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I wouldn’t describe 272 as low. 300 is the top limit, so you’re safe, but not low. I have to go from memory, as I’ve lost my test result history. I think I got down to around 220. It’s time there was more research in this area, though I doubt there will be any funding for it. At the moment, all we know is that lower is better. The lower you get uric acid, the faster old crystals will dissolve. That means less risk of gout attacks during uric acid lowering treatment.
If only the powers that be could grasp this idea, we would have much better gout treatment success rates. At the moment, patients often give up on allopurinol because they feel it is either making gout worse, or is no help. I know that doesn’t apply to you, John, so I’m sorry for using your thread for a personal rant.
I’m not sure what to do next.
What is concerning you about gout right now? I’d love to help more, if I can.
Continue here if you like, or start new topic(s) with your most important questions, opinions, or experiences.
Your uric acid is too high. That normal value is only a laboratory statistic. It has no medical value.
You must talk to your doctor about medication to reduce uric acid to 5. If your medical history dictates it, he might recommend 6 as the upper limit. If possible, I recommend aiming lower than 5 for one year to reduce the time you are at risk of a gout attack. Your doctor should also advise you about pain relief for the first few weeks of uric acid lowering treatment.
I cannot comment on other aspects of your blood test results. I am not a doctor. My job is to advise you what to ask your doctor, and to help you understand what your doctor tells you.
I hope this helps you work with your doctor to control your gout. If anything I have said is not clear to you, or if you have other questions, please tell me.
Just realised that I didn’t explain “I had thought gout was more short sharp attacks, which can occasionally last longer rather than this constant low level swelling and mild pain?”
Gout attacks, medically: acute gout, are caused when your immune system gets overwhelmed. If there are only a few visible uric acid crystals, your immune system engulfs them, and you feel very little. Once overwhelmed, they secrete chemicals that attract more white blood cells, and promote cells to divide rapidly providing more defenders. All of this produces redness, fever, swelling, and pain. Apologies to any human biologists for the simplistic view.
Between those two experiences, there is a whole range of pain levels. Sometimes it’s just a little numbness or pins and needles. Other times it’s full blown agony. Mostly, it’s somewhere in between. These are all symptoms of the war between your immune system and varying numbers of free uric acid crystals.
Good point – @kipper – where are you? Hope all is well.
Mark, the thing we all worry about most is the next gout attack. Though this is extremely painful, and to be avoided at all costs, medically, it is not particularly serious. Psychologically the pain, and worry about more pain can be devastating. However, it is temporary, and not life-threatening.
The real problems go unseen until it is too late. Uric acid crystals around joints prevent cartilage, tendon, and bone from repairing themselves. This process happens every day that uric acid crystals are present, whether you notice their presence or not. Some of the resulting damage will recover if uric acid is lowered sufficiently, and old uric acid deposits dissolve. However, the longer this is left, the less chance of repair, and greater chance of joint replacement or amputation.
Uric acid crystals will eventually spread to all joints and beyond. When they collect in soft tissues, they form lumps called tophi. These are most noticeable in the skin. They might look ugly, but usually don’t cause too many problems. However, they might restrict mobility, or burst through the skin risking painful infection. Tophi will eventually spread to all organs. There is a real danger of kidney disease, heart disease, and other organ damage. You can see more details at http://www.goutpal.com/gout-symptoms/tophi/
All of that leads me to advise you that option 1 and 2 will not work. By the way, slightly lowering uric acid doesn’t always reduce gout attack risk. It is one factor, but whenever you have uric acid crystals present, you can get an attack. Attacks be triggered by trauma, illness, saturated fats, or anything that causes old crystals to start dissolving or new ones to form. 0.3 is a target that gives a margin of safety. 0.36 is the absolute upper limit.
The great thing about allopurinol is that it has been used to treat gout safely for many decades. There are scare stories, but they do not apply if the correct procedures are followed.
First, high risk groups can be screened for sensitivity risks before allopurinol starts. These are Han Chinese, Thai, and Korean with Chronic Kidney Disease.
Second, dose should be started at 100mg per day.
Third, kidney function and liver function tests should be taken with uric acid test whenever there is a dose increase. Testing should be done at least once per year for life.
The psychological implications of daily allopurinol for life are harder to resolve. Personally, I wear glasses every day, and have done since I was a boy. I was very reluctant to do this at first, but only made my own life miserable by not being able to see properly. I also waited longer than I should have before starting allopurinol. But I am so glad I did. It removes an enormous worry when you know you are doing the best you can to protect your body moving through middle-age (I’m 56). I get a real sense of achievement when I hear friends and acquaintances moan about their gout. I know that mine is controlled, and I do not need to worry.
Finally, Mark, I hope I can persuade you not to worry about taking allopurinol. Many of the so-called side effects that get brought up on this forum are the same as the effects of anxiety. I’m convinced that people worry so much about allopurinol that they make themselves ill. If you are unfortunate enough to be one of the few who definitely cannot tolerate allopurinol, then there are alternatives. Febuxostat is the obvious choice, and more are in development.
