Mini gout flare whilst on Allopurinol

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This topic contains 17 replies, has 3 voices, and was last updated by  Keith Taylor 1 year, 11 months ago.

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  • #1559

    Gout Patient
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    Hi,

    Starting a new topic as requested.

    I was diagnosed with gout about 6 weeks ago, in my left foot (not the big toe, but more on the left of my foot). It was so painful, at first, I thought I had broken it!

    Anyway, blood tests confirmed gout. I took Naproxen for about a week until the swelling had subsided, then Allopurinol for about the last 3 weeks (200mg per day). A second blood test (about 10 days ago) confirmed the uric levels were falling and are now at the high end of normal.

    I now have the figures from the GP:

    8 July: 526 µmol/L
    28 July: 309 µmol/L

    That’s a remarkable drop in 3 weeks, I hope the readings are accurate!

    Everything seemed to be improving until a few days ago when I’ve had another gout attack. Not even close to being as bad as the first one, but still red, swollen and quite painful. I’m taking Naproxen to calm the attack, whilst staying on the Allopurinol. The Naproxen seems to be working and this morning, whilst the swelling is still there, there’s less redness and ‘heat’.

    I *think* this is normal and that this is simply the Allopurinol working and dissolving the crystals and whilst this happens, you can have further mini-attacks.

    Do you have any suggestions? I’ve been really strict with my diet since my diagnosis: no alcohol, very little meat, no seafood and lots of fruit/vegetables. And about 3-4 litres of water per day!

    Many thanks,

    Dave.


    Can 2 x 100 mg Tablets cause a mini gout attack?

    Is 200 mg allopurinol OK?

  • #1568

    Keith Taylor
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    Dave, thank you so much for digging out those test results.

    Now, though you say you were first diagnosed with gout 6 weeks ago, uric acid crystals have been building up for years before that. It’s impossible to know exactly when. There are now advanced imaging techniques that paint a better picture of your uric acid burden. But, we can manage without those.

    We just need to know what to manage. There are 2 things:

    1. Uric acid burden
    2. Gout Pain until uric acid burden has mostly dissolved

    Your test results show your uric acid is well under control. You could go lower if you wanted to as a temporary measure for a few months. Most doctors will only agree to this if you have visible signs of tophi. I’m guessing this is not the case for you. So, all that’s left to do is to maintain regular tests. I recommend monthly tests, at first. As your results stabilize, you can extend the interval. Always test at least once per year. Uric acid tests should be accompanied by kidney function and liver function tests. That is usual for most doctors, but always best to check.

    You might find fluctuations in uric acid test results. This is normal, especially if your appointments are at different times of day. However, you should soon see a natural average. Ideally, this will fall below 300μmol/L, but 309 is very close. If it does start to rise as you get older, you might have to increase allopurinol dose. This is fine, as you are well within the maximum dose.

    For a few months, you are absolutely right when you say “I *think* this is normal and that this is simply the Allopurinol working and dissolving the crystals and whilst this happens, you can have further mini-attacks.”

    For this reason, good gout doctors usually prescribe pain control for a few months. There are several different approaches to this. Some doctor prescribe daily colchicine for a few months as a preventative. Personally, I think if you are managing OK without that, then best to stick to naproxen.

    All I would say, if you are incapacitated, is to speak to your doctor about paracetamol, or similar compatible painkiller, to take alongside naproxen. I think it’s important to stay mobile when you have a gout attack. That, at least for me, stopped gout attacks sticking around for many days.

    All in all, Dave, I’d say you are well on the road to recovery. Your diet seems healthy, which will be good for other potential health problems that often run alongside gout. Of course, if I need to clarify anything, or you get other questions, just ask.

    I’m sure your gout attacks will become fewer, and less intense, as you continue to bring uric acid under control. It amazed me how little gout hurt when I knew my uric acid was safe, and occasional flares were just a sign of old crystals dissolving. 🙂

  • #1571

    Gout Patient
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    Hi Keith,

    Many thanks for the detailed reply. I’ve scheduled another blood test for a week’s time and will post the results here. I guess there will be some natural variation in results, but it should be on or around the 300 mark? If for some reason (and I can’t imagine how given my diet and allopurinol) it’s gone up, should I suggest a higher dose of allopurinol?

