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THose numbers are very interesting John, <I've only seen your first post…the last is awaiting approval.> Nobody else has been watching excretion so closely.
What is clearly indicates that excretion of uric acid is very dependent on the concentration in the blood. My rule of thumb is that without intervention, excretion maxxes out at near 3/4 grams/day and that's precisely what you showed before treatment. Life would be so simple if that max rate would continue as we lower our uric acid production but as you see, it drops proportionally as uloric does its work (I've edited that last sentence becasue I misread your 17.8 as SUA rather than uriniary UA…sorry for any confusion)
Perhaps that is the single best argument for the most extreme treatment: combining probenecid with allopurinoll or febuxostat.
Concentration of urine uric acid is only of passsing interest and useful only to avoid forming kidney stones with a high concentration of urate and an acidic urine.
I know that if the blood level is below 6, the crystals start to dissolve. Does the same apply to the urine levels (UAU) ?
I think the correct assessment is that at a uric acid of 6.0 you will cease to deposit NEW crystals. How much dissolves is open to serious debate…I have had small tophi persist for YEARS and YEARS in spite off constant SUA below 5.0 (with 400 mg. allopurinol.) So once an attack subsides we might very well view the crystals as somewhat “walled off” and semi-permanent.
But I think it DOES apply to kidney stones that are not walled off and thus will dissolve in a alkaline medium that is low in urate…but urate stones seem to be of less concern these days than joint “stones”.
rucyrius said:
really? colchicine staves off an attack… no one here in NY has ever recommended that for me.. does that mean your not on allopurinol? do you have high uric acid levels?
I have been on allopurinol almost 20 years. These toe “twiinges” that I referred to all came while on a recent trial couple year regimen of 200 mg. There was also some suspicious knee and shoulder pain too but whether they were gout related is guesswork.
When on 300 or 400 mg. allopurinol, I never had need for any colchicine at all. I;m on 300 mg. now and plan on staying there unless I see any 6+ UA readings, which I doubt.
Yes, colchicine is VERY effective when used at the first sign of an attack…and very little is required, one or two pills. But let an attack run for a couple days and then you need some high dosing to be effective.
DO make sure of your diagnosis before starting on any of these lifelong regimens.
Absent completely incontrovertible symptoms Your rheumy should aspirate a joint and look for crystals under polarized light.
Risk of allopurinol is VERY slight…uloric long term risk is unknown.
The major purines of the human diet are from protein and nucleic acid breakdown break down to guanine and xanthine, plus ingested xanthines.
What they all share, including uric acid, is a double ring structure that humans have llost the enzyme to break down. The ultimate oxidation product, i.e., the simplest form of this ring is URIC ACID. THe bloodstream hasn't clue one which food put the double ring structure afloat only that it must be dealt with and it is converted by the enzyme xanthine oxidase into uric acid, whether it came from a pea, a cup of coffee, a veal thymuus (sweetbread,) a sardine, or a soy bean.
Other animals have an enzyme called uricase which can break this bond but humans do not so we are limited by the kidney's slow ability to excrete the product.
It is not one food or another food that causes urate overload, any more than it is calories from bread or meat that make us fat…it is the totality of input exceeding the totality of output that fills us with urate (or fat.)
Flood your body with vegetable xanthines (major final purine) and you will get gout. In fact didn't we have a vegetarian on board with gout recently? Remember, a floating xanthine molecule does not fave an attached “V” to it to show it came from a coffee bean…it is identical to one that would have an attached “M” or “F” (for meat or fish.)
Of course, never underestimate that in general, an all vegetable diet is much lower in purines (xanthines, nucleic acids) than a high meat diet. But a vegetable purine cannot be ignored in a mixed diet.
And all that is why so many of us prefer to take allopurinol and forget all about these bothersome details. 😀
john,
You gotta make do. If you cannot find a pain free window, then just start tomorrow.
Which drug are you going to use?
