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Wow, Ayman, great first post, with lots of information. I’ll make a general observation, then go through your numbered list.
It’s almost certain that you have hereditary gout. You’ve possibly made this worse with bad diet choices, but it’s likely it would have happened anyway. Improving your diet is good for general health, but unlikely to improve your gout much. Though you first noticed gout aged 30, uric acid crystals will have started growing before that, so you have around 12-15 years of uric acid crystals to get rid of before you start to control gout.
1) Gout Shoes. Because uric acid crystals damage joints, you need strong footwear that gives good support to feet and ankles. To help with gout flares, it’s best to get a size larger than you need, then wear extra socks for comfort and to avoid cold. By using two or more pairs of socks, you can vary the amount of padding to match the swelling from gout.
2) Donifoxate 40 mg (febuxostat). Donifoxate is an Egyptian brand of febuxostat, which is commonly sold as Uloric. The only reason to take febuxostat is to lower uric acid below 0.36 mmol/L. However, in order to get rid of 15 years of uric acid crystals, it is healthier to reduce uric acid much lower than this. I can see from your profile, that 80mg febuxostat has not reduced uric acid enough. As I’ve written in Is 80mg Uloric always enough, you might need specialist help to increase your febuxostat dosage, or supplement it with probenecid.
I can also see from your profile that you’ve take Zyloric (allopurinol) in the past. I wonder why you stopped this? Unless you have problems with side-effects, allopurinol is usually the fastest, safest, most cost effective option for uric acid lowering.
3) Medication during gout flare. Colchicine is good and effective, if taken at first sign of a gout flare. Sometimes it is best supported with an anti-inflammatory. In severe attacks, it is also good to alternate the anti-inflammatory with a pain-blocker. A good pharmacist or doctor should be able to recommend a safe combination of pain relief that is very effective. You should not stop Donifoxate during a gout flare. This applies to all uric acid lowering meds – once started, they must be taken every day unless severe side-effects happen.
Your doctor’s explanation of flares during uric acid lowering is wrong. It has nothing to do with walking. It has everything to do with partially dissolved uric acid crystals. It is an expected effect of uric acid lowering. That’s why we need pain relief during the early months of uric acid lowering treatment. It is also why I recommend getting uric acid as low as possible for one year, as this significantly reduces the time you are at risk from a gout flare.
4) Gout weight loss. The significant point is that you have 10 to 13 kg extra flesh that is a big source of uric acid (human meat is very rich in purines, and is usually a bigger source than the meat and fish that we eat). Also, the extra weight puts more strain on joints that have been weakened by uric acid crystals. It is best to lose weight gradually at .5 to 1 kg per week.
5) Exercise and gout. Be careful! As I mentioned above, your joints are weakened from uric acid crystals. Avoid stressing joints. However, exercise is good, so walking, swimming, cycling, etc will help gout.
6) Gout and stress. There’s very little evidence to link uric acid with stress. There used to be a couple of researchers, but at least one has retired. It should not be an issue if you are getting the correct dose of uric acid lowering meds. To reduce anxiety, I recommend simple mindfulness training. Do you need resources?
7) Purines in gout diet. That’s a very strange list. Do you have a source, as I don’t understand how it is linking purines with uric acid. Vegetables do not raise uric acid. Animal purines are easily offset by other foods in a balanced diet. Good gout diet planning is all about what you do eat, not what you should avoid. Excess calories and excess iron are more important than excess purines. These excesses lead to uric acid buildup, but this takes many months. Binge eating, starvation, and Free Fatty Acids (FFAs) can have immediate effects on gout attacks.
8) Natural Uric Acid Lowering. Good gout diet is NOT about adding certain things to your diet. It is about reviewing your entire diet. Then, you might be able to make changes that will make a slight difference. Adding flaxseed to a bad diet is a pointless waste of time and money.
Ayman, my best tip is: get an effective and safe plan for lowering uric acid. As I’ve indicated, this takes a few months, so you probably also need a gout pain control plan. Once those are in place, you should consider a healthy eating plan that supports your gout treatment plan(s).
If your doctor can’t help you with those plans, I can.
I’m in the process of moving this gout forum to a new website. Simply ask for personal gout treatment plans.
Absolutely fantastic news, Paul.
Sensible doctors will always advise against binge-drinking, but it has more to do with general health than gout.
Please remember to get that check-up in a year. It’s best to have uric acid, kidney function, and liver function tested at least once a year for all gout sufferers. Better safe than sorry.
I know you’re going to have a great Christmas, Paul. 🙂
It’s the first time I’ve heard any suggestion of links between the common cold and gout. I can’t think of any likely link, so I’d say it’s most likely to be coincidence.
What worries me most is that you’ve had gout over 5 years, and doing nothing to control uric acid. Also, there are dangers to taking baking soda without medical supervision.
If you need help with controlling uric acid safely, Rian, please ask in the new gout forum.
Hi again, jgee
I should point out that I have no medical qualifications. I can advise on gout from experience, but my only advice on strictly medical matters is “you need to discuss this with your doctor”
That said, I’m happy to share my limited knowledge of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs).
Both indomethacin and ibuprofen are NSAIDs, as are naproxen and diclofenac. There are also many less well-known NSAIDs. They all work in similar ways to reduce inflammation, and all NSAIDs carry the same health warnings about heart risks. Apparently risks increase the longer you take NSAIDs, especially at the max strength required to appease the gout gods. My understanding is that slight variances between different NSAIDs mean that individuals might find one better than the other.
Personally, ibuprofen always worked for me, but other people have said the same for naproxen. What really matters for gout is that NSAIDs are used in the right way.
First, they are not a long-term solution for gout. They are useful for new gout sufferers who might not qualify for uric acid treatment. Once gout has worsened to more than one flare per year, uric acid treatment should commence. If this is managed correctly, NSAIDs will not be required after a few months.
