrong, and I can make excuses all day. At least I’ve got a gout forum that reminds me daily how important it is. You and the others keep me on the right track – most of the time.
What finally convinced me was a broken knee that I ignored for a short time, thinking it was just another gout attack. It coincided with other trauma that I needed to recover from, and I knew I’d never make it if I didn’t act on my gout immediately. I went into battle, and within 6 months, gout was but a memory. The battle against gout was easy, but the battle with doctors to get the right treatment was hard.
The right treatment is to go at the speed that suits you best. You need 2 weeks between changing dose, and re-testing. A month is fine. Much longer, and you risk losing impetus. Also, delay between testing means extending the length of time you are at risk of another gout flare. 100mg is the perfect start, but rarely the right dose. You need to get below 5mg/dL as soon as possible, as the 6 to 7 range is a hellish place where crystals are constantly dissolving and reforming. For you, that means get below 300?mol/L, and avoid 350 to 400 (ish).
Now I’ve started allopurinol, I wish I’d done it years ago. I have definite signs of joint damage. It does not affect my mobility much, but I sense I’ll need joint replacement in years to come. Maybe that would have happened anyway? I’m not here to convince you one way or the other. But, I can say, hand-on-heart, you will make the right decisions for yourself if you make daily contributions to this gout forum – your own and other people’s topics.
I’m going to close for now with a truism I developed some time ago:
With uric acid lowering treatment, you might get a gout flare. Without uric acid lowering treatment you’ll definitely get a gout flare!CRP is an inflammation index. It is affected by many things, and not very useful as a diagnostic tool. However, it is useful to track it regularly, as spotting significant changes early can prompt your doctor to more specific investigations. Important when you take allopurinol or Uloric, but probably useful for any meds.
I’m far more interested in your other abbreviation – nz.
New Zealand labs that I have seen use mmol/L for uric acid test results, but there could easily be others that use mg/dL. The number needs a scale, otherwise I’m clutching at straws here. There are reasons for gout flares at 5mg/dL, but my advice will be much more relevant if I am certain about the numbers. Also, some earlier results, would be useful.
For any other visitors reading this. Keeping a diary of uric acid test results is one of the best things you can do for gout management. Record the date, number, and units of measure. Even better, record it in your Personal Gout Profile, on the page that shows when you log in.
Are you sure it’s mg/dL? I’ve assumed you are in USA, but you won’t be the first here who has mistaken 0.5mmol/L for 5mg/dL. Also, I have no medical training, so other tests don’t mean much, but your second line doesn’t look right! CRP?
The real puzzle is how can a doctor get away with medical negligence for 15 years.
The only reason for taking allopurinol (or any other uric acid lowering treatment), is to make uric acid safe.
Normal is not safe. Normal is a useless laboratory statistic that says “Hey, we tested 372 people, and the average uric acid was 6.2 mg/dL. Applying Normal Distribution statistical analysis, this gives a Normal range of 5.1 to 7.6 mg/dL. (Obviously, not real numbers, cos it’s all b*ll*cks)” Medically, this is meaningless, and dangerously misleading. It has puzzled me for years that doctors can be so blind to this. When you tell them, they look at you askance. sid vicious had a word for these people, and I’m going to start a private forum so I can have an appropriate rant at this obscenity.
uptownbob, you haven’t told me your uric acid level, but you do not really need to. It is over 6mg/dL, which is the maximum allowed for gout patients. 5 is safer because it gives you a safety margin for natural fluctuations. I always advise a year as low as possible to get rid of old crystals as fast as you can.
Uric acid lowering treatment is like anesthetic during surgery. You keep measuring and adjusting the dose so it’s right for the patient. Anything else is dangerous.
It’s great that the rest of your bloods are “normal.” Normal is good for kidney function and liver function tests, and all gout patients should get these whenever uric acid is tested. Normal for uric acid is meaningless.
Post your exact uric acid result here, and let’s get a plan to make sure 2015 is the last year you ever have a gout attack.