I hope this helps you decide. If there are any of my points that are not clear, or that you disagree with, please let me know. I hope I can help you get gout under control, but I want you to feel comfortable with whatever you decide. If you want to pursue lifestyle improvements then let’s have a serious discussion about all the things you might do. Personally, I tried it and found life more tedious than a hedonist like me can bear, but it might suit you.
It is great news that your uric acid is below 300 ?mol/L. That means your blood uric acid is in the safe zone, but it might take several months for existing uric acid crystals to dissolve.
One way to reduce that timescales is to increase allopurinol, and aim even lower. You should discuss this with your doctor. Some doctors are receptive to this idea, others will advise you to be patient. Whichever you do, you should maintain adequate hydration to allow dissolving uric acid to pass through your kidneys. Skimmed milk and coffee are particularly good for reducing uric acid. Also, try to keep joints wrapped to maintain temperature, as uric acid dissolves better at warmer temperatures. Don’t overdo this however, as direct heat is not good for inflammation.
It is important to realise that diet is only one factor that can affect gout. Ideally, a 5’10” person should maintain weight below 173 pounds http://www.goutpal.com/2269/losing-weight-with-gout-foods-to-avoid/
This is only a guide, but generally speaking, excess tissue is a source of uric acid. Meat and fish is the other source. Your diet is not very bad, and your uric acid is safe, but if you want to try and remove reliance on allopurinol, there are improvements you can make. If you choose to do that, I recommend you stay on allopurinol for at least a year. You should also wait until you have not had a gout flare for 6 months. I can help you with an alkaline diet at http://www.goutpal.com/gout-diet/gout-diet-menu/. By it’s nature, an alkaline diet is very good for gout.Gout flares during early months of allopurinol are common. They happen as partially dissolving crystals get attacked by the immune system. Usually this has nothing to do with food, but as humans, we always try to make connections. If it is food-related, the gout attack is not related to immediate purine intake. Latest research shows that is actually Free Fatty Acids in food that trigger immune cells to respond to uric acid crystals. It is just coincidence that most high purine meals tend to be high in saturated fats.
Usually, doctors prescribe colchicine or other pain prevention during the first few weeks of allopurinol. Has your doctor ever discussed this?
I hope this helps, John. If what I say conflicts with other advice you have had, please let me know the specifics, and I’ll try to explain the confusion, or improve my explanation.
Mike: “And we are all, after all, unique experiments of one!”
The wisest words ever spoken about gout.
@benedict Colchicine should prevent flares happening. If not then usual procedure is:
1. Anti-inflammatory to reduce inflammation and pain.
2. Pain-blocking analgesic to block any remaining pain.If ibuprofen is not suitable, you could try other NSAIDs such as naproxen, Alternatively skip straight to pain-blocker. I’m surprised your doctor hasn’t suggested paracetamol, which is a special case analgesic. I don’t know all the medical details, but it is not generally regarded as an anti-inflammatory, yet it has anti-inflammatory properties. I guess if I understood that, I’d be earning $1000s an hour as a medic instead of running this website 🙂
The research on omeprazole is inconclusive. One report was unable to establish a link between omeprazole and gout, yet another claims that in a few rare cases, it does raise uric acid.
What concerns me most is that several of the common causes of acid reflux are also associated with increased risk of gout. These are:
- Obesity
- High intake of table salt
- Low dietary fibre
- Low physical exercise
Of course, what I don’t know, John, is if any of these apply to you. A good starting point, if you don’t mind sharing the information, is your height and weight. I’m guessing, because you seem to be focusing on diet, that you might feel that your diet is not good. I like your idea of adopting an alkaline diet. That is certainly good for gout, and should also help the acid reflux problem.
Diet changes take many months before you get the benefits. It is best to start as soon as possible, but introduce changes gradually. Rather than a specific eating plan, it is best to start thinking about food differently. To start an alkaline diet, just start replacing meat with vegetables, and snack on fruit. Once your body adjusts to eating less meat and more plants, you can put more effort into specific recipes and meal plans to optimise your diet. This isn’t a temporary ‘detox’ – it is a lifelong improvement to eating habits. I can help with specific problems that you might face, so just ask.
In the long run, you might reduce your dependency on allopurinol. For now, you need to make sure your dose is right to bring uric acid down to 0.30 mmol/L or lower. Regular testing is important, so as dietary changes take effect, you can reduce the dose to maintain safe uric acid. It might be possible to reduce allopurinol to zero, but your main concern, to prevent serious joint damage and other health problems caused by gout, is to keep uric acid at a safe level.
GoutPal readers should note that, though this view of potassium bicarbonate for gout has been presented as scientific research, it has not actually been reviewed according to the original source.
I’m far from convinced that adding potassium bicarbonate is an effective gout cure. If you have potassium imbalance, it is through bad diet, or through other illness, as well as diuretics in some circumstances, as described above.
In the case of illness, the you need treatment for that illness. Illnesses likely to lead to potassium shortage include prolonged diarrhea, prolonged vomiting, and hormone problems such as over-production of aldosterone by the adrenal glands.