I'm reminded of the wonderful old lyric, God knows why:
“If you can't be with the one you love, love the one you're with!”
Started taking thiazide diuretics in the late 1970's…by the late 80's I was having hobbling foot pains that lasted 3 days on crutches.
By about 1990 I had the single crippling attack of podagra that lasted 9 days before I took a course of 22 colchicine in a day that stopped the attack. I went onto 400 mg. allopurinol a couple weeks afterward and have settled on a dosage of 300 mg./day.
So at around 19 years, I think I am, hands down, MR. ALLOPURINOL!
I have not had an acute attack in 19 years. I also switched away from thiazide diuretics to a loop diuretic, furosemide (Lasix.) I think perhaps absent the decades of thiazide I might never have developed gout. But one cannot turn back the clock.
John,
You have a confusing array of possibilities between Hallux limitus, pseudogout and gout. So anyone looking at an X-ray seeing deposits will not be able to easily differentiate…all three conditions cause deposits and two of them calcium and all three cause foot pain at the bunion joint. Odds are good though that you have only ONE condition…I'm fond of Occam's Razor!
I would give a try wilth allopurinol (or Uloric if you have good insurance and don't mind taking a brand new expensive drug) for a year or so and making sure ALL your uric acid readings are below 6.0, or better yet 5.0 if you have visible deposits.
If much of your pain goes away, you have your answer. If not, you can pursue the other possible diagnoses.
nokka,
Let me summarize:
You've had 3 attacks in 10 years and aren't keen on going on allopurinol for life as a result. This is a perfectly reasonable assessment that I think many people would make. You are considering dietary alternatives given blood UA levels that aren't very high and might never cause another attack. Perhaps a semi vegitarian, low drinking lifestyle with spirits replacing beer can get you from here to there with never another attack or else just rare amd mild attacks. That seems a reasonable hope or even expectation. Give it a whirl.
If it turns out that you are getting more frequent attacks or have that ONE attack that you know you will NEVER allow again, then you might want to rethink the situation and allopurinol is there for you. With me I could have lived with the 3 day hobbles from pain in the arch or ankle a couple times a year but the 9 day attack of podagra from Hell told me it was time for allopurinol. THAT level of paiin was inhuman.
I have never tried any dietary restrictions because to me a meal without meat isn't a meal
so I never recommend any other than avoiding too much beer. Coincidentally, a pile of horrific pressure has had me drinkking about 3 lites of dark beer a day for the last 2 weeks…no problems! Thank you allopurinol 300 mg.So, when and if it becomes time for you to start allopurinol you'll KNOW…trust me on that.
Jared,
I have not seen your Post #3 yet so I'll just address Post#1.
Since you claim no health insurance I assume you live in the land where anything is available to the rich and the poor can go f%#k themselves.
I appreciate that multiple visits to check on uric acid can cost $THOUANDS$ without health insurance. I suggest you go ONCE to a doctor and get an Rx for allopurinol 300 mg. x 90 WITH 4 refills….demand that,,, and fill it at Wallmart, Costco or Target. Three months of allopurinol will cost you $10 at these discounters $40 a year.
Alas, you will need to pay the doctor ONCE…becasue they own the game and we cannot write our own prescriptions (unless you live close enough to Mexico to buy WITHOUT prescription…but then you won't get the wonderful discounter price.)
No, there is no dietary substitute for allopurinol or probenecid.
dan,
Unfortunately by having gout we get no special absolution from torn knee cartilages, from ripped apart shoulder rotator cuffs, or from osteoarthritis, costochondritis, blown vertebral discs, shin splints and twisted ankles..
So a joint that is gouty responds well to gout treatment but other pains may have nothing to do with uric acid and may have to be dealt with the same way that non-gouty people deal with them.
One question is this: If I am not taking enough AP, will tophi continue to build?
And the answer to that is a big YES!
If I had severely tophaceous gout I would take probenecid AND allopurinol and aim for uric acid levels below 4.0 to dissolve as much deposited urate as the blood and lymph systems can reach.
