Can Stopping Drinking Cause Gout?

Stopped drinking beer, good gout diet, but foot swollen

Stopping Gout Together Forums Help My Gout! The Gout Forum Stopped drinking beer, good gout diet, but foot swollen

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    • #9301
      YahooUser
      Participant


      Stopped drinking beer, now eating and drinking all the right things swollen foot

      Hi all

      I’ve had gout on and off for many years, moved to a warmer climate and it kicked off again with my left foot being swollen and red on the side and very painful. My Wife laughs now because I like my beer daily. I have now stopped for 5 days, cut out red meat, fish, cheese and replaced diet with loads of water, chicken, rice, cherry juice, eggs, bananas etc. The things I read are good for me.

      Now my left foot is swollen again and going red just like it did when I was drinking beer and eating fish and red meats.

      I thought it was going to prove to me that it was my bad diet but this proves me it wasn’t.

      Any reason why it is attacking me again?

      thanks so much for reading

      Rob


      Can Stopping Drinking Cause Gout?

      Will Stopping Beer Make Gout Better?

    • #9302
      nobody
      Participant

      Hi!
      The reason it is attacking you is that you had untreated gout for many years. You’re probably going to be stuck with this problem for quite a while.

      Even if your gout could be managed by changing your diet, it would probably take months or years to improve and even longer to go away completely.
      The most practical way to manage gout starts with getting the amount of uric acid in your blood tested several times and doing some detective to get your hands on as many old test results as you can by asking your previous doctors and so forth.

      Be careful about what you’re reading. Most of what you can read about what’s “good” for you is BS.
      Switching from red meat to chicken isn’t going to help unless you have an iron problem or were eating the wrong meats. Likewise, fish isn’t necessarily worse than chicken (though some fish dishes definitely are).
      Unless you have a different health problem which would require you to avoid high-fat dairy, eating appropriate amounts of cheese is less problematic for gout than eating animal flesh. The general recommendation is to consume low-fat dairy instead but you would of course need to consume unusually large amounts in order to get enough protein.
      You could in principle also eat more eggs instead of animal flesh (again, depending on your other health problems).
      There is of course more to diet than eating from some kind of “good food” list and avoiding what’s on a “bad food” list. It’s easy to eat too much rice for instance.

    • #9407
      Keith Taylor
      Participant

      Hi Rob (@yahoouser)

      I echo everything nobody said. Also, I’d strongly recommend seeing your doctor as soon as you can get there to get uric acid tested. With lockdown, that might be delayed. But once you are able, it’s your best start.

      Once you do get the test results please let us know what your uric acid level is and what your doctor advises.

    • #9427
      YahooUser
      Participant

      Thank you for your great input! I am unable to get a uric acid test kit here in the Philippines at the moment but will get one and my levels checked when I get back to the UK.

      I have to say that after reading comments and other pages 10 days ago I bought some apple cider vinegar. I have 3 caps with water 3 times a day and I have no pain or swelling and I have been eating fish etc without any problems.

      It seems to be helping enormously

      thanks again – Rob

    • #10347
      Chris Clemmons
      Participant

      Hey bud,

      I’ve had gout since my early 20’s. Loved beer, still love bourbon. Here’s a simple bit of advice that keeps you away from the doctor.

      Drink 1/2 to a full gallon of water every day. When I adhere to that 1 thing, I can pretty much enjoy whatever I want without risk of a gout attack. The days I don’t, I will feel the gout moving in.

      Example, I haven’t had alcohol in 10 days, but have had some bbq brisket. I drank only 1/4 gallon of water yesterday w/2 cups of coffee and woke up today with gout in my ankle. It’s not just about what you eat, it’s about ensuring your body has the proper hydration.

      Suck down the water, and you should see the frequency of your attacks reduced. When one does begin to surface, hit the indomethacin quick, before it turns into a full blown attack.

      Just my $0.02, good luck!

    • #10348
      Chris Clemmons
      Participant

      Another thing to mention is that the Gout Diet recommendations are likely not going to have much of an impact on your actual gout flares. Recent studies are showing that diet doesn’t really have a noticeable impact on your uric acid levels, and that it is almost solely genetic factors that drive gout flares. For instance, the study below shows that dietary factors have a less than 0.3% variance in uric acid levels, to whereas genetic factors vary those levels by as much as 23%.