In the case of diet, you can improve potassium intake from my High Potassium Foods List at Foodary. Note that the key to potassium management is to get the right balance of sodium and potassium. That list at Foodary is part of a series of articles about alkaline diets. Diets that alkalize the body will help gout sufferers, by making uric acid more soluble. I have more information at Alkalizing Gout Diet Menu .
Note that dietary improvements can help gout, but they might not be enough. You must always get uric acid tested at least once per year, and ensure it never rises above 5mg/dL
The thing about colchicine is, though very good at stopping inflammation getting worse, it does not reduce existing inflammation, or pain. Though inflammation will eventually subside naturally, it often takes time, as you are experiencing.
I always found gentle exercise helped. To get to the point where you can bear to exercise, it depends on how bad the pain is. You can reduce inflammation with ibuprofen, or other NSAID. If that doesn’t reduce pain enough, you can support it with a pain blocker. Your doctor or pharmacist can advise what pain blockers are compatible with your NSAID. I was advised to alternate ibuprofen and paracetamol every 2 hours up to 4 times a day. I was also once prescribed with tramadol to block pain, but found it affected my mind too much.
I hope it goes soon, Mike. Be patient – you’ll soon have uric acid safe, and this will be just a bad memory.
Terise, I can’t advise you to ignore your doctors advice.
What I can advise is this:
When you get the scripts filled, ask to talk to the pharmacist. Make sure he/she knows all the meds you are on, and that ibuprofen and naproxen don’t seem to work for you. Explain that Indocin seem to work most of the time, but you need more help sometimes. Ask if there is anything he/she can recommend that is safe to take with your other meds. This might be Over The Counter, or you might need to try get a prescription. Hopefully that will see you with better pain control until your allopurinol removes the need for it.
My 2 weeks interval for testing is a minimum wait time. It does not matter too much if it takes longer between tests. That just means it takes a little longer to get to the right allopurinol dose. Let’s just say, make your appointments as soon as you can, but not less than 2 weeks. It takes 2 weeks for the allopurinol dose change to register correctly in your uric acid test results.
I feel for you with your poor healthcare experiences. Despite that, you do seem positive about your future. I particularly like ” Now that I am taking the Allopurinol, hopefully things will start to improve.”
I’m certain that they will improve. If you get dark days, come to the forum, and let’s talk about it. As long as we stay focused on getting your uric acid down to 5 or lower, all will be good.
Thanks for this post, Carmen.
I like to take the view that gout sufferers can eat anything they like, so long as they are careful. Careful means eating food that matches your gout treatment plan. The trouble with that is, I do not know what your treatment plan is!
I believe that gout diet is part of gout treatment, and that has to be personal. Especially with diet, when everyone has different favorite foods. I cannot see the point in producing a general purpose gout diet plan. It can never suit everyone, because we all have our personal likes and dislikes.
All I know about you, is you love beer and steak. When I don’t have enough personal information, my fallback position is “Start with a healthy diet!”
In gout terms, a healthy diet is one that avoids excesses of the 5 bad gout foods. A good starting point for gout sufferers is a Mediterranean Diet, or an Alkaline Diet. Be careful with diet plans, as there is even more rubbish about them on the Internet than there is about gout. I’m trying to redress the balance at Foodary.com, and you can ask food questions at Foodary.org. Note that I emphasize avoiding excess. That means you can eat some steak, and drink some beer. Just do not eat or drink too much. Also, make diet combinations that work.
Drinking beer within normal alcohol consumption guidelines will not make gout worse. Make it even better, by making sure you drink plenty of water, skim milk, coffee, or other gout-friendly drink before and after the beer.
Eating steak as part of a healthy diet will make hardly any difference to your gout. I require more personal information to be precise about this. However, there are very few cases where a small amount of steak each month will have any significant effect on gout. The key to this is to eat steak properly. Do not think you can get away with a 32oz steak and a few fries every night of the week. That is not only bad for gout, it will kill you through heart disease or similar. Eat steak properly by:-
1. Buy the best quality steak you can afford, and trim off excess fat. Saturated fat triggers gout attacks, but fat adds flavor to steak, so be careful. Balance the saturated fat in steak with unsaturated fats.
2. Eat 4oz red meat once or twice a month.
3. Make a tasty meal with at least 3 times plant to animal calories.I’ve found that the easiest way to eat more healthily is to make small changes every week.
If you are used to big slabs of steak with few vegetables, it is hard to switch to a meal that is mainly veg, flavored with a few strips of delicious seared steak. Change slowly by reducing the steak size and increasing the veg.
For this reason, I prefer eating guidelines to recipes. You can eat anything you like in the right combination. For classic steak try a healthy seared steak and steamed vegetables dinner:
1. Cube and boil a few potatoes. I prefer to leave skins on and microwave rather than boil. Better still, substitute other root vegetables.