Excellent find, Mike. Every sentence on that page shouts why I run GoutPal. I have reviewed the full Gout Doctor article on GoutPal.com. Also, I changed your link to my article because the article you linked to is no longer available.
To all gout sufferers, everywhere:
Not long after I started this forum, a wise man said you have to train your doctor. After a few years, I realize the truth of it. That begs the question: “who will help me train my doctor?”
I will!
The conclusion of that article reads:
There is a wide variety of barriers to effective care for gout, which is a very common and uniquely curable, chronic inflammatory arthritis. These barriers largely reflect commonly held negative stereotypes of the patient with gout and poor knowledge and interest in gout among doctors. Appropriate education, possibly assisted by recent drug development and new scientific evidence is opening a new ‘window of opportunity’ in gout management and should improve the standard of care.
To which I respond:
We can overcome the barriers to curing your gout. These are personal barriers that require a personal approach. I do not blame you for these barriers, but I will help you recognize them, and help you learn how to deal with them. I’ll help you educate your doctor so that he knows what is the best form of gout treatment for you. We will create your own ‘window of opportunity’ to manage your gout easily, and improve your quality of life.What are your barriers to living gout-free?
A uric acid lowering plan starts with knowing your level. If you’ve not been tested this year, get a uric acid test today. If you have been tested this year, post your results, and we’ll work on a plan to make it safe.
Gout pain comes from your immune system, when it reacts to uric acid crystals. Colchicine works by poisoning your immune system. It has no effect on pain, but might stop it getting worse. Only ever take a maximum of 2 per day. If you leave it until gout flare has got serious, then colchicine is not much use. Anti-inflammatories will reduce swelling and pain. Compatible painkillers will block any remaining pain, if necessary. The 3-line attack always works, but you have to take the right strength, and get the right package for you. Sometimes it takes a while to find the right anti-inflammatory that works for you. Most gout sufferers here seem to favor naproxen, ibuprofen, or Indocid (indomethacin). Have you tried any of these, Mike?
Good to hear from you again Chris.
Don’t confuse allopurinol with gout pain.
You are at risk of gout flares until all the old uric acid crystals have dissolved, which might take months. If you get a flare, colchicine at the very first sign will help stop it getting worse. Anti-inflammatory will reduce swelling and give some pain relief. Compatible pain killers will make residual pain bearable, if necessary. Don’t give in to the gout pain – get a job to take your mind off it.
The only way you can shorten the time you are at risk of gout flares is to get uric acid lower. Make sure you get regular blood tests for uric acid, kidney function, and liver function. Post your uric acid results here, and I’ll encourage you to get better quicker. Don’t bother with the liver and kidney results. I won’t understand them because I’m not a doctor. Your doctor can use them to keep you healthy.
I’ve just been looking at some photos of Cabrammatta. Looks amazing! I saw it described as “Sydney’s culinary united nations” which reminds me of special time I spent in Hong Kong. Can we start a fund to fly me out there?? 🙂
Gout pain control and uric acid control are 2 different things. You cannot have gout pain without excess uric acid, but the crystals that cause the pain might be several months, even years, old.
Pain control is easy if you focus on pain control. Uric acid control is easy if you focus on uric acid control. If you mix them both up, you just get a painful mess that prolongs the pain and might make you worse.
The doctors are to blame! First thing they tell you when you go with gout is that you have to change your eating habits. They never tell you that this might make your gout worse, and they never help you to deal with it.
If you get uric acid safe, you will never get a gout flare again in your life. But, it takes several months to get rid of old crystals. You need a plan to deal with this.
As I said in your other thread: let’s create a gout pain treatment plan that works for you, and let’s create a uric acid lowering plan that keeps you safe. It’s up to you how you want to do it – just keep asking the questions until we get your gout under control.
Colchicine at the first sign of a gout attack helps stop it getting worse. Anti-inflammatories reduce inflammation, and start to deal with the pain. Compatible pain-killers block any residual pain until the anti-inflammatories take effect.
