Hi Mark, and Happy New Year to you. I hope we can make 2016 the year you finally get rid of all gout pain and discomfort.
It’s great to see that you are taking allopurinol. That is the easiest way for most people to resolve tophi. By getting your uric acid level low enough, all your worries about gout will disappear. But, it takes time.
You probably have around 14 years of uric acid crystals deposited all round your body. With allopurinol, you can cause these to dissolve, but you have to get uric acid as low as you can. The ‘toothpaste’ in your foot is certainly uric acid crystal deposits. Though you have no physical signs yet, you can be sure that uric acid crystals are spread round other parts of your body. The professional rheumatologists advice recommends aiming for lower than 5mg/dL until the uric acid crystal burden is mostly removed. Therefore, it makes sense to go for the maximum dose of allopurinol.
The maximum allopurinol dose is 800mg per day in USA, and 900mg in UK. Doctors have the ability to prescribe off-label doses of higher amounts, or they can also add probenecid, which works for gout patients who are under-excreters of uric acid.
Allopurinol dose should be increased slowly, with at least 2 weeks between tests. Blood tests should include kidney function, and liver function, as well as uric acid.
Pain control is required until most of the uric acid crystal burden has dissolved. I was prescribed preventative colchicine for two weeks around each allopurinol dose increase. Outside that time, I was prescribed additional colchicine to take at the first sign of a gout attack. Even with the colchicine, some gout attacks might start. In that case, your Nabumetone is useful, and you might get even better relief if Nabumetone is supplemented with a compatible pain-blocker. Ask your doctor for a safe combination that allows you to keep active. Gentle exercise resolves gout pain quicker. It will also help you lose weight. Gradual weight loss (say 2 pounds a week) is one of the best things you can do for your gout.
Mark, I hope this helps as a starting point. Every year, I help people control their gout, and allopurinol is usually the easiest and safest way to do that. It’s very important to control uric acid properly, and also to understand that pain control is vital until old uric acid crystals are dissolved.