2. Season and sear the steaks and cut into strips
3. Steam peas or green beans. Add other seasonal veg whenever possible. Variety is good.
4. Serve with your favorite good quality sauce. Always check labels, and reject anything with unnatural additives – better still, make your own steak sauce.
5. Consider improving the plant:animal ratio with salad leaves or mixed salad. I have a reputation for piling my plate with spinach leaves.I’ve deliberately left quantities out of this recipe. It is a question of personal taste, and this quick simple classic steak dinner is more a meal idea than a recipe. For me, recipes need to be tailored to personal requirements. I’d love to make gout recipe planning another GoutPal service. If anyone wants me to consider this, please add your comments, and I will do more personal gout recipe planning.
Starting last first. I think it is your doctor’s job to test uric acid. It is a very precise process, and most people simply do not have the patience to adopt a rigorous testing regime that is required for consistency. They can definitely help some people, and I can definitely help people learn to use them properly. However, I need to turn the question back to you, and ask why you want a home testing kit. What do you think you will learn about your uric acid control that you will not get from doctor visits?
You are right about the 24-hour urine test. This determines if you are an over-producer or under-excreter of uric acid. It helps to determine the best form of treatment for you. There’s not much more I can add until we know the results. However, I must point out that your uric acid target should probably be 6mg/dL. That is the target advised by American College of Rheumatology for gout patients with kidney problems. This is a very complex area, and I recommend consulting a rheumatologist with kidney experience, or nephrologist with gout experience. If your clearance rates are normal, it might be acceptable for you to aim for the safer target of 5.
Tim, you should also realize that your gout has not gone away between the flare-ups caused by shrimp. It is there every day, slowly damaging your joints. I think you have been lucky not to have more attacks during your 20 years. However, that can happen with some people who do not get gout attacks despite high uric acid levels. Personally, I think this is worse. That might sound stupid, but I say it because the gout attacks are a strong signal to most people that they must get uric acid under control. Without those warnings, you risk joint damage from untreated high uric acid. I wrote about this in Is Gout Painless?
Hot dogs are bad on many levels. Worst of all, as with all highly processed food, they contain loads of chemical additives. Our bodies produce extra uric acid to try and reduce the harmful effects of these chemicals. If you must eat a hot dog, make it yourself. Top quality meat, fresh or dried herbs and spices to season. Make your own bread and mustard sauce.
The meat part of that recipe does contain animal purines. Limit red meat to one 4 ounce serving per month.
Neither of those properties will cause a gout flare. They both increase uric acid, and when this goes over 6mg/dL, you lay the foundation for gout attacks. Crystals of uric acid form in your joints, but we now know that these do not start the gout flare.
To get the gout flare, the third bad property of hot dogs comes into play – Free Fatty Acids. The saturated fats promote the inflammation response to the presence of uric acid crystals.
Lemon water might help as part of a well designed gout diet plan, but it will not make a dog good for gout.
If you want to eat hot dogs with gout:
1. Make your own from quality ingredients and no additives
2. Once a month
3. Add lots of salad or other plant-based food.Sorry for delay in replying @wpack3
Diet is a long term control for gout. Allopurinol is an immediate control. I think your doctor is suffering from wooly thinking about patient-centered gout control. 5.3 is acceptable for people with kidney problems, or other issues that prevent increasing allopurinol to the correct dose.
It is not certain that you will have another flare. My recommendation for an increase is based on the guidelines from the American College of Rheumatology. They do allow for the higher level of 6mg/dL, but in these cases, patients are probably being monitored quite closely. The reason for the safe level being set at 5 where possible is to give an adequate safety margin. Also, there is no downside to going lower than 5, and plenty of benefits. Main benefits are a shorter period of time you are at risk of a gout flare, and better chance of repair to damaged joints.
I’m a great believer in improving diet. Once I started allopurinol, I felt I could eat anything, and reverted to many bad eating habits. Too much food, especially meat and fish. Eating takeaways late at night after excess alcohol. Then I realized I was seriously at risk of heart disease or other obesity-related problems. I’ve improved my diet considerably but even after a year, I’ve probably got another year to get where I need to be. If I had to, I’d make a deal to get higher allopurinol dose for 1 more year until I get down to normal body weight.
Will, I’m not sure what works best for you, but if it helps, I’m happy to email your doctor with the medical references that support the move to 400mg per day allopurinol. As I say, you’ll probably be alright with 300, but I believe 400 is a safer option. If you agree that the diet option is better, I can help you with that too. Your doctors advice to “just watch my diet more carefully” is, in my opinion, inadequate. You need specific advice that matches the food that you like. Eat food that you like, sufficient (not excess), mainly plants.
Kate, no fish is truly bad for gout, if eaten sensibly in a healthy diet. All fish is bad for you if you eat too much of it. I like to find recipes that make fish a good part of a healthy diet. Tell me what is your favorite fish, and I’ll try find some good gout recipes for fish.
chadp, what kind of hot dogs are you eating that are made out of fish? Sounds gross to me. A fishy alternative to hot dogs for me would be a healthy fish sandwich. Mackerel, or other oily fish, in a spicy sauce with salad sounds perfect.
