Sorry for my delay in responding. Thank you for your patience.
Your problem is one of my main triggers for starting me on a rant. The others are:
- Normal uric acid levels.
- Sharp, needle-like uric acid crystals.
- Foods to avoid that cause gout.
- Vegetable purines.
There’s at least one more lurking in my mind. I’ll resist the temptation to think about my list of common gout misunderstandings. Let me focus on your common problem of gout flares during uric acid lowering.
To understand it, you need to understand how the gout pain pathway works. Now, that doesn’t mean understanding all the intricate biochemical details of inflammasomes and the inflammatory response. Even the best scientists in the world are still working out exactly how pain signals are generated during gout attacks.
I’m talking about the basic building blocks of the gout pain pathway. I call it U-D-R-P The Gout Pain Pathway. In a nutshell: gout pain results when our immune system is overwhelmed by the volume of invading uric acid crystals. The signals for reinforcements produce inflammation, which is the root of gout pain.
If we look a little closer at our immune system, we see how white blood cells fight uric acid crystals. White blood cells work by engulfing foreign invaders in our bodies. This kills bacteria and viruses, if they don’t kill us first. But uric acid crystals cannot be killed. However, once they are surrounded by white blood cells, uric acid crystals are no longer a threat. That is why gout attacks subside naturally in a few days.
There’s 3 interesting points here:
1. This process happens even on days when you do not have gout pain. Every day that uric acid is above your crystallization point, is a day that uric acid crystals are forming somewhere in your body. If the numbers are low, the crystals just get engulfed without fuss. Most days, there are insufficient crystals to cause an attack. But, our bodies are storing an increasing load of uric acid crystals coated in dead white blood cells. This is what we refer to as the uric acid burden.
2. Most of the uric acid crystal fighting is done by white blood cells that we developed for the purpose. But, other specialist cells get caught up in the battle. That includes the cells that were destined to repair bone, cartilage, tendons, etc. So, joints don’t get worn away by sharp crystals. The permanent damage is caused by the maintenance crew called to war. Do Gout Crystals Kill Tendons, Or Just Their Babies? Note that it isn’t just tendons. Those little babies destined to repair your heart valves aren’t spared. Gout is fatally brutal. If in doubt, read Can Gout Kill You?
3. At last, we get to your problem, David. Regular visitors get to know that my trigger points cause mammoth posts. Other rants are available.
Some of the foregoing isn’t really a rant. Every gout sufferer must realize the vital importance of lowering uric acid. If you do not get uric acid low enough to dissolve the uric acid burden, you will die a horrible death. I emphasize this, despite knowing that you are sensible, David. Other readers don’t always get it.
When uric acid levels fall, old crystals start to dissolve. When they do, the cloak of dead white blood cells falls away. For a short period of time, dissolving crystals are exposed to our immune system again. Battle recommences.
It can be a slight skirmish. It’s why we sometimes feel a little feverish when starting uric acid lowering. It can be a full blown gout flare. But, it differs from the battle we grew used to when crystals were forming.
I mentioned earlier, we often do not have a gout flare when the burden is growing slowly. But, uric acid lowering is a much faster process (if it’s done correctly!). So, we often experience pain in joints that we’ve never noticed before. Also, it usually affects more joints at the same time.
I think it’s now time for me to finish with my usual: “If you want clarification on any of the points I made, please ask”. That is not a trite response. I just condensed 10 years of research into an hour of writing. I’m bound to have missed something. And the only reason I do this is to help you understand your gout (and polish my ego, of course! 😉 )
The real reason this has caused me to write a longer post than normal, is your bloody doctor’s attitude. I have said on many occasions – I’m not here to bait doctors. But, this is the exact problem that leads to many gout sufferers stopping their treatment. Doctors talk of non-compliance as if everything is the gout sufferers fault. But, why would you continue taking something that is causing you pain, if you don’t understand the situation?
What’s worse is, it’s easy to avoid. The professional recommendations for gout management include clear guidance on pain control during the first six to twelve months of uric acid lowering.
Some gout patients are lucky. Like you, David, they might get by with occasional Advil, or similar. Others have their quality of life destroyed. Needlessly.