Secondly, NSAIDs should be just one part of your pain control plan. You can reduce dependence on NSAIDs by incorporating colchicine and/or a compatible pain blocker (often Tylenol, subject to doctor or pharmacist safety check).
I’ve never seen anything to suggest that age should be a factor. Having said that, I’ve never investigated it. I leave that sort of thing to the doctors, while I focus on optimum uric acid treatment that removes the need for pain relief as soon as possible.
Hi John, and welcome to the forum.
I understand you’ve suffered some delays due to a problem with your activation email. I hope that’s all sorted now.
You’ve posed a very interesting question here. I love that you are analyzing your food intake and looking for patterns. You might have hit upon a new gout phenomenon that’s only just being recognized by top gout researchers. Joosten has identified that Free Fatty Acids (FFAs) are probably responsible for most of the gout flares previously attributed to purines. He argues that uric acid crystals alone do not cause gout flares. They need a catalyst. The most likely candidates are FFAs, especially stearic acid. Stearic Acid is apparently common in nuts. I thought I’d prepared a list of stearic acid foods, but I can’t find it. I’ll keep looking, and report back.
We had an interesting discussion about this earlier ( https://gout-pal.com/gout-pal-forum/please-help-my-gout/ffa-foods/ ). Interesting, but intense. Theses cutting-edge gout debates are very interesting. But. they’re tiring because all the reports are very scientific, and take some deciphering.
The easy way out of this is to drop uric acid below 5mg/dL. Once the bulk of old uric acid crystals have dissolved, you never have to worry about purines and FFAs. I notice from your profile that you are on allopurinol, John. If this is being managed properly, you should soon be able to stop worrying about nuts.
Hi Mike, and thanks for taking the trouble to post your gout history. You’ve given me sufficient facts to paint a clear picture, and one that is familiar to many GoutPal members.
At what point is allopurinol indicated?
The professional recommendations indicate that uric acid lowering treatment is not necessary if you have less than 2 attacks per year, and no visible tophi. Tophi are often quite difficult to detect when small. As with all recommendations, this is a general guide that must be considered in the light of specific patient details. So, the recommendations certainly include you as a candidate for uric acid lowering, and allopurinol is the usual first choice.With a family history of gout, I would be tempted to say, allopurinol should have been started one or two years ago. As you can see, gout has got progressively worse, and that was predictable.
There are sometimes reasons why allopurinol might be delayed. All these reasons relate to eliminating things that might be causing high uric acid, including:
1. Certain drugs for other health problems
2. Environmental factors such as exposure to toxins
3. Bad dietMike, I don’t think the first 2 factors apply to you, but the third one clearly does.
Now, some people believe that delaying allopurinol while you try to correct your diet is a good thing. I used to think that way, but I know I was wrong. When you think this through, it makes no sense to delay treatment.
Let’s say that diet can eventually cure your gout. Even at it’s best rate of performance, it will take years of extreme food and lifestyle adjustments to get from 473 down to 300. I doubt this is actually possible, but let us say that it is. Let us also be generous, and say that you can achieve this in 5 years. That would mean that uric acid crystals are still building up for at least 4 of those years. That’s 4 years of agony that you do not need. Because I’m an idiot, I delayed even longer, but my joints are suffering because of that.
It makes absolute sense to start allopurinol now. If it is managed properly, that will get rid of old crystals, and allow your joints to start repairing themselves again. That allows you to feel good about exercise, and gives you a better chance of improving your lifestyle. Once you are in control, you can reduce allopurinol to maintain uric acid at 300. As you improve your diet, you will be able to reduce your allopurinol dose.
We do not know, at this time, if you can ever reduce allopurinol to zero. But now is not the time to worry about that. I hope I’ve proved that you must use allopurinol to dump the damaging crystals now. That gives you your best chance of minimum allopurinol in future. It also minimizes your exposure to NSAIDs.
Mike, you’re not cursed with genes that give you gout. You’re blessed with genes that give you the intelligence to control it. Let’s start fixing your gout.
I’m here to help, every step of the way.
Now, that’s what I love to read!
Still a little gout, but you know it’s getting better. I remember that feeling with happiness.
It’s gonna be a great Christmas, Paul. 🙂
It’s great to read that switching blood pressure meds has saved you from the terrors of gout.
Over the year, there have been many posts here about this problem. I would have thought that it would have been dealt with by now, but clearly not.
To gout sufferers of the world, who are on BP meds, use this as a warning. You have to discuss this with your doctor. If there are no alternatives, then use uric acid lowering meds to make your blood pressure meds safe.
First off, side effects of any drug are always important, and cannot be ignored. For common side-effects, a good doctor will warn you in advance, and suggest when it is appropriate to stop and return for an early prescription review.
The symptoms you describe are new to me. I hate to issue ‘stock answers’ but anxiety from ill health and new medicines might be an answer. Another common problem with wrongly associated side-effects is the coincidence of another illness or dissociated factor.The main problem is, your initial prescription is not ideal.
Safe allopurinol dosing works as follows:
1. For those ethnic groups most at risk of severe allopurinol intolerance, there is a genetic screening test. I’m fairly sure this does not apply to you, Chris, so I’ll disregard it here.
2. Take kidney function and liver function tests. These should always be done when uric acid tests are done, but often get missed. Gout patients should be aware of this, and always insist that all 3 tests are performed at least once a year. The combined data held in those tests gives sufficient information for proper planning and control, rather than guesswork. (Who’d have guessed that I’ve had accounting and computer systems training!!)
3. Start the dose with 50mg allopurinol daily.
4. Repeat the 3 blood tests 2 to 6 weeks later. Review properly and increase allopurinol by 50 – 100 mg as indicated by blood test results and patients side-effects.