What fish recipes do you all want to see?
Eating cherries and drinking water are always generally “good for gout”
However, what matters most is what is best for your gout. Cherries with orange juice, and water with lemon, are both likely to help a little bit. But if they do not make your gout safe, they are worse than nothing, in my opinion. Maybe that is controversial, but it is what I believe. By doing a tiny bit to make a slight improvement, all you do is delay the time to get uric acid safe. Every day that your uric acid is above 5mg/dL is another day you endure long term joint destruction. The problem here is that joint destruction is very slow. You do not feel pain from that until your joints are damaged. It has nothing to do with gout attacks that come and go – they are a warning signal. If you ignore the gout attacks, or mask them with cherries, orange juice, lemons, and water, you simply make your joints worse in the long term.
The gout attacks also get more frequent, more severe, and more widespread. Eventually, gout pain takes over your life, so best to stop that as soon as you can by getting uric acid under control. If it is not too high, there might even be dietary ways to reduce uric acid low enough. It’s best to start by posting your uric acid test results, and adding them to your personal gout profile. Then we have a good, factual, starting point for effective uric acid control.
@terise I rushed that last reply as soon as I saw your post, as I wanted to make sure you got it before your doctor visit.
If you have been, I hope you have been clear with her. You need proper gout pain control now. That means a safe combination package that is strong enough for gout pain. If possible, colchicine to limit the spread of inflammation. Anti-inflammatories at maximum strength to reduce inflammation and pain. Analgesics to block any remaining pain.
Secondly, you need the program I described to get your uric acid safely down to 5mg/dL or lower.
Gout diet is only relevant if you have a bad diet. Yours sounds pretty healthy, so I do not think it is an issue. I’m annoyed your doctor has confused you with this, without checking first that you already have a healthy diet. I’m really angry she has advised against asparagus, cauliflower, spinach, mushrooms, peas, beans or lentils. We have known for many years that vegetable purines do not affect gout. It is disgusting to me that people make gout patients suffer even more by confusing them about diet. If you are worried about your diet, then I can help you make better food choices. But, from what you have told me, there’s no need to worry.
I’m really disappointed that my service levels have not been good enough. I cannot trace your earlier reply, so I cannot say anything more than SORRY. Now that your first post has been moderated, all the rest will be published immediately. I’m going to experiment with that setting, and allow first post without moderation. I only do this to protect people seeing some of the appalling stuff that certain idiots try to post here. If that makes life harder for you, then I want to try the no-moderation option. As I say, it’s an experiment for now, but thank you for bringing this to my attention.
I’m truly sorry that it took so long to moderate your response. I’ve had a really hectic few days, and I released the tension by going out with friends and family yesterday. This is an inevitable delay that is going to happen occasionally because there is only one of me. In the past, other members have volunteered to do some moderating to ease the burden. If anyone is interested in doing this, please let me know.
Terise, my main concern now is that I can help you control your gout and live a happier life. I’ve also been frustrated by medical care. Trying different doctors is one approach, but I learned that another very good option is to train your doctor to be better at treating gout. It can require perseverance, but it is possible. All you need to do is be very clear about what you ask for. I hope my previous post has done that for you. Basically it is a gout-strength combination pain relief strategy, and a safe uric acid control plan.
Along the way, there might be things your doctor says that you don’t understand, or symptoms and experiences that you don’t understand. That is what I am here for. Tell me about these things, and I will find the answers that match your unique, personal situation. You, your doctor, and me. We all work together to help you control your gout.
Gout pain treatment is your immediate priority, but most important is getting uric acid down to 5 or lower
Colcrys is good to prevent gout pain, but expensive. You can get help at Needy Meds – http://www.needymeds.org/generic_list.taf?_function=name&name=colchicine
That site also has lots of info on finding other sources of medical help. For now, let’s focus on training your doctor.
If getting Colcrys is an option for you, then let me know, and I’ll help you with the best way to take it. Note that, now your first post has been moderated, then subsequent posts are published immediately.
Indocin is a popular anti-inflammatory for gout, but there are other choices. Work with your doctor to find the one that has least side-effects for you. Everyone is different, so it’s a question of trying different ones. Most people seem to think that naproxen is best. Personally, I used to use ibuprofen before I got gout under control. Whichever you try, make sure your doctor understands you need the maximum safe dose for gout.
Often with gout, anti-inflammatories are not enough. There are several analgesics that are safe to take alongside anti-inflammatories. Paracetamol (Tylenol) worked for me, but ask your doctor about different choices that might be better for you. The plan is, you take the Indocin (or other anti-inflammatory) every 4 hours. After 2 hours, if you cannot bear the pain, you take a paracetamol (or other safe analgesic), and alternate the two. Make sure you stay within the safe limits of both pain-killers. Make sure you ask your doctor clearly what the safe limits are, and also read the labels to double-check.