You are absolutely right – no single painkiller will control a full-blown gout attack. But, the right combination of compatible treatments, at the right strength, will definitely control gout. It is a question of finding the right package for you. Let’s start by you sharing exactly what you are taking now, and anything you have tried in the past with reasons why you stopped taking it. We can work together to make sure your gout pain does not stop you enjoying life.
The only reason for taking allopurinol is to get uric acid down to a safe level before it kills you. I can’t discuss it properly without your blood test results. If the dose is wrong, it is a very bad thing, but the dose is decided by your blood test results. 300mg might be the right dose for one person, but a terrible dose for another. Only your uric acid test result can tell what you need.
This is great news, Will.
You still have a few months before gout is completely under control, but you are definitely on the right track.
Gout flares are still a risk until the bulk of your uric acid crystals have dissolved, but these get less intense, and less frequent, as time goes by. If you do notice a twinge, Colcrys at the first sign, and Indocin if necessary, will soon clear it up. I hope you can stay confident if the occasional flare bothers you.
Thanks for the update, and I hope you’ll stay in touch – maybe your perseverance will encourage others in a similar position.
Wow, Mark, thank you for your kind words. I love being thought of as a fountain of knowledge. For the past 10 years, I’ve built up my own knowledge, with a view to passing it onto other gout sufferers.
Now, I realize that it isn’t just about the knowledge. It’s more important to think about how gout knowledge affects each individual. In the past, I’ve tended to get stuck on science. In the case of starting allopurinol during a gout flare, just like many other aspects of gout management, the science is changing.
It used to be that all doctors recommended waiting until a gout flare subsided before starting allopurinol. It’s never been clear exactly why this is the case, but it is embodied in many professional recommendations. Recent science has shown that, medically, there is no reason to wait. Indeed, because it is important to get uric acid safely down to 300 ?mol/L (or lower), the sooner you start, the better.
However, the most likely explanation for the enduring view that you wait for the flare to finish, is probably more psychological. Doctors know that there is a good chance that patients will associate allopurinol with gout flares, and so patients will be tempted not to take it. They seem to hold the view that there is a better chance of longterm success with allopurinol if patients wait.
Personally, I can see many flaws in the logic of that argument. But, I’m saying that as someone who completely understands the process that causes flares as uric acid lowers, and someone who completely understands the dangers of delaying uric acid treatment.
What really matters, is the individual gout patients understanding.
Most of all, this means having the right attitude to gout pain control, and the confidence to deal with that pain during the early months of uric acid control, when risks of gout flares continue.
So, what’s the answer to your question: “should I be waiting a little longer before starting the Allopurinol?”
I can tell you what my answer is to myself, if I’m asking the question. What I need to do for you, Mark, is to help you understand the principles involved, so you can make your own choice. Therefore, I have to throw the question back, and ask:
1. What do you think is the reason to delay?
2. How would you react if you felt your current attack was subsiding, but flared up again as soon as you took allopurinol?
3. Do you expect to get flares from taking allopurinol? If so, how will you deal with them? How long are you prepared to deal with them?
I had to consider those questions, and many more, before I took the decisions about my own gout treatment that suited me.What matters most to me, is that you feel comfortable with your choice, and you feel comfortable with returning here at any time to ask any questions you like about your gout.
“The flares have increased in frequency since starting uloric, but the intensity isn’t as bad.”
That was also my experience with allopurinol.Has anyone else noticed that flares are less intense when taking uric acid lowering meds?
It looks like the Colcrys scam is coming to an end. To celebrate generic colchicine in 2015, and my 10 years of GoutPal, I’ve reopened this thread from @limpy
What do you think about the new generic colchicine from Prasco Pharmaceuticals, or the alternative to Colcrys – Mitigare? How have prices changed this year for you?
I wonder if it was news of my 10 year celebrations that made the authorities take note 😉
Whatever, the good news is that generic colchicine is back, so I’ve reopened this thread from @darrenbruin
Thanks also to @limpy for raising issues about Colcrys price. I think there’s a similar discussion about colchicine costs, and I’ll probably reopen that as well. Also, thanks to everyone else who contributed.
