Hey James, that was well worth waiting for! 😀
First, a massive thank you for inspiring me to write Don’t be a Gout Statistic. Please note, that is not a personal response to you. It is some general thoughts I have about the value of gout statistics. Ie, gout statistics are very important in the context of general gout guidelines. But, they are mere pointers for investigation and action, when it comes to personal gout management plans.
So, for point (1), I can’t agree with your rheumatologist. That does not make him wrong. But, we have different reference points. I don’t want, or need, to discuss the statistics with your rheumy. What matters to me is, are you happy with allopurinol for life?
You might see I’ve flagged my allopurinol vacation article for review. I need to clarify general principles. But, beyond general principles, you need to be happy with your personal treatment plan. Of course, the idea of a break from allopurinol is a future concern. First, you must demonstrate that you have tight control over uric acid. And, your uric acid burden needs to be considerably reduced before you can contemplate an allopurinol vacation.
It’s up to you if you want to discuss it now, or in a few months time.
2) Thank you for those links. I’m short of time to investigate them fully at the moment. If you, or anyone else wants to prioritize this, I suggest a separate topic.
3) “take Allopurinol and you should be able to enjoy most foods in moderation without having to count life by the minute and avoiding all sorts.”
I don’t think avoiding certain foods is ever the answer. But, we all (gout sufferers) do it. What I learned most from controlling uric acid is that diet is very important for general health. No point in controlling gout, only to die of a heart attack.
I remember reading that allopurinol stops all uric acid production from food intake. And, it stops about half of uric acid production from our own flesh. So, for gout diet, there is no purine consideration when taking the right dose of allopurinol. And, the gout risks from being overweight are halved.
But, there’s more to life than gout control. Which is why I should spend more of my time adopting and promoting EFSEP. But, that’s a different topic.
Gout Pain Control
If “as required” gout pain control works for you, I think that’s best. Personally, I also preferred this to preventative gout pain medication.
The most important thing for all gout sufferers is to feel comfortable with their personal gout pain control therapy. Then, gout attacks are much less fearful. And, your last question about gout attack risks on allopurinol become less important.
In principle, I answered that in the article you inspired. But, on a personal level, I’d need much more precise information, James. Risk of gout flare depends entirely on individual uric acid levels. Both current, and historic. Historic uric acid levels determine the size of your uric acid burden. That, in turn, determines part of the risk factor for gout attacks. But, the risk is in 2 parts: risk from new crystals forming. And, risk from old crystals dissolving.
The risk from the uric acid lowering part of the equation only comes into effect when uric acid crystals start to dissolve. At core body temperature, this is 400 μmol/L (6.8 mg/dL). Lower at the joints due to temperature, so certainly not a consideration at this stage in your gout recovery.
[skip next 2 paragraphs if this is getting boring]
Once you lower uric acid to therapeutic levels, you might be able to titrate allopurinol treatment to slow down the rate at which old crystals dissolve. In theory, that would reduce the risk of gout flares from allopurinol. But, you also have to consider the lifetime risk. This is an exercise in improbable uric acid lowering measurement, and incredibly complex gout flare risk assessment. My mind boggles at the complexity of risk assessment at each joint with the range of differential temperatures; uric acid burden; and localized uric acid blood concentration.
Academically, it might be an interesting project. In practical terms, the way to reduce the risk of gout flares is to aim as low as possible for uric acid. And, if you’ve tested positive for low uric acid excretion rates, supplement allopurinol with uricosuric gout medicine.
Sorry, my last few paragraphs got outrageously technical. In short:
A. Be confident with gout pain control.
B. Get uric acid as low as possible.
C. Stop worrying about gout flare risks.
Thanks again, James, for your continuing support of GoutPal. I look forward to your next inspiring contributions.