5. Repeat step 4 until target uric acid level for the first year of treatment is achieved.Based on all of that, my advice would be to drop allopurinol dose to 50mg daily rather than stopping, then get the plan back on track during subsequent visits.
By the way, I think this is a global problem with allopurinol dosing, so just as important to all gout sufferers, whether you’re in Vietnam, Scotland, England, or USA. I used to naively think that doctors would follow professional guidelines, and introduce safe, personal, gout treatment plans. I now realize we must do this ourselves, and rely on doctors for general health advice, blood tests, and prescriptions.
Good luck Chris. As ever, if any of my points are not clear to you, please let me know.
No worries about rushing to reply, Kevin. Sometimes I have trouble posting as quick as I would like.
Everything sounds nice and positive. It’s nice to see things moving forward.
Meat and three is a new thing to me. I’m looking at some stuff now, and salivating.
The thing that strikes me first is, it’s almost a perfect gout-friendly meal. First, we have to change it to meat and four, or meat and five. Second, we have to adjust the meat portion size, so just one of those tasty ham hocks. Third, this should be an occasional treat rather than an every day meal.
You’ve given me some great stuff to work with, Austin. I guess I should stop messing around, and come up with some meal plans.
Stay tuned.
Wow, thanks Paul. You’ve made me realize I’m coming across as anti-doctor, which is not at all helpful. I’ll change my ways, because you are absolutely right. Our doctors help us stay healthy, and understand more than I will ever know.
I describe the British gout guidelines at [edit: link no longer available] at the top of the page. It’s hard to believe it’s almost 9 years since these were published. They are a great guide to better gout management, but really only the start. Things have moved on since they were published, and what really matters is a good personal plan. I hope I can work with you and your doctor to get the right personal plan for you. Please look at my response to Kevin yesterday ( /gout-pal-forum/please-help-my-gout/have-been-taking-300-mg-daily-allopurinol-for-over-a-week-now/#post-22132 ). Though the guidelines provide a framework, there are several points that require personal choices. I believe it is a question of making logical decisions within this framework. I hope the 4-phase approach helps you and your doctor breakdown the big gout management problem into manageable chunks.
Thanks for encouraging me to think more positively, Paul. I’m not yet certain how I can improve my responses to be more helpful, but you’ve definitely shown me that I need to work harder at promoting the doctor-patient relationship.
As for Brighton… Many years ago, I worked in London. One of many highlights was weekend trips down to Brighton. I absolutely love the place. If I had an ounce of sense, I’d hop on the train now. On the other hand, I’ve got fantastic family here in Yorkshire, with a date at my sister’s tonight, and a massive family party on Saturday. Brighton’s gonna have to wait. But hopefully not for long.
Hey Kevin, great first post.
I’m pleased you are finally taking control of your uric acid, so I hope I can help you do this successfully.
I’m not happy with your treatment plan, but it’s better than nothing, and something we can work on to improve. Before I can do that, I have to turn the tables on your main question (“I am curious if anyone can estimate when I might start seeing light at the end of the tunnel”) and ask you: “How long do you want it to take?”
There is no simple formula to say how long it takes to get rid of gout permanently. We do know that uric acid crystals mostly dissolve when uric acid falls below 300 ?mol/L [hint: copy and paste mu from the table in the right side bar, or type
μ]In good uric acid lowering treatment plans, you have 4 phases:
1) Titration – increase allopurinol dose to achieve target uric acid for phase 2
2) Debulking – maintain low uric acid until 6 months have passed without a gout flare
3) Stabilizing – reduce allopurinol dose to achieve no higher than 300 ?mol/L. You might need to go a little lower to account for cold working conditions, but this is something to consider later.
4) Maintenance – monitor with annual blood tests for the rest of your gout-free life.For safety, all blood tests should include liver function and kidney function tests, as well as uric acid.
So returning to the question of how long it takes, I hope you can see why I ask how long you want it to take. In the following list, I’m going to give you some facts that your doctor should know. I can see you’ve been badly let down in the past. I hope, with the facts, and a clear idea of what you want to achieve, you can train your doctors to give you better treatment. Each of the 4 phases is variable, and though you can’t easily forecast the duration, you can certainly lengthen or shorten them:
1) Titration is much quicker if you opt for the minimum period between tests. That is 2 weeks. I can accept up to 6 weeks, but anything beyond that just says to me that somebody isn’t taking gout recovery seriously. It’s not necessarily wrong, but is 11 wasted weeks what you want?
2) Debulking is much quicker if you get uric acid as low as possible. There is no lower limit for uric acid. The main problem is persuading doctors that it is healthiest to aim for a very low target. If you need help persuading them, I can dig up some facts and figures about the dangers of allowing uric acid crystals to hang around longer than necessary.
3) Stabilizing isn’t much of an issue really, though it can be done quickly or slowly according to patient preference.
4) Maintenance. The whole point of the above is that by reducing the first 3 phases, you increase this 4th phase. Gout-free happiness for more years.And the short answer is – get below 300 and my rule of thumb is one month for every year you’ve had high uric acid. Get below 200, and you can probably halve that. This is totally unscientific, but should give you a ball park you can work with.
As for diet, forget it! Gout is not an eating disorder. Just eat a healthy balanced diet (i.e. good for your heart etc), and let allopurinol take care of everything else.
Kevin, I hope this helps you get the gout treatment that suits you best. It’s a bit long-winded, so if I need to clarify anything, please ask.