We have a branded alternative to Colcrys – Mitigare – and now we also have generic colchicine from Prasco Pharmaceuticals. Who’s buying cheaper alternatives to Colcrys now?
What are you paying? How much will you save in 2015 compared to earlier years?
Most important of all, when are you going to get uric acid safe, so you never need gout pain relief?
“ I?m beginning to think we have to really be our own advocates and actively participate in the process”
Extremely wise words!
It’s the first time I’ve encountered dry eyes with uric acid lowering medication. My quick look at the research indicates rare occurrences, but these are associated with allopurinol hypersensitivity. I’m surprised it’s happening with both allopurinol and Uloric. I am left wondering if it is not some form of dehydration associated with your kidneys processing the meds. Is it happening when you are sufficiently hydrated? The best judge of correct hydration is urine color. It should be pale straw colored. Anything darker indicates dehydration.
As you can see, I’m not familiar with what is happening here, but I hope your next rheumatologist can offer better explanations. For want of a better explanation, I’m wondering if you are normally a little dehydrated, then the extra work involved in excreting by products of the meds might be making this worse. I’m happy to be wrong with this, as I’m guessing, really.
As for questions for the rheumy, most are a matter of whatever you are unsure of. To give you a framework:
1. Is there any underlying cause of high uric acid? Culprits are environmental toxins, commonly lead, meds for other conditions, and unhealthy eating. Unhealthy eating is best judged by whether you are overweight, and if you eat more than 20% animal flesh. Purine control is over-rated as a gout diet yardstick – if diet is healthy by modern nutrition standards, purines are highly unlikely to be a factor.
2. If there is no underlying cause, then you have to accept uric acid lowering treatment is safer than not having it (which I think you do accept). A 24 hour urine test will determine if uricosurics will be helpful. Your rheumy will probably insist on 2 weeks without allopurinol/Uloric before the test. Armed with all the facts, it becomes time to choose the right treatment to make uric acid safe.
3. Both you and your rheumy need to be aligned on the best uric acid target, short term and long term. Long term is set at 5mg/dL max by the professional guidelines. Short term, I believe uric acid should be as low as possible for around one year to give the best chance of recovery. This is a plan you can develop your ideas on, in this forum, before and after your rheumy meeting.
4. When treatment starts, dosage has to be guided by blood test results. Anything less is unprofessional. 2 weeks after any dose change, you need uric acid, kidney function, and liver function tests. The results of these not only guide dosage changes, but they also guide review of side-effects.
That should give you a framework for a personal plan. Build around it with questions that are based on your personal history. When you login, use the profile to keep your personal gout facts up to date. That’s your area to keep your personal notes, but it also helps people who respond to make sure advice and suggestions suit your profile. You can also update your profile easily by clicking your highlighted name – e.g. @squilliam
The value of a personal gout plan lies in the detail. Making sure you understand each step, and making sure all aspects are tailored for your personal facts, needs, and preferences. Just keep coming back and develop your profile, before and after your rheumy meeting. You’ve got unlimited access, 24/7, so make the most of it.
I’m impressed that you’re reaching out to other gout sufferers. Collectively, we all make living with gout easier for each other. I’m committed to getting this forum back to being as busy as it was before my accident, 4 years ago. Thank you for helping me do that, with your posts.
I think ESR at 23 is unremarkable if you have inflammation left in your foot.
You don’t say what you’ve arranged to do next. In your situation, I would wait for inflammation to go, then arrange new blood tests after two weeks being inflammation-free. That should give more accurate results on which to base a diagnosis.
The temptation, of course, is to forget all about it, once the pain and discomfort goes. That might delay a proper diagnosis. I hope you get retested, and come back to share your results.
Have you noticed the new points system?
You can see your GoutPal Points (GPPs) at the bottom of the right-hand sidebar. I reset the points to zero the other day. 4 members were lucky to get points at around 100 times usual value. Let’s call that an unexpected early-bird bonus for @jason-smith1977 @wpack3 and @christopher-tran
No need for other members to be jealous – there’ll be lots of opportunities to earn bonus points. Your best chance comes from posting lots of interesting comments about your gout. Also join in with other members discussions. More opportunities for GPPs are in the pipe-line.