    Other than that, I just stay with the medication (200mg of allopurinol, naproxen as necessary) and the mini flares should stop in time?

    Best wishes,

    Dave.

  • #1573

    Keith Taylor
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    Yes Dave.

    I know you’ve written your responses as questions, but they can also be read as statements. You’re doing everything right. So, if you are happy with progress, then it’s good to continue as you are.

    There’s not much point in speculating about your next test results. But it’s great to see you’re getting those all-important tests to monitor your progress.

  • #1662

    Gout Patient
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    Hi,

    Quick question – I’ve just had another blood test and am waiting for the results. I’ve subscribed to Patient Access so I can check online.

    The new ones aren’t there yet, but I noticed on the older ones that

    I now have the figures from the GP:

    8 July: 5.6 mmol/L was Serum UREA level (normal quoted 2.5 – 7.8mmol/L)
    28 July: 309 µmol/L was Serum URATE level (normal quoted 200 – 430µmol/L)

    Is there any different in these and should I be asking for one or the other?

    Many thanks,

    Dave.

  • #1700

    Keith Taylor
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    Thanks for those, Dave.

    Urate is uric acid. Strictly speaking, it’s a salt of uric acid. I nearly always use uric acid instead of urate. I feel that it is more widely used in our world. Urate seems more common in the medical world, but uric acid is still most common, in my experience.

    Urea is completely different. The urea test is part of a standard kidney function test. In my opinion, kidney function (and liver function) should always be run alongside uric acid tests. Uric acid is a specific test that is vital to gout diagnosis and treatment. These other tests are good indicators of general health. The results need to be interpreted by someone with far more medical knowledge than I’ve got. In the context of gout management, these tests help:

    1. At the diagnosis stage, as a general purpose tool for ruling different diseases in, out, or maybe.
    2. At the treatment stage, as a check for adverse reactions to treatment.

    I’m not qualified to talk about your urea test result. I believe that these results are most valuable when compared to earlier patterns.

    I could talk for a year about uric acid test results. But, I’ll try to rein it in. As I said before, 309 is pretty good.

    I have to warn against anyone taking those normal ranges seriously. They should be banned! People think “normal” means “usual” or “acceptable”. Lab results do not use the word “normal” in this way. It is a statistical term that defines a specific type of averaging – The Normal Distribution.

    Another way to consider it is this. Take a room of healthy adults mixed 50% men and women. The normal range for breasts and testicles is both around 1! Do you want that as a basis for medical treatment?

    Normal ranges are ignored by anyone with more than half a brain. If any doctor tries to pass off 430μmol/L as acceptable they need to be retired. Or, buried, as they do with their other mistakes.

    You’ve done it Dave! All day, I’ll be ranting to myself about Normal Uric Acid!

    Quick somebody – warn the neighbors! 😉 😀

    P.S. Thanks for another interesting post, Dave. Keep ’em coming.

  • #1709

    Gout Patient
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    Hi there,

    Latest test results back:

    8 July: 5.6 mmol/L (Serum UREA level)
    28 July: 309 µmol/L (Serum URATE level)
    19 August: 337 µmol/L (Serum URATE level)

    A negligible difference between 28 July and 19 August?

    Something to be concerned about?

    Many thanks,

    Dave.

  • #1713

    Keith Taylor
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    Concerned might be the wrong word. Let’s say vigilant.

    The reason for taking allopurinol is to get uric acid below 300μmol/L. Therefore, if I got that result, I would increase allopurinol dose. But, there might be medical reasons why that’s not appropriate in your case.

    It’s time to discuss it with your doctor.

    I can’t quite see the timeline. Is the first result during an attack before starting allopurinol?

  • #1715

    Gout Patient
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    I’m trying to remember myself..! 🙂

    I had a massive flare-up initially, eventually followed by the diagnosis. This was all done through my work’s private medical healthcare.

    Went to the GP, who did a blood test and got the 8 July: 5.6 mmol/L (Serum UREA level). Gave me some colchicine which appeared to help but then there was a second flare-up.

    so I went back to the GP, who gave me Naproxen and Allopurinol. I took the naproxen for about a week until the swelling subsided and then started allopurinol, which I’ve been on ever since (200 mg per day) leading to these results:

    28 July: 309 µmol/L (Serum URATE level)
    19 August: 337 µmol/L (Serum URATE level)

    In terms of symptoms, there’s no real pain, just a little soreness and a small smount of swelling which is only properly visible when I look at my feet side by side!

