Gout Flares during Urate Lowering Therapy

Stopping Gout Together Forums Help My Gout! The Gout Forum Gout Flares during Urate Lowering Therapy

This topic contains 11 replies, has 5 voices, and was last updated by  Cindy 1 year, 3 months ago.

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  • #3649

    Christopher Husada
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    Ŧallars: Ŧ 2.31
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    I’m 22 years old. I’m from Indonesia. I read the article in this site about why it’s painful during gout lowering treatment. I’ve been having gout since 2011, it’s been going on for 5 years I left my gout untreated. Until march 2017 I decided to fully treat my gout. I lowered my SUA level from 9.5 to 6. Last time I check, april 18th 2017, my SUA is 6. By the time i’m writing this, the date is May 14th 2017. So, my ULT been going on approximately 2 and a half months.

    I understand that during lowering treatment, we might have caught another flares-up, sometimes in places that never been attacked before. In just 2 months since I took 300mg of allopurinol continuously until today, I got series of flares, 4-5 times. For 2 months I haven’t been able to walk like a normal person (the only near-normal-condition is half limping). Every time I got flares, I took NSAID (90mg of Arcoxia – Etoricoxib) and 0.5 mg of Colchicine. I took Colchicine daily for prophylaxis. What I’ve been meaning to ask is: is this really normal? if so, why? Mr. Keith Taylor said if it hurts, then it’s working (old crystal dissolving)….but now I have a lot of doubt whether it is feasible or not, because whenever I nearly recover, the next week I got another flare, so that I can’t enjoy days like a normal person would.

    I haven’t seen a rheumatologist before. Please anyone help me, i need some answers. This is another useful information i wanna share to help diagnose what’s best for my condition:
    Flare location is in my left foot, the tophi (pain spot) is in my subtalar joint between my calcanaeus heel and talus bones. In my right foot, the spot is rather on top of my foot, and inner side. Neither big toe’s are harm (i never experienced pain in that area). Is gout relatable with muscle trauma? because once before i have gout, i did running, karate, and other exercise that uses both of my pain spot.

  • #3652

    nobody
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    Ŧallars: Ŧ 470.84
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    Hi,
    Curing gout is typically painful but it needn’t be that bad.
    I wonder if you might suffering needlessly because of the dosing of the drugs you take. More on that later.

    Diagnosis over a web forum is basically impossible and I can’t tell you what’s normal because everyone is different (you’re much younger than most gout sufferers, my SUA was never as high as yours used to be and so forth). But in answer to your questions:
    -connections between gout and both recent and old trauma (the trauma need not be major) are possible
    -it doesn’t seem uncommon to experience ongoing serious symptoms over several weeks when initiating ULT

    You haven’t explained all your circumstances or the rationale of your doctor for prescribing the doses you’re taking but assuming you do not have unusual conditions or drug intolerances…
    -this might be controversial but while guidlelines in many places would have you target a SUA below 6 with ULT, my opinion is that the target should be lower inasmuch as you are experiencing serious gout symptoms. On top of that, have you established how much your SUA typically varies? You aren’t testing it very often and for all you know it might be well above 6 most of the time. The lower your test results, the larger your safety margin against variations. And the maximum allopurinol dose is much higher than 300mg.
    -0.5mg of colchicine is a much lower dose than 90mg of etoricoxib. I don’t know how large you are but chances are your colchicine dose was insufficient which is why your symptoms didn’t abate completely or came back constantly. Trouble is, if you’ve used colchicine every day for 2 months, now might be the time to think about discontinuing it rather than increasing the dose. The longer you take colchicine, the more pernicious side effects you’ll get (though your dose might have been low enough to mitigate that). There are alternatives to colchicine but they have their own issues.
    In other words I think you might benefit from an appointment with an experienced rheumatologist who could review your medications.

    The following is only an anecdote but when I started pharmacological ULT for real, I was initially testing every 2-3 weeks and got a result well under 4 the second time.
    Not that I recommend you actually try to get your SUA that low. But 6 is probably still too high for your deposits to dissolve fast enough to spare you unnecessary misery (though that might depend on the temperature, your diet and the amount of water you’re drinking, how good your body is at excreting UA and so forth).