      So, drink more water to help your body process and flush it from your system, and don’t worry too much about your diet.

      “Results
      Seven foods were associated with raised serum urate levels (beer, liquor, wine, potato, poultry, soft drinks, and meat (beef, pork, or lamb)) and eight foods were associated with reduced serum urate levels (eggs, peanuts, cold cereal, skim milk, cheese, brown bread, margarine, and non-citrus fruits) in the male, female, or full cohorts. Three diet scores, constructed on the basis of healthy diet guidelines, were inversely associated with serum urate levels and a fourth, data driven diet pattern positively associated with raised serum urate levels, but each explained ≤0.3% of variance in serum urate. In comparison, 23.9% of variance in serum urate levels was explained by common, genome wide single nucleotide variation.

      Conclusion
      In contrast with genetic contributions, diet explains very little variation in serum urate levels in the general population.”

      https://www.bmj.com/content/363/bmj.k3951

      • #10350
        nobody
        Participant

        We’ve heard it all!
        Garbage study, garbage results.

      • #10360
        Eide
        Participant

        BMJ is a respected peer reviewed journal, and the article Clemmens linked to is peer reviewed. I haven’t read the article myself, but I am not myself a medical professional so my opinion on its quality wouldn’t count for much either way. However, it is precisely because I am a layman in this field that I must trust peer review. Someone on the internet simply calling peer review garbage should rightly be dismissed, even if he did qualify his claims – unless he did so by referring to peer reviewed studies himself.

        This is Alpha and Omega for anyone wishing to do their own research: if this is not my field, then I am not in a position to decide who qualifies as an expert. I have to rely on whomever is regarded as an expert in the field in question. Sure, there really is a lot of toss bandied about in every field of human endeavour, but even toss may sound like ice cream to the uninitiated. Which is why the layman should never dismiss peer review, nor listen to non-peer reviewed claims that peer reviewed research is “garbage”.

      • #10364
        nobody
        Participant

        @Eide It’s logically impossible to trust peer review in this field (as well as many others) because peer reviewed papers naturally contradict each other.

      • #10369
        Eide
        Participant

        This may well be true, and the article you called garbage may well indeed be garbage, but wouldn’t it be irresponsible for me, a layman, to simply take your word for it? If I were to be so trusting, I might end up buying homeopathic remedies from someone who told me the same thing: “don’t listen to the medical community, that’s rubbish. You want something that works, you come to me”.

        You may well know better than the researchers of the paper above, but I don’t know that. I can’t know that. I can’t know that you are correct in your statement about peer review, either. Contradiction in peer review isn’t unusual – two contradicting papers can both be sound. The purpose of peer review is to ensure that the methods leading up to the conclusion are good.

        Now, I do get the distinct impression that the medical field relies on received knowledge more than it should when it comes to gout, but then I haven’t seen received knowledge peer reviewed. When a paper passes peer review, I wouldn’t accept it even from an authoritative source if they simply dismissed it off-hand. Substance must be refuted with substance. If you say there is no substance, well it looks like substance to me, so where does that leave us?

      • #10371
        nobody
        Participant

        Eide, a cherry-picked peer-reviewed paper is nothing like “the medical community”. Are you a physicist or something?
        Nevermind the drivel that routinely gets greenlighted by reviewers in many fields: in many cases, outright fraud gets past peer-review as easily as legitimate medical research because it’s unrepeatable. And fraud happens to be cheaper…
        What’s irresponsible is not calling out mis/disinformation in no uncertain terms, early and often.

        I naturally agree there’s nothing wrong with peer-reviewed publications contradicting each other. You may trust the process although I personally do not, but that trust can not logically translate to every claim made in any peer-reviewed publication. That is the issue here, not the process.
        Refuting the appearance of substance with substance would be a great way to waste my time, a lesson I have learned too many times already.
        You ask “where does that leave us?”. Well, instead of explaining what you figure appears like substance, you could explain the substance of your own thought process about the issue as well as the reason you care about it in the first place… then we could perhaps address that. We obviously have no authority and are of course not trying to review random papers.
        If I may repeat myself, the reason most people who come here shouldn’t care is that most people aren’t going to be able to treat their gout through diet anyway.