The gout diet advice you have been given is so out of date it was probably written with a quill. Ignore it. If you don’t eat red meat, and limit white meat and fish to once or twice a week, your diet is perfectly OK. Bad diet can make gout worse, but your good diet has nothing to do with your gout, so stop worrying about it. Your gout might be due to other meds that you take, but it is probably due to genetics. You can’t change your ancestors, so you need to talk to your doctor about uric acid lowering.
Allopurinol is best, but let me know first if you are of Han Chinese, Thai, or Korean descent.
Assuming you are not in those ethnic groups, start allopurinol at 100mg per day.
Discuss at target uric acid level for your first year of treatment. 5mg/dL is the absolute maximum, but I recommend as low as possible unless you have other medical problems that might stop this.
Arrange blood tests for 2 weeks after you start allopurinol. Increase the dose every 2 weeks until you get to your target uric acid level. Your blood tests should include liver function and kidney function. Makes sure you get these tests, as many doctors do not bother checking.
After one year, if you have gone at least 6 months without a gout flare, you can ease back on the allopurinol dose to maintain uric acid no higher than 5mg/dL. Make sure you get uric acid, liver function, and kidney function tests at least once a year.
“I am committed to getting my UA below 5 mg/dl” – that is music to my ears, Moises. If there is anything I can do to help you achieve your uric acid commitment, please let me know.
@benedict the specific gene associated with allopurinol hypersensitivity is HLA-B*5801.
This might be found in anyone, but is most common in people of Han Chinese or Thai descent. The specific advice from American College of Rheumatology (ACR) guidelines is to pre-screen “Koreans with stage 3 or worse CKD [Chronic Kidney Disease], and all those of Han Chinese and Thai descent”
This prescreening advice is essentially an economic test. Those groups are most likely to have the gene, so the risk justifies the cost of the test. People outside those groups might still have the gene, but it is so rare that it is not considered worthwhile testing.
In all cases, we start the dose at 100mg per day. This identifies people who are intolerant, before dose becomes too high. This is the level of safety required, so you know what to think of any doctor who suggests starting at 300mg per day. I believe the signs of rash in hypersensitivity are obvious, but the kidney function and liver function tests also add a further level of safety.
Allopurinol intolerance has been mentioned in another thread recently. To be clear, if the HLA-B*5801 gene is present, then allopurinol should never be prescribed. For other intolerance, desensitization often works. This is achieved by very small increments achieved by dissolving a tablet and slowly increasing the solution strength and/or volume. Of course, other uric acid lowering drugs are now available, with more in development, so allopurinol desensitization might not be necessary.
Moises, I’m sorry that you are struggling to get a proper blood droplet.
There are many considerations here, but I can only write from my own experiences and common sense.
Firstly, as this is a medical matter, you ought to consult your doctor. I have no idea if the inability to draw a droplet of blood from the finger has any medical significance.
Years ago, when I had a meter, I was frustrated initially at my lack of consistency. I adopted various rituals to try to remove any variables, and for a time I focused carefully on the lancet settings. By experimenting with different settings, I eventually found the setting that enabled me to perform the test. Note that I do not consider the droplet size to be large – just sufficient to cover the designated area on the strip. If it is too large, it can also affect results, as can an insufficient sample.
I do not have personal experience of diabetic testing, though I have known people who have had to test daily. From what I saw, the tests were quite different. However, I must stress that I have very little expertise here. I do know that if I ever had a question about my meter, the support staff at Arctic Medical always gave prompt and professional service. They may well have advice about blood testing.
Also, if you consult your doctor, or practice nurse, they might be able to advise on better techniques or different sample sites.
My main concern however is “I took my last allopurinol November 30. I stopped taking it because I could not tolerate the gut discomfort it caused.”
With allopurinol, the correct starting dose for allopurinol is 100mg. If it causes discomfort, there are several options. You can take it at different times of day. Before, during, and after meals. You can take it with other meds that reduce gut discomfort. In many cases, this is not a physical reaction, but an anxiety related condition based on starting a new treatment. It is important to take this seriously, but not so seriously that you become more anxious. Starting any new drug can cause initial side effects that pass after a few days. You need to work with your doctor to find ways round your allopurinol intolerance.
If you really cannot tolerate allopurinol, then it is vital to discuss alternatives with your doctor. Wait a week or two to ensure no allopurinol remains in your system. Then arrange a 24-hour urine test to assess your uric acid excretion rate. If this is low, your doctor should prescribe uricosuric drugs to encourage excretion. If not, then consider Uloric.
Please remember that, every day your uric acid is high, the resulting crystals are destroying your joints. This happens whether or not you experience flares. Uric acid control is vital, and your doctor has a duty of care to help you control uric acid safely to 5mg/dL or below.
Home test units are fine for people who want more data to help them manage gout. However, they are not a valid substitute for professional medical care. At the very least, you need the additional blood tests I described in my 8 rules for allopurinol dosing: https://gout-pal.com/gout-pal-forum/please-help-my-gout/gout-advice-please/#post-18611
I hope you can sort out your problems with the uric acid test kit, but I’m even more concerned that you find an acceptable way to control your uric acid.