    • #3655

      Christopher Husada
      Participant
      Ŧallars: Ŧ 2.31
      GoutPal Carer Badge Rank: Carer

      Thanks for the clarity of the issue, actually I feel better now. What you said is true, my actual target SUA before the initiation of ULT is below 4, and my schedule for another lab test is this Saturday, hopefully the result shows me that I got lower than the last result (below 6, or better below 5).
      another question:
      1). If I take one 0.5mg Colchicine/day for, say 1-2 months, is it advisable? just for prophylaxis. It’s just I want to prevent another attack coming while i’m on ULT

      2). I read somewhere and base on my last doctor told me before, that while i’m on 300mg of allopurinol, lab test should be at least once per 30 days (1 month) to really know whether the 300mg dose works or not. Can anyone elaborate?

      3). And lastly, this is just another personal hypothesis, if I got the next lab test a much lower SUA than before, and if I got another flare not long after that, than can I assume that this is the real application of the “old crystal dissolving” theory?

    • #3656

      nobody
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      My assumption would be that your old crystals have already been dissolving, but slowly. Too slowly.

      There’s no magic about 30 days. The ideal time between tests depends on what information is needed.
      If you were doing well and both you and your doctor were confident no adjustment was needed, you might be tested less often. But you’re not doing well.
      Blood tests are not the only source of information. When you say “for 2 months I haven’t been able to walk like a normal person”, that suggests something is not ideal.
      If I understand well, your allopurinol dose has not changed for 2 months. That is a long time.
      Maybe another doctor would have increased your dose without waiting for a test but if your doctor thinks more information is needed before acting, you need to get tested soon.
      Getting your SUA to 5 or below until the symptoms go away sounds like a reasonable target.

      I don’t think I’ve ever taken colchicine daily for more than 6 weeks. I doubt you’d be harmed by taking such a small dose a little longer but I really don’t know. Others have experienced side effects from prolonged use.
      There are alternatives to colchicine if your body needs a break but as I mentionned, the alternatives are harmful in their own way. It’s a matter of balancing risks and I think you need an experienced doctor to do the balancing.
      An alternative to taking colchicine every day is to take it as soon as you start feeling symptoms. But of course that’s not practical as long as you are suffering from constant symptoms.

    • #3663

      Christopher Husada
      Participant
      Ŧallars: Ŧ 2.31
      GoutPal Carer Badge Rank: Carer

      Well, thanks again for the answer. This clear things up. I finally get the big picture of what I should do now and next.

    • #3686

      Keith Taylor
      Keymaster
      Ŧallars: Ŧ 1138.53
      GoutPal Scholar Badge Rank: Scholar

      Hi Christopher,

      I’m really pleased you’ve got the answers you need. So, massive thanks to nobody for helping you out. It’s comforting to know that gout sufferers can get answers to questions, even when I’m busy for a few days.

      Christopher, I hope you’ll create more new topics with any other questions, experiences, or opinions about your gout. Good luck with your continuing recovery.


  • #3799

    d q
    Participant
    Ŧallars: Ŧ 340.34
    GoutPal Scholar Badge Rank: Scholar

    Hi Christopher, as most of your questions have been addressed by nobody I won’t get into details however I wanted to re-assure you that what you are experiencing is exactly what I am experiencing.

    It has been almost 8 weeks since this attack started. My first attack was when starting 200mgs of allopurinol which settled within a few days I then started 300mgs to drop my UA further and I got hit with the big attack, that settled after about 3-4 weeks but I still had lingeriung pain and it seemed I was going through gout hell (search this site for information on that) the moment I then started 400mgs to attempt getting out of gout hell and the pain has slowly been getting better and better. I still am feeling residual pain and am due a further blood test to see my results on 400mgs. I should have the results for that in a week.

    100mgs allopurinol took me to 555
    200mgs allopurinol took me to 388
    300mgs allopurinol took me to 33k
    400mgs allopurinol not yet known.

    Be tough, I know exactly what your going through and I hope the above helps.