      • #10376
        Chris Clemmons
        Participant

        Well look at that Nobody, it seems you agree with the “garbage” study I posted…

        “If I may repeat myself, the reason most people who come here shouldn’t care is that most people aren’t going to be able to treat their gout through diet anyway.”

        The study posits that diet has little to do with the variation of serum uric acid levels, and that genetic factors play a much bigger role.

      • #10378
        Eide
        Participant

        The million dollar question is: Why should I listen to you? I’m not a physician, I have no medical training of any kind. How am I supposed to separate the wheat from the chaff? No one says peer review is perfect, but it’s what we’ve got. Fraud is certainly a problem, but it is hardly rampant. And peer review is still the best we’ve got.

        So do I trust peer review? Of course. I have no choice. The alternative is much, much worse. But what does it mean that I trust peer review? Do I take it on faith? Not at all. It means that peer review is statistically more likely to provide good information. And as a layman essentially makes an unqualified guess as to which authority to listen to, it is certainly advisable to go with the ones with the best track record.

      • #10382
        Keith Taylor
        Participant

        I agree with you Eide, that peer review is more likely to be trustworthy. But the report that started all this is not relevant to patient oriented gout care. Annoyingly, it was also not relevant to the year old thread that had been diligently responded to. (not by me – I must have had insomnia that day)

        In other words, you cannot simply take it at face value. So you must discuss it with your doctor or other professional adviser who is familiar with your medical history.

        That’s the main reason I stopped providing a library of publications. But I am happy to email anything as long as I can send it to the gout patient and his doctor.

      • #10386
        nobody
        Participant

        You do listen to me as a matter of fact and it’s not my business why you do. But once again: do not trust me! You do not have to trust peer review either. It’s pointless and harmful to do so.
        You have of course not used statistics in this n=1 thread so I find it rather hypocritical that you would now turn to hypothetical stats. And you well know, it is not the case that people assess a statistically significant number of claims or that random claims are equally pertinent.

        By the way, while cherry picking is the larger issue by far in my experience, there’s no shortage of climate non-science that gets published… and not only in crap journals since high-visibility publications such as Nature* are a prime target for bullshit.

    • #10351
      Chris Clemmons
      Participant

      I’m sorry. I didn’t know this was one of those forums where we are rude to each other.

      I’ve followed the dietary guidelines, it never helped. The only thing that’s ever helped is water consumption. Considering I spent an entire year drinking bourbon/beer daily, red meat, and all the things I wasn’t supposed to, and had ZERO gout flares because I simply drank more water, anecdotally, goes to show what “garbage” those dietary recommendations are.

      But hey, go ahead and continue to advise something that doesn’t work. I’ll let you be rude to other people ✌️

      • #10353
        nobody
        Participant

        I was nicer in the other thread but if you go out of your way to misguide readers, civility isn’t going to ensue.
        Most dietary guidelines are poor to terrible (I don’t know which ones you’re talking about).
        Gout is a slow disease which can produce no symptoms for a while regardless of what you drink or don’t drink.

    • #10354
      Chris Clemmons
      Participant

      There’s no intentional misguiding here. Your comments are intentionally derisive and assume you know better than everyone else. Mine are providing an alternate perspective on the disease, as I have been suffering with it for over a decade and understand it well.

      None of the recommendations on dietary restrictions worked for me. The only thing that has ever helped is water consumption. This is indicative of genetic factors playing a larger role in gout flares than dietary guidelines that assume everyones triggers are the same.

      Point is, if the dietary guidelines aren’t helping, try something else like increasing water and see if that helps. Maybe it will, maybe it wont. Everyone is different. Assuming otherwise is arrogance.

      • #10355
        nobody
        Participant

        Projecting much?

        Dietary guidelines can only help if they’re sensible, which is often not the case.
        Triggers and dietary factors aren’t the same thing.