Good meals, Austin – I like a challenge 🙂
For this to work properly, I really need a recipe, or at least a list of ingredients that I can work with. A very rough example of what I mean is:
Before: A typical steak-and-potatoes meal
8-ounce rib-eye steak
Whole baked potato with sour cream and butter
1/2 cup steamed broccoliAfter: A Mediterranean-style steak-and-potatoes meal
3-ounce rib-eye steak
3/4 cup Garlic and Lemon Roasted Potatoes
1/2 cup steamed broccoli
Grilled Fennel
That is courtesy dummies.com but please don’t take nutrition advice from that site. I haven’t reviewed their Mediterranean advice yet, but their alkaline diets advice is truly appalling and very very wrong.
Please note that this is not an example of a gout-friendly meal, but more an example of the type of approach I would take. This specific example doesn’t include enough information about how it improves your diet. It takes me quite a lot of time to do this, so I don’t want to do it if it isn’t something you would like to do.
The principles are to reduce meat, increase veg, add other gout-friendly ingredients. Changes are best made gradually. If you cannot envisage lowering meat portion sizes to the ‘after’ recipe, then there’s not much point in considering these improvements.
As I say, if you think this is something that will help you, please give me a bit more information about your favorite meals. Then I’ll explain how to make the meal healthier.
Thank you for your information, Austin. I’m really pleased that you’re starting on 50mg allopurinol. It’s the first step in reaching your first goal. Before I discuss your other goals. I’d like to make a few points about allopurinol treatment.
It’s best practice to start on 50mg, as that will determine if you can tolerate it. Most people can, but better safe than sorry. You will need to be tested again to get the dose right. The best time is every 2 weeks, as that is how long it takes for results to stabilize after an allopurinol dose change. It’s good to include kidney function and liver function tests. The maximum safe level for uric acid is 5mg/dL, but it is best to go lower for your first year of treatment to get rid of old uric acid crystals as soon as possible.
As crystals dissolve, they can trigger a gout attack. This is good, as it shows you are recovering, but obviously not pleasant. The way to deal with this is through good pain control. I’ve just described good gout pain control to Paul. The colchicine is optional but useful. The key to success is a combination of anti-inflammatory and pain-blocking meds. When your doctor starts the allopurinol, ask for maximum strength scripts for an anti-inflammatory and a compatible pain-killer. If you decide to include colchicine, remember the maximum is 2 per day.
3.) Loose about 40 pounds.
Weight loss is best done slowly, as rapid weight loss can trigger gout attacks. 2 pounds a week is good, and in 20 weeks, it’s much more likely to stay off than if you lose it quickly. Which brings me to…2.) Avoid foods that might make my Gout worse.
4.) Not live on a boring diet like I?m currently doing.
Rather than thinking about specific foods to avoid, it is far better to think about total diet. It has to be balanced so that you get an adequate amount of all the nutrients you need. In that respect, the main thing to avoid is excess calories. When you overeat, there’s more of the meat that is the biggest source of uric acid – your own flesh.The easy way is: Eat Food. Sufficient. Especially Plants.
Eat food means avoiding highly processed food-like substances. We all love junk food, but it really isn’t good for gout. Mostly, it’s high-calorie, which I’ve mentioned. But also, junk food tends to be high in Free Fatty Acids (FFAs). Recent research suggests that FFAs are the main cause of gout attacks, as they seem to be the catalyst that provokes our immune response to uric acid crystals. Therefore, it’s far better to eat whole foods, and prepare your own food rather than rely on ready meals and takeaways.
Sufficient. The excess weight issue again.
Especially Plants means that most of your food should be plant based. This does not mean you have to become vegetarian. Rather, see meat as a treat. Or follow the traditional Chinese way of using meat as a flavoring in vegetable based dishes. Please note that the Chinese food we see in most restaurants is a Westernized misinterpretation of healthy food. Far better to find old traditional recipes, and make your own. Similarly, traditional Mediterranean meals are mainly vegetable-based. With oily fish as the weekly animal protein, and monthly treats of meat. If you prefer a more scientific approach, alkalizing diets are always high in fruit and vegetables. They’ve also been shown to be useful at lowering uric acid.
I think food boredom comes from the feeling that you can’t eat what you want. My approach is entirely different. I look forward to a delicious roast dinner once or twice a month. In the meantime I create delicious spicy vegetable dishes that I love. I might be slightly overdoing the mackerel and tuna, but allopurinol fixed my uric acid, so I don’t worry about that.
I should point out that this is not an instant fix. It’s good that you are starting allopurinol Austin because that puts you back in control. With diet, changes will, and should, take longer. I find the best way to start is with your shopping list. Each week, reduce the animal content. Reduce the processed food-like substances. Increase fresh or frozen fruit and veg.
Also, you can set me a challenge.
Tell me your favorite foods that you think you cannot eat, and I’ll try to find ways to incorporate them into a gout-friendly diet. I can’t promise a meat feast, but I’m sure I can avoid boring.
Thanks Paul for your detailed response.
Alcohol is always a tricky subject when related to gout. The science is very confusing, with some studies linking alcohol to increased gout attacks, and others saying it has little or no effect. My problem with all these studies is they are just statistics. What really matters is the effect on you as an individual. Even then, what is more important is the effect on your treatment plan.
As far as your treatment plan is concerned, quite frankly it’s a mess. Your doctors ought to be aware that the British Rheumatologist Guidelines put 0.30 mmol/L as the safe maximum. They also state that a lower target is advised in the early months of treatment in order to encourage dissolving old uric acid crystals. When these guidelines were published, and later joined by similar American guidelines, I thought that gout treatment would improve dramatically. Sadly, it hasn’t, because most frontline doctors are ignorant of the professional guidelines.
I honestly believe that the only thing that will wake these people up is a few well-publicised negligence cases. But that doesn’t help you now, Paul. My best advice is to ask your doctor to read the rheumatologist guidelines. These are widely available online and on my website via the search box, but it’s your doctor’s job to read them, not yours. Tell your doctor that you want a long term target of less than 0.30 mmol/L and a short term target of “as low as possible” The UK maximum recommended dose for allopurinol is 900mg per day. I can testify that there are no bad effects from that dose. Rheumatologists suggest that higher doses are safe under medical supervision, but you probably won’t need that.