I am going to make an iconoclastic pronouncement here: Do NOT ice a gouty joint. THat icing recommendation is a knee-jerk reaction from doctors who see all swelling as from a common cause…gout is different.
So just like one should never ice a severe case of frostbite, do NOT ice a gouty joint, it will only cause more crystallization. HEAT the joint and keep it nice and toasty warm.
To add to trev's request for your SUA let me say that fever is QUITE common with a gout attacks…as are chills and general malaise. Your doctor can not be more mistaken.
Good treatment is precisely 300 mg. allopurinol/day forever, best started at some time when a full blown attack is not in progress. If you are taking it now, continue taking through any attacks. After a while it will stop the attacks completely.
Ang,
Your situation is DIRE and I'd seek a couple more doctors to do battle for you. Perhaps the BEST nephrologist in your state. As you know, you are no longer in Stage 3 kidney disease ( >30GFR) but stage 4…and stage 5 is dialysis or transplant. When you say you were “normal” in August, do you mean as in the sense of a GFR around 100? Or just normal for stage 3?
Since ancient times gout has primarily killed by the destruction of the kidneys and it pertained until the invention of the antiuric acid drugs a half century ago. (Maybe soon it will be found that heart failue is the end-point of gout, who knows.)
Did you go many years with untreated UA's like that 12. If so gout caused kidney disease goes into the lead as likely causes of your bad kidneys. IF that happened to me I would be talking to a good malpractice lawyer about suing any GP whao saw that 12 and did nothing about it.
This is so complicated that you need the best opinions in the field with the very best data that can be found. One of the reasons that I remain skeptical is that Uloric is BRAND NEW and nobody can say what the long term effects are on the kidneys or on anything else except the bottom line of the manufacturer. If it were me, in the absences of consensus of the MAYO and CLeveland Clinic specialist, I would go with urate lowering to help your kidneys. BUT if a rapid worsening occurred only since you began Uloic, I would strike that agent from my list.
A rash is usually nothing, but a rash that develops soon or immediately after starting a new drug points to a hypersensitivity reaction and usually means STOP THE DRUG. Worse is the co-development of angioedema which manifests as swollen lips, eyelids, tongue and sometimes difficult breathing. Itching and rashes can sometimes be caused by the low functioning kidney also…wastes build up.
When you see your nephrologist, discuss getting on a list for kidney donation…sometimes the wait is long and the earlier you get on it the better. ANd we'll all hope you'll never need to use your place in line.
AFTER RE-READING THESE 2 DOZEN POSTS, WHAT I WOULD DO FOR MYSELF IN YOUR SITUATION IS TO CHANGE TO ALLOPURINOL
…there is just too much risk that Uloric is NOT the drug for you. WHat you DO know for unassailable facts are that you ARE taking Uloric and you are doing very poorly.
On a slightly related note, I have just read about some uric acid researchers who found their urine samples had gone cloudy (you wouldn't believe the stuff I read sometimes). They ascertained that the cloudiness was uric acid crystals, and the sample temperature was, from memory, 24 degrees (centigrade). When heated up to body temperature, the crystals dissolved.
I've often read about the phenomenon, and of course, being me, I tried it. It's absolutely true. I guess if I wanted to get really nuts I'd have tried passing a large parcel of cold urine through some filter paper, keeping it cold, and tried to scrape off some crystals and toss them under the microscope.
But that seemed a but TOO “water-sportsy” for me.
I wouldn't recommend 3 colchicne a day for an extended period…you'd probably soon develop the worst kind of incontinence…the back kind.
The body doesn't tolerate long term colchicine in anything except the tiniest dosages. I think it should be reserved for allopurinol initiation and the BIG attack (and then taken quickly and in a large amount.)
But get on the 300 mg. allopurinol as soon as you can.
And talk about being dismissive about gout with that “garden-variety” nonsense. Part of the problem with doctors and gout…they treat it lightly and stupidly.