        In any case, no one with a clue ever suggested that dietary recommendations is a good way to treat most cases of gout.
        So I urge you to get up to speed and take care of your health with a uric acid lowering drug if you need one. You may be able to tell if you need one with two or three routine blood tests (or simply by looking at the results of past tests). Sometimes the results are borderline, which would leave you with uncertainty. But often enough, the results clearly show people need to be on such a drug.

    • #10356
      Chris Clemmons
      Participant

      That depends entirely upon the age of the patient, and the drug in question. Popular drugs like Allopurinol have a lot of long term health risks, and are associated with an increase in mortality.

      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1767024/

      Febuxostat has been known to increase the rate of heart attack in patients.

      Drugs like Colchicine are fairly low risk, but may not be entirely effective, depending on how your body metabolizes/interacts with them.

      With all drugs, especially some of the gout drugs, there runs the risk of interactions when treating acute health issues. The more drugs you take, the more likely you are going to find an interaction. Overall, the fewer pharmaceuticals you have in your system, the less you have to worry about potential interactions. Example: If you are taking DayQuil or something with dexomethorphan to treat a cold, and end up taking sumatriptan at the same time for a migraine, you could find that you go to sleep and never wake up again, as both operate on the seratonin system. If you are on a long term prescription of say, Allopurinol, you now have a smaller tool box to treat acute health problems and run the risk of interactions you aren’t expecting.

      Point is, drugs aren’t always the best option, especially if you can find a non-medicinal way of preventing flairs. I’m 33. Taking a drug for the rest of my life runs the risk of cumulative harm, as there is no biological free lunch. For someone who is young, if a solution that is non-pharmaceutical can be found, it’s likely to have less of a negative impact down the road. So, once again, genetics and other factors play a big role in how to address gout, and one should be encouraged to try as many different solutions, in a scientific manner, as possible before resorting to pharmaceutical interventions.

      ——————

      To address your other comments: No one in this forum has suggested treating a gout attack with a dietary change. Dietary guidelines are prophylactic/preventative. So, why you are bringing that up is beyond me. Everything I’ve discussed thus far has been about preventing further attacks.

      Furthermore, if one is claiming that diet impacts your uric acid levels and thus, hyperuricemia, then one is postulating that dietary factors are “triggers” of gout attacks, as the consumption of said foods would lead to hyperuricemia and then a gout attack. So, again, your response makes little sense in this conversation.

      • #10357
        nobody
        Participant

        You are confusing gout and attacks, which is why my response made little sense to you.

        And you keep cherrypicking (at best) information to mislead people. Allopurinol and febuxostat are dangerous drugs but do not have the issues you claim and, used properly, would most likely make you healthier assuming you actually needed them. Postponing the use of these drugs is of course an option but you would most likely be worse off in the long run for not taking them earlier… again, assuming you actually needed them. Drug interactions aren’t a major concern because you can always stop taking these drugs, whether it be for the duration of an unrealted illness or for good.
        I assume you mean NSAIDs by “drugs like colchicine” since that is a unique drug. This drug class kills many thousands every year.

    • #10358
      Chris Clemmons
      Participant

      I’m not confusing anything with anything, but hey, what do I expect arguing with a troll named Nobody.

      Have a good day.

    • #10361
      Keith Taylor
      Participant

      Occasionally we write with passion in forums and things get slightly out of hand. My best advice is to change any negatives into positives and find ways to move forward with better treatment.

      Anyway, I am mostly here to call out to Eide ( @karl-aksel-eide ) about peer review. Because I’m passionate about research and I would like to discuss this more. But not on this topic. So I hope you can start a new topic about any aspect of your research that you feel like discussing. Then I can also address the issues that you have raised here.

      Very interesting Eide. So thanks and I hope we can discuss gout research further. I can also explain my personal views on why I feel this particular study is potentially misleading. Of course, nobody may have different reasons. But I respect the tremendous effort he devotes to helping gout sufferers on this forum.