Thanks Paul.
Can I assume you are @robpp ? I’m a bit confused by name and email differences. I can change these if you are likely to call back here from time to time.
I was prompted to give a shoutout because you are actually the oldest member here. That’s oldest as in longest-serving, not necessarily oldest by age! I’m going through the old forum slowly, and summarizing earlier discussions, as part of my 10 year celebrations.
You registered on May 5, 2008 5:37 pm. The website is older than that, but old records from the first forum software could not be carried forward. If you don’t need my gout support service any more, I’ll close the account. When I summarize this, I’m surprised to see that the advice I gave over seven years ago, is still valid for most people. In 2015, I’m focusing on a more personal approach, so nowadays, I would look for personal feedback on the 4 points I mentioned, with one or two other significant points for gout pain control.
I would be really interested in more details of how you learned how to stop the gout pain, and take control, if you have time to share them.
Wow Luke, great news.
I look forward to you getting uric acid completely controlled – then every weekend can be as good 😀
Hi @lhaymond I hope you’re making progress.
Did what I wrote make sense? Let me know if I can clarify anything, or help more in any way.
Hi @donna4878
It’s been a while, but I just noticed you’ve dropped by again.
It would be great to know how you are progressing. Why not start a new topic to tell us what’s happening with your gout these days.
Hi again, @squilliam
I hope what I wrote was helpful. Please let me know if I need to clarify anything. Sometimes I cram too much information in one post, so let me know if you have any more questions.
Also, it’s nice just to share experiences on a day-to-day basis. Another young gout sufferer just joined. Check the profile for @christopher-tran (Gout Boy). The forums work best when members reply to other member’s posts.
Allopurinol dose has to be tailored to every gout patient individually, based on the results of blood tests.
For some people, 150 is too high. For others, it is too low. Same for 300mg, or any other dose.
Also, doses change at different stages of your treatment, if it is managed correctly.
There is a test phase, one or more titration phases, a debulking phase, one or more stabilization phases, then a maintenance phase. The only one that is fixed for everyone is the first phase. The test phase dose is 100mg daily. 3 Blood tests are required after starting allopurinol, whenever dose changes, and always at least once per year. The tests are uric acid, kidney function, and liver function.
In the titration phase(s), allopurinol dose is increased to get uric acid as low as possible. Once it is as low as possible, the debulking phase continues until six months after your last gout attack. Then, the stabilization phase(s) reduce allopurinol dose. Allopurinol dose needs to be slowly reduced until uric acid is 5mg/dL, or slightly lower. That gives your maintenance dose, which continues for life. It is important to continue the 3 tests at least once a year. Test results might indicate occasional adjustments.
If allopurinol is managed properly, then uric acid is soon controlled to safe levels, and gout attacks will slowly disappear. If it is not managed correctly, it is a complete waste of time. If the dose is too low, it can cause problems, but there is no fixed amount of allopurinol. It is a matter of determining what dose is right for you. That is why blood tests are so important. Uric acid, kidney function, and liver function must all be monitored responsibly.
If you are experiencing kidney or lower back pain, you must consult your doctor immediately.
It is quite likely that recent gout flares are because uric acid crystals are dissolving. Partially dissolved crystals can cause gout attacks. However, as long as you maintain safe uric acid levels, those attacks will get less frequent, and less intense.
Without physical examination, it’s impossible to know if exercise is contributing to pain, or if it is entirely down to old uric acid crystals.
Exercise can be tricky to manage for gout patients. On one hand, exercise is generally good for gout. On the other hand, joints are weakened by the presence of uric acid crystals. Therefore, it is best to avoid stressing the joints with exercises that could overstretch tendons, or induce impact damage to cartilage and bone. There is some evidence that shows that, if damage is not too serious, then joints will repair themselves slowly, once old crystals have dissolved.