    GP appointment next Wednesday, we’ll see what they say!

    • #1731

      Keith Taylor
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      I look forward to your next report, after Wednesday, Dave.

      As the timeline is a little vague, I can’t fully explain the small rise in your uric acid level. The most likely explanation is that levels can drop during an attack. This is because uric acid that would have raised your result, in dissolved state, has changed to gout-inducing crystals. Speculation.

      I’m hoping your doctor says something like “increase allopurinol to 300mg per day. Arrange another blood test in 2 weeks. Take the naproxen, if you need it, at the first sign of a gout attack.”

      It’s good to know your inflammation is not too severe. I hope you are one of the lucky ones who has a relatively pain-free recovery period.

      Going back to your original post, I think you are managing this very well. The important thing is to talk about anything you are worried about as it happens. That’s what I’m here for. There’s every reason, Dave, to think that you’ll be completely gout-free in a few months. Then, you can stop worrying about diet. But, always eat healthy.

      So, now I’m happy that you are getting uric acid under control, I’ll return to the start: “no alcohol, very little meat, no seafood and lots of fruit/vegetables. And about 3-4 litres of water per day!”

      Alcohol is up to you.

      Little meat is good. My mottoes are:
      1. Meat as a treat (e.g. Mediterranean style eating).
      2. Meat as a flavouring (I’m looking into it).
      3. EFSEP – Eat Food. Sufficient. Especially Plants.

      Seafood is just a form of meat to me.

      Lots of fruit/vegetables – brilliant for gout. Variety is good.

      3-4 litres is up to you. The best advice is to disregard specific amounts. You need sufficient fluid to ensure urine is pale-straw coloured. Completely clear is an indication of over-hydration. All fluid counts, even the water content of food.

  • #1725

    Gout Foodie
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    Gout is the result of urate levels being too high for your body to process, therefore some crystallises in joints. And genetics is largely responsible, along with metabolic syndrome (usually from being over-weight). That about sums up the problem. If you need to take anti-inflammatories you are not taking enough Allopurinol. Men can take up to 600mg per day. The doctor gave me that short but oh-so-sweet explanation in less than a minute. He has one patient who is taking 900mg per day. I now take 500mg per day and my gout is remaining controlled. Purines, the pre-cursor to urate are in all foods. It is the basic building bloc of food, but is present in higher quantities in some foods more than others. Being a non beer drinking (usually) vegan means I don’t eat purine heavy foods anyway. I am also trying to lose weight, but honestly, I win a few battles, but I am losing the war. I am seriously thinking about bariatric surgery. So if you are on Allopurinol, but still getting attacks, you are not taking enough.

    • #1730

      Keith Taylor
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      Hi Rod,

      It’s great to read your contributions, and I hope your latest message encourages Dave to discuss his allopurinol dose with his doctor. But I have to add some points of my own:

      Anti-inflammatories and allopurinol are entirely separate. Anti-inflammatories, reduce inflammation caused by our immune system response to the presence of uric acid crystals. They act within minutes, though the full effect might take hours.
      Allopurinol reduces uric acid. If the reduction is below 5mg/dL (300μmol/L), uric acid crystals will eventually dissolve. Allopurinol starts working immediately, but maximum uric acid reduction takes up to two weeks. The effect of reducing uric acid takes at least 6 months to dissolve most uric acid crystals, often longer.

      Therefore, recovering gout sufferers often need anti-inflammatories for a few months, until most old uric acid crystals have dissolved. That is true for any uric acid lowering treatment, including febuxostat, or diet.

      The recommended maximum dose for allopurinol is 800mg per day USA, and 900mg per day, UK. But, all doctors can prescribe whatever dose they think is best. Higher allopurinol doses might be justified, as long as they are medically supervised with frequent kidney function and liver function tests.