I’m sorry if I upset you about your gout getting worse, but this is the fact that stupid doctors need to understand. There is a point at which soluble uric acid turns to crystals. Anything below that is safe. Anything above that is dangerous. I know that less crystals will form at 0.52 than at 0.66, but that is not a particularly good thing. It might mean that it takes slightly less time to recover, but you should be recovering now. I’m struggling for words to describe how annoyed I am about this. Doctors need to realise how dangerous it is to have uric acid crystals in the body. Unless uric acid is lowered below the crystallisation point, treatment is useless.
So, your gout treatment plan needs to be lowest possible uric acid for at least a year, then relax allopurinol dose to maintain no higher than 0.30mmol/L (the rheumatologist’s maximum). You need a minimum of 2 weeks between allopurinol dose changes to get accurate test results. Anything beyond 6 weeks means you or your doctor aren’t taking gout seriously.
I don’t know if this helps, Paul, but I had to see 3 doctors before the 4th one realised that everything I said made perfect sense. I was prepared to demand to see a rheumatologist, but fortunately I didn’t need to do that. 75% of UK doctors have no idea about gout, and our American GoutPal members have shown it’s a similar situation in the States.
Once you have that plan, the only other concern is dealing with gout flares until the majority of old crystals have dissolved.
The first step is optional, as not everyone can tolerate colchicine. If you can, then for 2 weeks after each allopurinol dose increase, take a colchicine at bedtime. This is a preventative measure that stops most gout flares, but sometimes they still happen. Also, you have to be prepared for attacks outside the 2 week period. If you feel any gouty twinge in the morning, take another colchicine. Maximum 2 per day. Colchicine does not help swelling or pain. It just inhibits inflammation by poisoning your immune system. Fantastic with care, but not for everyone.
To tackle the inflammation, your naproxen helps. I get a bit confused about naproxen dosage because there are naproxen sodium, and controlled-release versions. My best advice is to get a prescription for the maximum dose, and take as directed. For safety, I recommend naproxen as required, rather than as a preventative. Take the first dose with your early morning colchicine.
Like all NSAIDs, naproxen reduces pain by reducing inflammation. However, this can take a few hours, or even a few days. To get on with your life, you need to support naproxen with a pain blocker. Paracetamol is my choice, but your doctor or chemist can advise other safe alternatives that are compatible with colchicine and naproxen. Never take different NSAIDs together. Paul, you should get a prescription for the maximum dose, as we both know how debilitating the pain is. Take the paracetamol (or alternative) between naproxen doses. I do understand how difficult it can be to face work when you’re in agony. However, I also found that inflammation and pain tend to resolve quicker if I kept mobile. I have to say though, rather than doing a proper job, I was mostly sat at a desk! 😉
Obviously, it’s a personal choice, but I believe my 3-pronged fight against gout pain allows you to function. To me, it felt better to be active, rather than moping about feeling sorry for myself.As for your other points:
There’s a handy reminder about uric acid measurement scales in the right-hand sidebar, where it says “Stop Gout With Safe Uric Acid Levels”. There’s a link to more details, but if that doesn’t help, just ask for clarification.I hope I’ve described what you need to do about achieving your goals. Again, if I need to clarify, please tell me.
That just leaves alcohol.
I think it becomes a much smaller issue, once you have a viable treatment plan. That plan gives you two options:
1. Wait a few months until all chance of a gout flare has gone. Then celebrate 😀
2. Recognise that gout attacks happen during the first few months of treatment, and rely on your pain control plan. Celebrate now! 😀Whenever the celebrations start, let me know. If I can, I’ll be down the ‘Pav Tav’
Hi Austin, and thank you for posting in the gout forum. It’s very confusing when you get such poor quality advice from your doctor. I’ll go through your points, but first I’d like to thank Yakpi and Paul for their wise advice.
1. gout attacks for 3 or 4 years
This is unacceptable and dangerous. Gout is a progressive disease that destroys joints, and damages organs. Though your diagnosis is relatively recent, uric acid crystals have been building up for years. Those crystals must be treated urgently, by reducing uric acid to safe levels.2. avoid fatty meats
Sound advice, but I bet your doctor cannot explain why.3. google for gout diets
Please don’t. You will get reams and reams of misleading crap. Gout diet must be planned personally, to match individual needs. Gout diets are a long term part of an effective gout treatment plan. The best gout diet in the world takes many months to contribute. Diet might contribute to prevention, but it will never lower uric acid enough to treat existing crystals in a safe way.4. side-effects of the meds were worse than the gout
Dangerous, negligent, nonsense. The side effects of a doctor who prescribes ineffective treatment might be worse than no treatment, but that is not the same thing.Ignore diet for now, until you have an effective treatment plan. Without a treatment plan, it is logically impossible to have an effective gout diet. However, if you do want the best starting point for diet improvements, think about alkalizing or Mediterranean diets. Don’t google them – just go to Foodary.com for facts and for personal eating advice.
Austin, I’m throwing this back at you now. I can help, but I have absolutely no idea about you, or your goals. Tell me what you need to achieve, and I’ll help you achieve it. Ultimately, we all need personal gout management plans. But, we all have different ways of managing our unique situation.
I’ll end by asking if my responses so far make sense to you. If not, tell me, and I’ll try to clarify. To avoid being taken in by the rubbish that purports to be gout advice on the Internet, I’m also happy to explain why (almost) everything you read is wrong. Just don’t ask why some say one thing, and others say different. Give me the links to whatever you are reading, and I’ll explain why it’s right or wrong.