Common sense says that, if certain exercises are bringing on pain, they are best avoided until you have gone 6 months without a gout flare, whilst maintaining safe uric acid levels. It is very wrong to increase allopurinol dose without new blood tests after 2 to 4 weeks. These tests must cover uric acid, kidney function, and liver function. If kidney function and liver function results are OK, it might be a good idea to increase allopurinol again. The lower you get uric acid, the faster you dissolve old uric acid crystals. That, in turn, reduces the period of time you are at risk from gout flares.
I don’t think a rheumatologist would advise anything more at this stage, but consult one if you feel better. In any event, you need to take charge of your own uric acid tests. Get tested every 4 weeks or so, and post your results here. You need six months with uric acid below 5mg/dL, and no gout flares. After that, you can be fairly certain that most of the old crystals are dissolved. All you need to do then, is get the 3 blood tests at least once a year. You might be able to reduce allopurinol to maintain uric acid at 5. Just as with increasing dose, blood tests should also be done 2 to 4 weeks after reducing allopurinol dose.
A new gout member has committed to posting here every day for 30 days. I think that is a great way to stay focused on getting good control. Maybe 3 or 4 times a week is more realistic. My point is, by regular posting, you stay aware of what really matters. In this case, it is your uric acid levels first. We can also discuss exercise in more detail.
Hey Chris, I missed your reference to acupuncture earlier.
Have you read the discussion at https://gout-pal.com/gout-pal-forum/please-help-my-gout/chinese-medicine-and-acupuncture/
I wrote about an acupuncturist in Brisbane there. Is that near you?
Any improvement @terise
Why don’t you like taking allopurinol, Jesse? In most cases, it is the best way to get rid of gout forever.
Please post your uric acid test results, and I can advise you better.
Fred,
I believe the most effective medication for gout is allopurinol. There are alternatives for people who cannot tolerate allopurinol, but this seems not to be the case for you.
Allopurinol is only effective if it makes your uric acid safe. Please tell me your latest uric acid test results, and I can advise you better.
Hi Nigel,
1. What pain control have you been prescribed for your gout?
2. What are your latest uric acid test results?It’s important to separate pain control and uric acid control.
Pain control lets you get on with your life, if it’s done correctly. Prednisone is a steroid that will reduce inflammation. Personally, I don’t like it because of side-effects, and the fact that it knocks out some of your own natural anti-inflammatories. If it’s part of a package that works for you, then continue with it. Once you get uric acid under control, and go for six months without a flare, you won’t need pain control for gout.
Uric acid control should be very simple, but many doctors get it wrong. The only reason for taking allopurinol is to get uric acid to safe levels. I wanted to see your results first, because there are three different scales in common use, and I don’t want to confuse you by referring to the wrong one. If you haven’t seen your doctor yet, ask him to write down what he thinks is a safe uric acid level.
I believe, for the quickest way to get gout under control, you should aim to get uric acid as low as possible for one year, then review. That means increasing the dose to the maximum, in safe stages. The dose increases need to be controlled by liver function and kidney function tests. My tests showed no bad reaction to allopurinol, so my dose went 100, 300, 600, 900 over a two month period.
Reading between the lines, it looks like you stopped taking allopurinol during your gout flare. This is just about the worst thing you can do. Once started, the only reason for stopping it is because of serious side-effects, or because your doctor advises it based on kidney or liver tests.
Febuxostat is a useful alternative to gout, but should only be considered if you cannot tolerate allopurinol. Allopurinol has many decades of safe use history. The main problem with allopurinol is that it is often not prescribed properly. If dose is not sufficient to make uric acid safe, it is useless. In fact, underdosing of allopurinol is often worse than useless, because it can make gout attacks more frequent.
I’m really pleased you are going to share daily updates. In 30 days, you’ll be your own gout expert and be well on the road to complete recovery. You might have a few attacks along the way. However if allopurinol dose is right, these become less painful and less frequent. I’m looking forward to the day when you wake up, and need to think hard before you remember when your last gout attack happened.