      Purines might be in all foods, but, there are many different purines. Plant purines do not readily convert to uric acid in humans. Purine metabolism is complicated. But, the most important fact is that human flesh is the richest source of uric acid. Vegan diets need to be carefully managed, to avoid shortage of some essential nutrients. I need to do more research for the big picture. But, from a gout point of view, shortage of protein and calcium are big risk factors for gout in vegans. I’m interested in discussing vegan diet. However, Dave isn’t vegan, so I think it best to create a separate topic. (Now at Gout and vegans.)

  • #1749

    Gout Patient
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    Hi Keith,

    The GP appointment was today. You’ll be delighted to hear that she said:

    “Increase allopurinol to 300mg per day, as we need that figure below 300 µmol/L. Arrange another blood test in about a months. Take the naproxen, if you need it.”

    So, let’s up the dosage and see what the next blood test brings.. 🙂

    Many thanks,

    Dave.

  • #1764

    Keith Taylor
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    Brilliant! A doctor who understands gout. Lucky you. 😀

  • #2131

    Gout Patient
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    Hello!

    Ok, an update on some tests:

    05 Jul 16 Serum urate level 526 umol/L
    28 Jul 16 Serum urate level 309 umol/L
    19 Aug 16 Serum urate level 337 umol/L
    17 Oct 16 Serum urate level 267 umol/L

    So, looking good currently, but my foot’s still been a little painful and slightly swllen too. Currently taking 400mg of Allopurinol per day.

    Any thoughts/advice please?

    Many thanks,

    Dave.

    • #2133

      Keith Taylor
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      Hi David, it’s good to see your uric acid is now safely below 300 μmol/L. That should mean that your need for pain control will diminish. It’s really great to see some clear uric acid test result data. Thank you for that, but I have a question. You say: “Currently taking 400mg of Allopurinol per day.”

      When did that dose start, David? Is it an increase between the last 2 tests, that finally got your uric acid safe?

  • #2156

    Gout Patient
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    I’m not 100% sure on the exact date, but it’s definitely between the last two tests, when I went to see my GP about the serum urate level. So, I reckon towards the end of August.

    I’ve maintained a good diet: no alcohol and a reduction in meat consumption. I should probably drink more water, however..!

    I’m going to remain on the 400mg Allopurinol, take Naproxen as necessary and have another blood test in January unless something goes wrong. I’m surprised there is still some swelling, but it’s not much and just a little bit sore from time to time.

    Best wishes,

    Dave.

  • #2159

    Keith Taylor
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    Thanks, Dave, for the clarification.

    In my view, you are well on track to becoming gout free. 🙂
    Your plan is certainly above average. Whether you want to make more effort to get rid of gout quicker, is up to you. Here’s my thoughts on your progress:

    Allopurinol Dose
    This sounds right to me. You’ve increased allopurinol dose inline with blood test results. 267 is a perfectly acceptable target. It allows the uric acid burden that has built up over several years to dissolve. Most people would regard this as ideal. But, if you have visible tophi, or if you want to get rid of your uric acid burden quicker, talk to your doctor about further increases in allopurinol. Once the burden is significantly reduced, you should be able to slowly reduce allopurinol dose to maintain uric acid below 300 μmol/L.

    Because our bodies change with age, I strongly recommend all gout sufferers get a uric acid test at least once a year. That way, you can make sure it never creeps above 300, which might allow uric acid crystals to start building again.

    Gout Diet
    Your diet sounds good, as long as you are happy with it. Personally, since controlling uric acid, I’ve focused on trying to eat healthily. That’s usually the best thing for uric acid, as well as general health. If you are happy with your diet, all seems good to me. If not, we can chat some more.

    Hydration for Gout
    Hydration is always important for gout sufferers. This does not change on allopurinol. Some people might argue hydration is more important when on allopurinol. I won’t bore you with the details.
    If urine is darker than a pale straw color, drink more fluids. Water in all drinks and foods is part of your fluid intake. It does not need to be plain water all the time.

    Pain control during early allopurinol treatment
    As I mentioned, you have a uric acid burden from crystals that have formed over many years. It takes at least six months to get rid of that burden. Usually longer. During that time, naproxen as required is usually a very good strategy. But, don’t be surprised when old crystals dissolving cause a little discomfort. Take the naproxen at the first twinge, and try to stay mobile. I recommend a dance of celebration – gout pain when uric acid has fallen below 300μmol/L is a sure sign that you are recovering from gout! 😀

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