Imagine a doctor telling a patient he has “garden variety lung cancer” or he had a “garden variety stroke.”
For someone who has his foot in Satan's vise, one is rarely thinking about FLOWERS.
trev,
Remember those wonderful pictures that GP posted showing those urate deposits almost EVERYWHERE. All we can be REASONABLY sure of is how much is in serum becasue that's all we measure. How much is in the intracellular fluid, the lymph system, the organs, the ligament, within the bones, inside arterial plaque…these are things we'll NEVER know. I presume they havee taken the occasional cadaver and boileed it down to get the total urate load but it can;t be a common practice.
So if UA goes down when crystals deposit, does that mean my 3.5-4.5 was lower due to that?
CJ,
There's no way of knowing for sure unless you tested immediately before crystallization and you found some way to quantify the AMOUNT that crystallized…too many variables. The question is like asking an oncologist “Yes doctor I know I have cancer, but how many CELLS?”
I think the best part of the diet was the frequent enema.
Fave bit of twaddle: low amounts of starches, proteins and fats to cure obesity…today that's called a low-calorie diet. To be technical though, it would seeem to allow LOTS fo sugar.
These diets are a dime a dozen and if one counted back to the HAY'S diet of 1910 one could probably find 10,000 competitiors eager to sell you a book. THis one seems little different from most and a little less well thought out. He seems to like MAYONNAISE on everything (a mix of a little protein and a LOT of fat)…I wonder if he later changed his name to HELLMAN. <tee, hee>
These ancient diet gurus weren't big on consistency.
Check you UA as often as your insurance will allow…or what passes for insurance in SANE countries!
THe 1000 mg./day of probenecid is a minimal dose as was the 200 mg. allopurinol. Why is your doctor afraid of adequate dosing?
I am tempted to say, but I won't, if you have any allopurinol still lying around why not consider adding 200 mg. to your current regimen…nah, I won't say it.
I think that once you have gout you will NEVER get to the point where every crystal has dissolved, NEVER! Once gout develops you have LOTS of urate deposits, probably OUNCES rather than milligrams, many of which are so firmly enshrouded in encapsulating scar tissue and god-knows-what-other-detritus that it is with you forever. And there will always be that certain deposit that is close to breaking out.
Secret, as I see it, is to make surre that when the breakout occurs to make sure it doesn't tip the nearby body parts into a saturated condition.
A Gout attack is a localized condition and thus when a deposit erupts you don't want it to erupt into an area that is either too close to saturation, too acidic, or too cold.
An awful thought that we must all digest: ONCE WE HAVE GOUT WE WILL ALWAYS HAVE GOUT.
Corollaries are :
1. The faster we lower our serum uric acid the less urate we will deposit, i.e., treat uric acid EARLY before we have too may attacks and lay downn too much UA.
2. THe lower we keep our SUA the less likely a migrating deposit will redeposit
3. The lower we keep SUA the more likely we will NEVER suffer an acute attack, damage our kidneys or develop heart disease.
By this logic, once gout develops, running a 6.0 MAY be okay but running a 4.0 is a LOT better
To the precise question: Yes, when crystals dissolve UA goes up…when they deposit UA goes down!
Yeah,
I'm curious too. I did my post on the assumption that Gouch had NEVER taken the allopurinol but if indeed he DID and was taken OFF it at the inception of the attack, then his doctor made a huge mistake in judgement (he said as kindly as possible.
)sebastian (odd name choice for a woman,)
An elbow is not the most common joint for the first attack but it is by no means rare. If it IS gout, and it may well be, ibuprofen is NOT the drug of choice, colchicine is…then a far second is indomethacin.
First off, get your utic acid checked. During an attack it tends to be lower than usual so check back and see if you have any old blood test results that included routinge uric acid. If you don;t keep your results (and EVERYONE SHOULD) call your doctor and see if he has old records.
Then proceed with a joint aspiration like GP says, although a warning, this is easier said than done becasue some doctors tend to shy away from needles…(and that's only HALF a joke!)