  • #4058

    Christopher Husada
    Participant
    Ŧallars: Ŧ 2.31
    GoutPal Carer Badge Rank: Carer

    Hello everybody that read this thread, i want to update my condition. I wrote this thread 2 weeks ago. Since then, i haven’t got any flares up until May 28th 2017 (at this point, i thought “what is this? i’m on 300mg of allopurinol/day since March 27th 2017, not one day without 300mg of allopurinol, so logically speaking, my crystal should already be dissolving and i was confident that at this point my SUA will be lower than 5.0 because last time i checked on May 20th 2017, my SUA is 5.2).

    So, at May 28th 2017 i got another flare on the same spot i told everybody above (left foot – subtalar joint between the heel’s calcaneus and talus bones). I took emergency helpers like 90mg of Arcoxia(Etoricoxib) and 0.5mg of Colchicine. And then, i went to hospital to get MRI scan. The result was: my foot bone was intact, normal as new, but the doctor said something about the pad/cushion between that area of achiless tendon and calcaneus bursa being inflamed/swollen (right now, the information is still partial and i have to get to that hospital again to clarify the scan result).

    And then, on June 3rd 2017 i went to a lab to check my SUA (at this rate, i’m still on flare but subsiding slowly). The result was shocking, my SUA is 5.9, and that means my SUA rising again despite the fact that i’m taking 300mg of allopurinol daily since March 27th 2017 (3 months).

    Okay, enough of the backstory. Now, i want to get to the main point. Please anybody, especially Mr. Keith Taylor, to help me answer these questions:

    1). So is it possible that SUA fluctuates during Urate Lowering Theraphy? even if i’m taking allopurinol daily in order to achieve lower SUA level?

    2). I want to raise my dosage of allopurinol from 300mg/day to 400mg/day until June 18th 2017, which is 2 weeks, starting today, June 4th 2017 to observe whether my SUA level fluctuates again or not. Is this a good plan?

    3). How to prevent future SUA level rising again? because i’m on healthy diet, i’m not eating any high purine food or anything.

    Thank you for reading this, your answer might be a big help for me.

  • #4069

    d q
    Participant
    Ŧallars: Ŧ 340.34
    GoutPal Scholar Badge Rank: Scholar

    I will leave Keith to answer your questions in detail however;

    1. Yes, when you start ULT you dissolve crystals, when crystals are dissolving, they are released into the blood. During this phase UA levels will rise. Think of it like this, put a block of sugar in warm water and start stirring it. As more of the sugar dissolves, the concentration of sugar in the water rises hence why it becomes sweeter.

    2. It will more then likely fluctuate again and probably be lower as time passes.

    3. Taking your allopurinol medication correctly will eventually get you back on track and you may even possibly have to lower your dose later down the line.

    It would be wise to consult your rheumatologist before increasing your dose yourself however.

  • #4073

    Christopher Husada
    Participant
    Ŧallars: Ŧ 2.31
    GoutPal Carer Badge Rank: Carer

    Thanks DQ for answering my questions. That’s a relief to hear that the sugar block theory of yours. Actually, i’ve been thinking about that possibility for a long time, i wasn’t sure of my hypothesis but now your answer just strengthen my thought about that, so that i’m confident it’s not just me that have a hypothesis like that.

  • #4074

    Christopher Husada
    Participant
    Ŧallars: Ŧ 2.31
    GoutPal Carer Badge Rank: Carer

    One more question for everybody, this is regarding the block of sugar theory. I get it that the “warmer the water gets, the sweeter the concentration,” and the more dissolving of the “sugar block”. Ok i get it until that point.

    what i still don’t get is, why is it that it cause another flare at the pain spot on foot? because logically speaking, isn’t the “sugar block” concentration got decrease? got smaller? if it got smaller size why i still got painful flare that become obstacle for me to walk normal?

    • #4082

      Cindy
      Participant
      Ŧallars: Ŧ 10.10
      GoutPal Historian Badge Rank: Historian

      Hi Christopher,

      Here’s info from Keith’s website sub-title “Lowering Uric Acid Can Cause Pain”:

      Unfortunately, as they are dissolving, uric acid crystals shed the protein coating, and the immune system starts to attack again, which may result in a painful gout flare.

      Allopurinol Medication: Why It Hurts To Get Rid Of Gout

      Hope this helps answer your question.

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