August 29, 2015 at 4:32 am #21896
I am a 59-year-old female, somewhat overweight with Type II diabetes and controlled blood pressure. A little over 2 years ago, I awoke in the morning with horrific pain in my left big toe. Nothing I took made a dent in it. I went to my PCP who said he took a test for gout by in analyzing those tests later there was nothing about uric acid on it. So I pursued all kinds of tests, procedures and specialists for two years with no relief. I then insisted on a uric acid test and it was 7.1. None of the doctors suspected gout because I have NO redness or heat. It does become stiff and slightly swollen. My pain can last from 8-24 hours. I used Tramadol for the pain and it takes about 200 mg cumulative to make a dent.
Suspecting it was gout, he started me on Allopurinol 100 mg/once daily. He didn’t advise me of what havoc it could start and I had the most acute attack I’ve ever had in those two years. It lasted for 36 hours and only after he prescribed me colchicine did it help. After a month, my uric acid is not 4.6. However, the attacks have continued about every 4 days. Sometimes, I’ll have two bad days in a row, getting relief in time for bed. The intensity is less and it never lasts over 10 hours.
I tried to get a specialist to draw fluid from my joint but on the day of the appointment I was not in pain. He said unless it was incredibly swollen, he could never get enough fluid to analyze. So I’m left wondering if I even have gout. I am post-menopausal and this started a short time after going through “the change.” I have read that is normal for women to get it at this time in their life.
Has anyone heard of gout without redness or massive swelling or heat? I don’t have just one bad attack and wait weeks. This can be chronic pain 4/7 days per week, subsiding then coming back the next afternoon. My podiatrist insists it is nerve related from my back to my foot. Any help is appreciated.
August 29, 2015 at 5:39 am #21900
This is a tricky one, Susan.
On the one hand, I firmly believe that you are right to lower uric acid as you have done. I’m appalled that your doctor didn’t advise preventative pain relief, but it sounds as if you now have that under control. It also indicates to me that you do have gout, because you’ve described exactly what happens to most gout sufferers when they start taking allopurinol.
My concern is that you might also be suffering from something else. I have no medical qualifications, so I can’t help you much with that. However, the best thing to do is consult a rheumatologist. It seems like you’ve already done this, so the only other thing I can suggest is to wait and see if allopurinol controls your symptoms. This can take several months, but you can shorten that time by increasing the dose. If I were in your shoes, I’d try to persuade my doctor to prescribe the maximum allopurinol dose for at least six months. At the end of that time, if your pain was significantly improved, you could gradually lower the dose. If not, I’d still recommend keeping your uric acid below 5, but you’d also need to try and find a specialist who could investigate.
I hope this helps. Please let me know what you think.August 31, 2015 at 11:51 am #21903
Thanks, Keith. The specialist I saw was an orthopedic surgeon. There are no longer any rheumatologists near my home so I’m going to have to search for one near where I work. This will be the 10th physician/specialist that I’ve seen for this painful problem over 2 years.
I do have a question about increasing my allopurinol. Will that increase my attacks? I’m not sure I could go through what I went through back in mid-July again due to my job. Do I need to increase allopurinol with 4.6 as my latest uric acid level? I’m working on my fourth day of pain that starts in late afternoon. As I write this, I have a cold bag on my toe so I can tolerate the pain while sitting at my desk. It’s a miserable existence.September 1, 2015 at 3:16 am #21904
I’m amazed that 10 specialists have not suggested that the best option would be to reduce uric acid. This might not be your complete answer. However, I think it’s the best way to know if gout is really your problem. Once you get uric acid safe, you can review your symptoms.
Permanent low uric acid will solve your problem, if it is gout. The only other way to be 100% sure about gout, is to get a DECT scan. These are not widely available, but they are the perfect diagnostic tool for gout, if you can find one.
I can only advise on gout, so I’m going to continue as if that is what you have.
All gout sufferers fear gout attacks. But, there is very little you can do to avoid them until allopurinol, or other uric acid lowering treatment, has done it’s job. It is impossible to predict if an attack will happen or not whilst old uric acid crystals exist in your body. Therefore, your treatment should include pain control.
I follow my doctor’s recommendation, and always advise preventative pain relief for at least two weeks when you change allopurinol dose. After that, it’s a doctor-patient choice that is dictated by personal history and preferences. The point of that is: given the wide range of pain control medicines and devices, there is no need in this day and age to suffer immobilizing gout pain. Yes, you might get some discomfort, but this should be controllable.
Now, back to your allopurinol dose. There is no need to lower uric acid below 4.6mg/dL, unless your joints are particularly cold. The only reason I suggest it is that it will get rid of old crystals quicker. That reduces the number of months that you remain at risk of further attacks.
Your pain control choices do not seem ideal to me. I’ve used tramadol, and it is effective, though it made it hard to concentrate for me. From a gout point of view, if it blocks the pain, that is good. However, I do not think it reduces inflammation. It would be good to ask your doctor or pharmacist for recommendations about inflammation reducing meds that are compatible with tramadol.
I worry about using ice with gout. Yes, it can help with pain, but it also reduces joint temperature, making uric acid crystallization more likely. There is some controversy about whether ice or warmth is best as a non-medical pain control device for gout. Some people find relief using TENS machines. I’d say if ice is your best pain relief, keep the affected area at comfortable body heat when you’re not applying the cold-pack.
I’m hoping that your allopurinol will stop more gout attacks, Susan. If it doesn’t do that fast enough for you, I’ll try to help more.September 3, 2015 at 12:25 pm #21907
Thanks, Keith for your thorough response. I am trying to get into a highly rated rheumatologist. There is an incredible waiting period. I am still on the allopurinol and will talk to my PCP on my next visit when I see if my uric acid is still below 5.0. I still have been having pain but only in late afternoon to evening. Tramadol was prescribed because almost every podiatrist suspected it was nerve-based. My pain med doctor assumed that as well. The fact that I have issues with pain several times a week make me wonder if it is gout. And, the lack of any redness or heat is odd. So I’m hoping the rheumatologist can rule gout in or rule out.September 8, 2015 at 11:31 pm #21914
I’m looking forward to your updates. Please let us all know what happens next with your Primary Care Physician and your rheumatologist.
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