Sometimes, it’s just a matter of context. What is right for one gout sufferer might be wrong for another. I prefer to start with the gout sufferer, not the gout. I’m sure that we can train your doctor to give you the safe care you need.
I’m fine, thanks Paul. A little touch of depression, but nowhere near as bad as it has been.
Let me go through your points:
1. Alcohol. 2 out of 3 drinking sessions didn’t cause a gout flare, and I agree with Ron’s view. But, that’s not really the point.
If you believe alcohol is causing the attacks, then do something about it:
a) Don’t drink.
b) Day before a planned session, start preventative colchicine. 1 in the morning, and 1 at night. No more! Maybe 1 a day. Morning after, continue with pain relief if required.I’d go for option b, but remember, excessive alcohol can encourage dehydration, so take water immediately afterwards, and asap following day.
2. Missing work. I always say, if you fancy a day off, any old excuse is good enough. But gout should never be an excuse for missing something you really want to do. If you want to improve your pain relief, tell me, and we can discuss a better pain relief plan (separate topic, as this is getting too long).
3. Uric acid from .66mmol/L to .52 mmol/L. That shift means absolutely nothing as far as treatment is concerned, and uric acid crystals are continuing to build up. I’ve said as much as I can think of about uric acid targets earlier in the thread. What I really don’t understand is why 0.34 is a target? If I knew the reason for that target, I could discuss it sensibly, but it makes no sense to me.
4 “So Keith, was it the booze? Was it likely to happen anyway? It?s now 6 weeks into the allopurinol. ”
Probably not! Yes! At this stage, all you are proving is that you can tolerate allopurinol. It has had no significant effect at the current dose, and so your gout is six weeks worse.
SorryTo summarise: You need a uric acid target for the next year that allows you to dissolve old crystals at a rate that is acceptable to you. You need effective gout pain control to help you during that period. If alcohol remains an issue, deal with it by abstinence or preparation.
I’m not sure if this is sounding too blunt??
I think it’s time to reflect what are your important immediate and long term goals. Then we can plan how to achieve them. I.e. be clear about what you want, and I’ll do my best to help you get it.
How very strange. You know that tophi can be drained, I know that tophi can be drained, yet your rheumatologist says they can’t!
In his defense, surgery in any form should always be a last resort, and the general advice is usually along the lines of “do not attempt draining or surgical removal of tophi unless they restrict mobility, or are likely to burst.” It is much safer to encourage tophi shrinking by lowering uric acid significantly below 5mg/dL.
There is an interesting summary in “The last defence? Surgical aspects of gouty arthritis of hand and wrist”. Though that article is from Hong Kong Medical Journal, it does cite several studies by American and British rheumatologists.
@mjinpa Mike, thanks for that BP testing info. I’m sure it might help many gout patients who are also having blood pressure problems. I’ve been delayed with the Gout Resources website, as I’m putting forum updates as a higher priority.
@giddsey Paul, the anti-clunkiness program is underway. Let’s hope it doesn’t take the shine off the brilliance! 🙂Belated thanks for the update, Phil.
I can’t believe that a doctor in this day and age would suggest stopping allopurinol at the onset of a gout attack!
It must be nearly time for your next test?
It sounds like a good plan to me, except that there is no need to stick on 300mg allopurinol per day. There are very strong arguments for increasing the dose to get uric acid as low as possible. The most important thing though is to get lower than 5. If that requires more than 300mg, then so be it.
I didn’t realize naproxen is a kidney risk? I thought it was just heart and stomach related problems. Your comments made me take a look at http://www.niddk.nih.gov/health-information/health-topics/kidney-disease/analgesic-nephropathy-painkillers-and-the-kidneys/Pages/facts.aspx
It looks like that’s yet another reason for controlling uric acid as soon as possible.
Who will save us from the docs who can’t interpret uric acid results properly?
“the lower end of the too high spectrum” !! 👿
It’s like saying “Only a small tumor!”
Dangerous nonsense.
Mike, if you need help getting uric acid safe, just ask. Your doctor should give you target uric acid numbers below 5, a testing schedule, and some advice about pain control for the months until your uric acid is safe. If there’s anything you don’t understand about her advice, let’s discuss it.
Very encouraging fall in uric acid levels to 6.4! 🙂
In theory, that’s low enough, as the crystallization point for uric acid at normal body temperature is 6.8 mg/dL. However, joint temperatures, especially in the feet and hands is usually considerably lower, and so we really need to aim for 5 to be safe. Even then, deep sea fishermen exposed to prolonged extreme cold have shown that gout can occur even below 5! 😮
I like your thoughts on lowering pH, Phil. I’ve been meaning to start testing my pH levels regularly.
One of the reviews says the test area is too small to be able to see results properly, but maybe it’s a rogue review, as no one else has complained about this. Has anyone used pH test strips for checking urine? Any recommendations?Oops, sorry Paul, I missed a bit on stress and chrysanthemums.
Trust the world’s second most annoying newspaper to omit any links to the actual research! Anyway, here’s something that shows Chrysanthemums are not the only flower for gout: Can Natural Uric Acid Inhibitors Work?
Would anyone like me to do a follow-up to include the chrysanthemum oil capsule research? https://clinicaltrials.gov/ct2/show/NCT02213562 – due to complete March 2016
I’m not sure what the latest views are on the psychosomatic aspects of gout. The main researchers were Katz and Weiner, but nothing much happened after one of them retired. Again, if anyone wants me to see if there are more recent developments from http://www.goutpal.com/the-gout/?q=psychosomatic please ask.
Paul, you can’t blame me if I’m not part of the drinking session. I wish I’d got the train down to Brighton to supervise you. That sea air would’ve lifted my spirits!
I like that you are taking control with the 4 week testing schedule. Is that going to be this week?
” Why is it that all gout advice apart from here states avoiding high purine foods is the best course of action?”