Great discussion guys.
Special thanks to Mike for your kind words, and being a fellow Tyke. I’m in Shipley.
Colchicine
I changed my views on colchicine based on US research when it became the licensed medicine: Colcrys. The safety data showed that there was virtually no additional benefit from taking more than 2. About the same time, I learned how colchicine works, which let’s me see why maximum of 2 per day is good. Having said that, if I was in that sort of pain, I might be tempted to go further, but I couldn’t encourage others to do that.Colchicine is effective only when you take it at the first sign of an attack, or as a daily preventative. It poisons your immune system so you won’t produce more inflammation, but it does nothing for existing inflammation or pain. That’s why I always recommend backing it up with anti-inflammatories, as necessary. In extreme cases, I would alternate ibuprofen with paracetamol, as I was taught to do when I got hopitalised with gout over 18 years ago. There are other combinations of anti-inflammatory and analgesic, but best to get advice from a nurse, or pharmacist. Some doctors are also good at pain control.
Of course, it begs the question of how long you should take colchicine for. When I first started allopurinol, I did take one daily colchicine as a preventative, with a second an hour later if I felt a twinge. I can’t remember how long I did this for, but not very long. I reverted to as required quite soon, as I really didn’t want to be compromising my immune system any longer than I had to.
It might be significant that I went for the lowest possible uric acid, so as to minimise the risk period for gout flares.
Allopurinol
The golden rules on allopurinol dosing haven’t quite reached the front line in many cases. Key changes in recent years are:
1. Agree a target uric acid dose for the first year. This must be on a case-by-case basis taking account of gout history and any other ailments. Also consider pain relief strategy that matches the likelihood of continuing gout flares. If gout pain relief is in place, there is no reason to delay starting allopurinol.
2. Pre-screening for certain ethnic groups at risk of hypersensitivity.
3. Start at 100mg for 2 weeks
4. Review uric acid, kidney function, and liver function test results. Increase allopurinol dose gradually.
5. Retest and repeat every 2 weeks until target uric acid reached.
6. Retest at appropriate intervals – say 3 months
7. When uric acid has been below 5mg/dL and no gout flares for six months, start slowly reducing dose to maintain uric acid no higher than 5.
8. Review uric acid, kidney function, and liver function test results at least once per year for life.Because it has to be a personal plan, some of these steps might be adjusted to suit the doctor-patient relationship.
Target uric acid is the obvious one, but also test intervals and dose adjustments might vary depending on circumstances. The emphasis should always be on safety, so if in doubt, call in a rheumatologist.
The kidney function and liver function tests are another reason why home uric acid tests are not right for everyone. These tests are important for all uric acid lowering treatment, including Uloric (febuxostat). Some would say, especially with Uloric given it’s lack of long history.
As always, individual cases might differ. However, it is important that reasons are given, so at least you know your doctor has considered the latest guidelines, and is not simply repeating 20 years custom and practice. Gout understanding has grown enormously in recent years. However, from personal experience, 3 out of 4 doctors have not kept up. Early preventative gout pain relief and immediate aggressive uric acid lowering are the best chance your beleaguered joints have got.
I’m not sure you can claim it as medical fact without some reliable evidence. However, I’m pleased you are getting uric acid under control.
Sorry Robert, but there is absolutely no way I can give medical advice to a pregnant woman. She must consult the appropriate specialists.
Top of the class is the specialist who said your husband “should NOT STOP taking the Puricos during an attack.” If that specialist wants to graduate, he must arrange proper follow up testing. This should be monthly at first, but can become less frequent as uric acid stabilizes. Blood tests are needed for uric acid, kidney function, and liver function. Puricos (allopurinol) dose should be increased until uric acid is no higher than 5mg/dL. I recommend aiming for a much lower uric acid level for a year or so. This speeds up dissolving old uric acid crystals, and reduces the period of time you are at risk of more gout flares.
The only reason to stop taking allopurinol is if the other blood tests show abnormalities. If that happens, other tests might be required to try to prove if allopurinol is causing the kidney or liver results. If it is, then try another uric acid lowering drug such as febuxostat.
Stopping allopurinol for other reasons is very naughty indeed. If you stop taking allopurinol just because you get a gout flare, how are you ever going to control gout? I’m happy to help your GP off the naughty step with some friendly gout advice if he/she wants to learn.
1. Uric acid crystals are attacked by your immune system and other cells every day. When a critical number is reached, your immune system starts a process called phagocytosis. I call this “calling in reinforcements.” Most gout sufferers call it bloody agony! In between that reaction, and no noticeable reaction there is a range of symptoms. Tingling, pins and needles, numbness, itching, and redness are all common.
Note that the other cells I referred to are ones which were destined to replace bone, cartilage and tendon. Because these cells get caught up in the battle, these tissues do not get repaired, leading to joint damage.
Colchicine stops, or limits phagocytosis, so what you are experiencing is nicely described as a silent gout attack. Hope you haven’t got copyright on that, Benedict, because I will be using it in future.