An alternative for an easier diagnosis: get ahold of 12 colchicine and take one an hour. If it shows immediate and potent benefit it is gout, if it is useless, it is probably NOT gout.
sirlimpsalot,
I agree with GP that 6.3 is still not the safety level and that GP's advice to get a bump up to 300 mg. allopurinol is good advice indeed. Probenecid and colchicine (a combo drug called col-benemid is available branded and generic) is a good combo IF you have had a urine test and are determined to be an underexcreter.
All that said, a trial to 300 mg. is the better choice…one should not abandon the best drug on the basis of prescribing too little of it? THe fact taht your doctor stopped at 200 mg. without achieveing a <6.0 is a mystery and NOT good medicine.
You and I have both found that for an acute attack treated with coclchicine, pain relief and diahrhea go hand in hand (sorry about the vomiting…there is little doubt that the gastrointestinal tract does NOT like colchicine) The fact that you were cured and then had another attack a couple days later just means that the GODS were not in your corner and gave you another attack because they dislike uric acid over 6.0 for people with gout…and you cannot argue with Zeus' thunderbolt…although gout ight be handleed by one of the lesser gods with a small hand drill and a gleefull leer.
Can I presume that you are now taking 200 mg. allopurinoll PLUS the probenecid and allopurinol? THat should bring some relief soon AND get your numbers down BUT taking 3 drugs is thrice as likely to cause untoward side effects rather than just taking one. THe regimen of the three drugs is usually reserved for thouse with bad tophaceous gout and a desire to get UA down around 3.0. How much probenecid, how much colchicine?
Best choice SEEMS to be just one drug, allopurinol 300 mg. forever and aim for a 5.0 UA reading. Once it gets your UA under control you likely will noot be bothered by any more attacks.
It sounds enough like gout to warrant 300 mg. allopurinol for at least a year…if you still have some doubt about the diagnosis THEN go back to 200 mg. and see if that will still keep you pain free…and then 100 mg. Your correct diagnisis will soon become apparent.
Podagra is a better diagnosis of gout than an “inconclusive” joint aspiration.
“If your “sir” comes from the Order of the Garter, I'd loosen it a bit to get better blood flow to that toe.
(Keep your foot elevated and warm/hot.)
((Personal note to self: perhaps there are some people who need the FULL dose of 16 colchicine and 10 is not QUITE enough?{wink, wink, nudge, nudge!}))
I will go with gout-pal's assessment #2. Up your allopurinol by 100 mg. for a few weeks and then begin to taper down on the colchicine to see if you can quit.
Nothing wrong with one colchicine a day forever if you need it but much more than that should not be taken for years and years.
something is wrong here mmol is millimol, and the ususal British measurement is in Micromoles abbreviated with a gamma which I cnnot reproduce in a hurry.
Sebastian,
I see this post so I assume you have been okayed by the administrator, so ask away. I'll peek in and try to answer any questions you have after I get back brom the theater tonight (highly acclaimed new production of OUR TOWN in Manhattan.)
I agree with Tavery 100% here. Nobody with gout is going to prevent attacks with 100 mg./day and a months was long enough to determine that you can tolerate the drug (as is a WEEK.)
You need 300 mg. for a one YEAR trial to seee if that's enough; it usually is and that remains the dose that almost EVERYONE is on (that's why they make the 300 mg. tablet.
)Usher,
Beg borrow or steal some allopurinol so you are not without it for a fulll week, you might trigger an attack. Go to a pharmacist you know and ask for a “compassionate prescription” of 7 pills. They can do this in most states without breaking the law. In necessary they will call your doctor. Once you start allopurinol you can skip the occasional one or even 2 days because its metabolite, oxypurinol, remains active pretty long in your system but a week will deplete your system and if the body behaves like it does with most feedback systems, you'll produce even MORE uric acid than you usually do.
And tell your doctor to up your dosage ASAP.