Easy, lazy, 1970s, sell diets, ignore reality, don’t care. Take your pick.
For the true answer, I’d have to see the context of why they are saying it. It was very common advice started 40 to 50 years ago when people thought that gout was an eating disorder. Some people still think that. Many people don’t care because they can charge for diet ‘advice’ but not for medical advice. Some doctors think it because Continuing Professional Education is for other people. Bloody hell! I do CPE and I’m not even a professional. (Before anyone says it – not even close 😉 )
And finally, the “how long does allopurinol take” question.
3 Factors:
- How long has uric acid been over 6mg/dL?
- How much over, on average?
- How low is uric acid with treatment?
Of those, only the last one is controllable. Trials on Krystexxa, where uric acid is reduced to almost zero, proved that serious tophaceous gout can be beaten in 6 months. Your gout isn’t that bad, but you won’t get uric acid so low. Lower Uric Acid Gives Faster Gout Cure show us that uric acid crystals dissolve faster when uric acid is in the easily achieved 3-4 range. All we can say is go as low as possible. It worked for me 🙂
Old crystals making an appearance. I’d bet my life savings on it. Well, half of them – I’m saving the other tuppence for a rainy day.
It’s like an aftershock, and you feel worse because you thought everything was going OK. I’m certain that it is.
I remember when I was going through the first months, I learned to enjoy a gout attack (almost). When you know that you are below 300 μmols (below 5mg/dL) the only explanation is old crystals saying goodbye. It huts, but better out than in!
Beer and Gout Update
This is an old discussion about beer and gout. But it still contains many relevant and interesting points. But, for the latest gout discussions, you should read:
However, before you join those discussions, it is wise to read the facts about gout and beer:
I’m reviewing all my beer and gout articles. So, please share your questions, opinions, and experiences at Beer and Gout review.
Why worry about gout when you’re drinking beer? Is this new guy also a rheumy? Normally, if you wanted a tophi draining, I’d recommend a rheumy over any other doctor. I have heard in the past of some rheumatologists that don’t understand gout, but I’m hoping they are a very rare breed.
Without professional examination of your elbow, it’s impossible to know if draining is an option. It is certainly possible to get a large tophus on the elbow, cos I have one. But the spongy-hard stage that you describe was years ago. I do not believe I had a tophus at that stage, or maybe only a very small one. I think mine was bursitis caused by uric acid crystals affecting the bursa. When gouty swelling around the bursa disperses, then the bursa itself shrinks back to normal. Or at least it did in my case.
Anyway, even if your elbow can be drained, the proper solution is to get uric acid under control. Otherwise, it will just keep flaring. Worse each time.
It sounds like your doctor might not be very effective at advising you on the best uric acid lowering treatment. If you don’t have an option for a better doctor, then we’ll just have to educate this one. I can help you with a safe uric acid reduction plan, but what will you do about other health problems?
Hi Bob,
I’m sorry it’s taken me so long to reply. I’ve been depressed for a few weeks, but out of it now.
Special thanks to Paul and Ron for your comments. It’s nice to be among friends.
I’d like to try and make a distinction between exercise and mobility. Exercise suggests a degree of effort, and possible strain. Stress and strain should be avoided, but mobility encourages blood flow, which can improve circulation. This gets more complicated if heart disease, angina, and other circulatory problems exist, so professional medical advice is vital.
You need to find what works best for you, considering all aspects of your health and lifestyle. When I suffered from gout attacks, I found my best solution was to pop a couple of max-strength ibuprofen, and walk half a mile or so. In most cases, that got me walking comfortably. Stout footwear is best, to support foot joints.
Some people say they can only bear slippers, or no footwear. That puts steady walking out of the equation, but swimming or other light exercise might be an option. As I say, it’s personal. I found that, if I gave up and stayed in bed, or slumped on the couch, the effected joints seemed worse than with gentle exercise (i.e. keeping mobile).
Fundamentally, what is more important is to get uric acid under control. That means a reduction to below 5mg/dL. Lowering from 8 to 7 (or similar) is not going to change your gout in any significant way. I guess it might add a few months to your life, but what’s the point of that if you’re living in agony?
Bob, every day that your uric acid is above 6 is another day of gout getting worse. You might not have a flare, but the uric acid crystals are slowly growing. First they hurt like you’re feeling now, then it gets worse. More joints are involved, and each attack becomes more intense, and lasts longer. Eventually, crystals form lumps beyond your joints. Skin is usually first to be broken, then kidneys, then heart. But everyone is different. It might be your eyes first.
Best not to risk your organs, and do something about uric acid control today. If your normal uric acid reduction regimen really works, that is good. The only way you know is to test it. Get uric acid tests every month, and post the results here.
Please, always remember that gout attacks and uric acid level are not directly related. The gout attacks you get today are from crystals that started to form last year, or earlier. The longer you leave it, the worse it gets.
Brian, I know it’s tough, but you have to believe you can beat this. From what you’ve written, I think you’ve been given some pretty poor medical advice regarding your gout. Let me try and explain and encourage, but first a serious warning.
You haven’t said anything about ibuprofen in this post, but I notice it’s in your profile along with indomethacin. Please assure me that you take one or the other. You must not take both together. There might be an exception under strict medical supervision. But that’s beyond the scope of a gout forum. The correct indomethacin dosage for gout, for most people, is 50 mg three times per day.
When you were prescribed allopurinol, you should also have agreed target uric acid levels, and monthly monitoring with dose adjustment. At the same time, it should have been explained to you, that you are at risk of gout flares until most of your old uric acid crystals have dissolved. It’s impossible to say how long this will take, but the scale is months, not weeks or days. With more information, I might hazard a guess. But for now, you have to be patient.