2. Start allopurinol as soon as possible to reduce the time you are at risk from gout attacks – silent or otherwise. Research in 2012 proved that previous advice to wait until gout flares have subsided before starting uric acid lowering is wrong. Colchicine and ibuprofen will deal with your current attack, and allopurinol will not affect that. You should always Start Allopurinol Quickly, But Carefully.
Hi Will, welcome to the gout forum.
It is clear from what you have said that you do have gout, but the question is: Is it controlled?
To me, there’s no such thing as a “typical gout profile.” There are many different causes of excess uric acid. The common view of overweight gluttons is not typical. Excess weight plays a part, as it does in many diseases, but not being overweight is no guarantee. Just as not smoking is no guarantee against cancer.
In your case, you have the most common cause of excess uric acid – genetics. You can’t change your parents, so you have to control uric acid by other means. Allopurinol is the best option, and getting down to 5.2mg/dL is good, though strictly speaking, lower would be better. This is particularly true for the first year or so of allopurinol treatment. Very low uric acid is the best way to dissolve old uric acid crystals that have usually grown over many years.
Normally, I say that if you have maintained uric acid at 5 or lower for six months without a gout flare, you have gout under control. The six months starts as soon as you record a blood test result of 5 or lower, but restarts if uric acid rises above 5. I know that your case is borderline, but it strongly suggests that you have not yet got gout under control. The only way to prove that is rheumatological tests, but I believe these are unnecessary. If you increase allopurinol to at least 400mg, then you should be out of the risk zone in a few more months.
Until you are out of the risk zone for gout attacks, it is important to learn how to deal with them properly. Colcrys (colchicine) is great at stopping gout attacks getting worse. That is why it should be taken at the first sign of an attack, or as a preventative for the first months of uric acid lowering drugs. It works by poisoning your immune system. 1 pill is normally enough, but 2 might be required. 3 or more is dangerous. Excess colchicine will not make gout pain any less, but it will make you ill. Colcrys has no pain relief property. All that happens is, the inflammation subsides naturally, or faster with anti-inflammatory drugs. That’s why I always recommend a combination package, and colchicine-indomethacin is as good a combo as any.
Will, I hope this makes sense to you. You are so nearly there, that a little more allopurinol and patience will see you through to Gout Freedom. I know it’s disconcerting when the unexpected flare happens. However everything you describe says normal gout to me. And normal gout is very easy to treat, as long as you treat 5 as the upper limit, and aim much lower at first. Please stick to the maximum 2 Colcrys per day – there is no benefit from taking more.
If you need clarification on any of the points I’ve made, please ask. And please come back to share your progress in future.
Hi Steven, thanks for your recommendation about UrixTep Gout Treatment – Lower Uric Acid Levels Naturally Using Powerful Natural Super Foods including Moringa Leaves, Milk Thistle (SilyMarin), Curcumin and Bromelain (1 Bottle).
As you know, I encourage sharing gout treatments that fellow sufferers have found effective. However, links should be clear, so I have edited your original obfuscated link to one that clearly identifies the product. That edit loses the IP address for non-logged-in contributors, so I’ve added it back to your post. Note that, if this is a product promotion, rather than a gout sufferer recommendation, then product links should normally be pre-approved. I’m in the process of making these terms and conditions clearer, since they only appear on the registration page at the moment, but now there is no restriction to who can post, so you never see those rules.
Anyway, back to the UrixTep. This looks similar to other preparations that contain ingredients such as Moringa Leaves, Milk Thistle (SilyMarin), Curcumin and Bromelain. People have reported mixed results in the past. Maybe you could share a bit more information about how it helped your gout.
Nice to see your gout facts, Stephen.
I’m particularly interested in “Ironically I serve on a board populated by primary care MDs. I am the mandated patient rep.
Next meeting is in Dec”What a great opportunity to see what percentage follow the professional guidelines, and treat gout on an individual basis to ensure a treatment plan that brings uric acid down to 5mg/dL or less.
Thanks for your updates, Tom.
You are right that rapid weight loss can cause uric acid to rise initially, but in the long term lower weight usually means lower uric acid. One of my ideas on this is an approach to weight loss that keeps you safe. The plan is to take allopurinol as a temporary measure during the weight loss period, to stop more crystals forming, then reduce dosage as weight reduces, guided by blood test results.
Though I didn’t plan it as a temporary measure, I’ve been quite successful at weight loss. I don’t think I’m down enough yet to make my uric acid totally safe, but I’m interested to see if it has made a difference. I’ve actually stopped taking my allopurinol so I can get an accurate, untreated uric acid test. Then I’ll review to see what dose I need to be on, and try to assess if I can ever get uric acid safe just by diet.
I’m impressed by your positive attitude: “I suppose this is a long game, and I should not be disappointed in short term trends, especially in the beginning.” It’s always disappointing to think that you are doing everything right, but not reaping any rewards. The good news is, at least you know your number is too high, and you are doing something about it in your 50s. Should save you a lot of discomfort in later life if you get uric acid safe now.