Getting rid of gout takes time. I can help with specific things you can do to make this time shorter and less painful. I need more of your medical history to do this properly, but even without that, I can give you some general pointers. It’s up to you – just ask what you want from me.
Before I continue, you have to understand that gout is not an eating disorder. At your age, it is almost certainly genetic. That means that bad diet will make gout worse faster, but good diet might not be enough to control it. The first priority is to reduce uric acid low enough to ease the burden on your joints and other tissues. Once uric acid is under control, maintaining healthy weight with a balanced diet and regular exercise might reduce your need for allopurinol. That is not the issue now – you need sufficient allopurinol to get rid of old uric acid crystals as soon as possible. Without that, you just get frustrated, because all your healthy lifestyle improvements are never enough to fight crystals that have built up over several years.
Let me address some of the specific points you have made, then you can let me know how I can help you better.
1. “But, lately (the past three months) it has just gotten out of hand.”
Gout is progressive unless/until uric acid is reduced below 5 mg/dL. It gets worse every day irrespective of if you have a flare or not.
2. “In August I decided that I had enough of being overweight. I was 336 pounds and feeling like crap most days. So, I started dieting and exercising with conviction.”
Weight loss is good for gout. Rapid weight loss almost always causes gout attacks. 1 or 2 pounds a week is best. You should have a target weight that matches your height. As I said, I recommend allopurinol intervention, combined with weight loss. Once targets are achieved, and you are ‘all clear’ you can consider allopurinol dose reduction.
3. “About mid-October I had already suffered two gout attacks. I went to the urgent care. They told me that the low-carb diet was causing it, because of high protein intake. They gave me some prednisone and sent me home.”
They are bastards.
Your diet might not have been the best there is for gout, but high protein intake is not the reason. You were trying your best, and I think they could have given you a lot more encouragement to manage your diet more effectively.
Prednisone is very much a last resort for gout, but I don’t expect the bastards know why, or even care.4. “I switched to a low-calorie diet instead. I eat roughly 1,600 calories a day, eating whole grains, chicken, fruit and vegetables. I still do not drink soda. I don’t drink alcohol either. I am trying to be healthy as possible.”
Brilliant! The only thing better is probably 1600cal Mediterranean or Alkaline diet, but you can consider that when you’re ready.
5. “After about five days I was back to normal. I started exercising again, amping myself up to 3-4 miles a day. As of today, the gout is back again in force.”
Let’s be clear. The gout never went away. The gout flare subsided. Big difference. Gout is still destroying your joints and building up to a bigger attack, even when the flare has gone.
6. “The medicine prescribed to me isn’t working. I’ve lost 45 pounds since the end of August. So a lighter body, exercise, and healthy diets don’t seem to be helping. I’ve tried ingesting cherry juice, apple cider vinegar, and baking soda in the past. Those ‘natural’ remedies did nothing.”
Cherry juice sometimes helps a little bit with gout pain.
Apple Cider Vinegar can be an effective placebo for some people.
Baking soda can help lower uric acid, in the same way that an alkalizing diet can. One of those is healthy. The other raises blood pressure. Baking soda was thought to be safe last century. Doubtful now.7. “I plan on visiting my doctor this week. But, honestly she basically gives me the same packet of things not to eat and sends me home every time. It’s frustrating. This time I plan to be more assertive in trying to get help.”
Yep! Don’t leave there until you have a plan for uric acid control at least, and preferably some help with weight loss targets as well. Uric acid must be lower than 5 mg/dL, and I recommend 6 months as low as you can get. That minimizes the time you are at risk from another gout flare, and gives your joints the best chance of recovery. Allopurinol dose needs to be adjusted as directed by blood test results. I recommend 4 weeks between tests. 2-week intervals are the minimum to allow for dose changes to register. Anything more than 6 weeks between tests is a clear indication that gout is not being taken seriously.
8. “I just don’t know if I’m doing anything wrong. I’m trying my best here to be a healthy person and improve myself. “
Brian, you are doing everything right, and I feel you are definitely on the right track. Because you have not had the right explanations, it is very frustrating. Especially so, as you have to learn the science before you can tell your doctor what is needed.
If anything I have written here is not clear, please tell me, and I’ll try to clarify.
I’m trying my best to help you be a healthy person and improve yourself. Just keep coming back with your questions, experiences, and opinions.We’re gonna beat this!
Oh wow, if you can write your own HTML and CSS, then inputting into WordPress will be easy. I might even give you the job of styling it so it looks nice. My priority for the weekend is to get that project going properly. I’ll be in touch. Now for the gout stuff.
Blood pressure and gout are often linked. Choosing the right BP treatment is often all you need, so I’m glad it seems to be working. I’ve a couple of points:
1. If the reason for the switch to losartan is uric acid related, how come you haven’t had a uric acid test to confirm that both aspects of the change have worked?
2. Have you ever tried testing your own BP? The only reason I ask is that I suffer from what is commonly called “white coat syndrome.” I see a doctor (or nurse) and my BP rises. A nurse suspected this when she wasn’t happy with my BP, and retested. The next 2 tests went higher! She suggested I try the self-test room they have at the clinic. Sure enough, my BP was normal, and this was also proved by a 24-hour portable test machine. It might be completely irrelevant to you, but I can’t help mention it when the topic of blood pressure is raised.Acetaminophen is quite a strange drug. It’s not classed as an NSAID, but it does have some slight anti-inflammatory properties. I’ve used it in conjunction with ibuprofen, as well as on it’s own. You do have to be careful about maximum dose, as overdose does cause irreparable liver damage. I’m not aware of any safety issues at normal dose. Obviously, it’s much wiser to limit any pain medication, and try and remove the cause.
I have to leave for work now, but I’m looking forward to an interesting weekend. If you, or anyone else has any ideas about making my gout information more accessible, please feel free to deposit your messages in the suggestion box.