      • #10366
        Eide
        Participant

        If there are objections to an article posted in this thread, surely this would be the appropriate place to elaborate on those objections? I, too, am passionate about research, but I have no qualifications relevant to gout so I wouldn’t presume to lecture anyone on that score – and I would feel it awfully pretentious if I, a newcomer, were to create a thread on academic research in general.

        I also did not mean an attack on Nobody – I chose my wording carefully in hopes of avoiding that impression. Of course, I do not know any of you from Adam, but from what I can glean, he possesses a wealth of knowledge and experience. But whether medicus or Adam, when he dismisses peer review in such fashion, it does not give a favourable impression in terms of credibility, I’m afraid.

      • #10367
        nobody
        Participant

        I of course have no credibility. You don’t even know how many persons use this account (or their gender).
        The problem is the notion that peer review makes a claim credible. Among other grave consequences, crediting peer review as such opens the door to harmful mis/disinformation through cherry picking peer-reviewed publications. This is an especially serious issue in medicine but is of course by no means limited to “soft sciences”.
        Pretentiousness and other pseudo-interpersonal issues are of no consequence relative to the consequences of the spread of medical mis/disinformation. I would have thought this pandemic would have taught everyone this lesson!

      • #10368
        Keith Taylor
        Participant

        OK, we’ll discuss it here then.
        Here’s my views.
        Peer review is simply 1 academic agreeing with or disagreeing with another academic. A large part of their work is statistical. Therefore of little help to the individual gout sufferer. Very few of the academics involved have practical experience.

        This is not totally wrong. But it is mostly irrelevant to patients. I’m sure they can justify that by saying it was never intended to be practical guidance. But the reality is that gout sufferers read this stuff and get misdirected.

        In real life, we each need to recognize different research objectives. Academics will provide lots of untargeted research. Our doctors should be able to filter which studies are relevant to each individual patient. Us patients should attempt to understand the principles. Then discuss the options with their doctor against the background of medical history, best practice, and personal goals.

        In other words – never trust anything proffered by an “expert”. Unless they can explain why their recommendations apply in any given situation.

      • #10372
        Eide
        Participant

        I cannot agree with your assessment of peer review. Peer review is not just one academic agreeing or disagreeing with another; typically several external reviewers are involved (in this particular case, three). It is also not their job to either agree or disagree per se, but to analyse the methodology. Peer review is the cornerstone of science. Sure it has flaws, but it is the best system – perhaps the best possible system – for advancing scientific knowledge. And the history of peer review is also preserved here, so we can read the reviewers’ assesments of the study. It is all very transparent.

        Your criticism that the paper in question can be misleading to gout sufferers, however, I can fully agree with. Most people will derive their own conclusions from the conclusions of the paper (“oh, so does this mean that…”), and most researchers do not caution against such pitfalls – they are writing for their own academic community, after all. Usually, scientific papers need to be dumbed down before they can be properly disseminated to the masses – though it often falls on journalists, who aren’t really the right people to do so.

        Your last couple of paragraphs echo what I said on this topic, so we are basically in agreement. I just think you mis-characterised peer review a tad.

    • #10370
      Keith Taylor
      Participant

      I’ve just had another thought…

      Who is the better expert? Someone who has mastered the art of getting research published? Or someone who has successfully controlled gout for many years despite widespread poor quality of medical services?

      • #10373
        nobody
        Participant

        I vote: someone who has mastered the art of getting research published, mainly because it’s in most cases easy to control gout despite the widespread poor quality of gout care (which does not reflect on all medical services).
        I unfortunately happen to be a slightly more difficult case but that still doesn’t make me an expert.
        What makes someone an expert I think (and the main job one would want an expert to do in the first place!) is publishing guidelines, not research.

      • #10374
        Eide
        Participant

        Ah, but isn’t gout a very individual experience? So however much a person may be expert on his own condition, it may be anecdotal to another.

        The art of getting research published is the art of being an expert – so long as it is peer reviewed. Publishing outside of peer review (or in phoney peer reviewed journals – such as the infamous paper “Get Me Off Your F-ing Mailing List”) – is not much of an art. Graham Hancock may be a popular and well published author, but none of his output has ever come close to passing muster in academic circles.

      • #10375
        nobody
        Participant

        People who publish may be experts at publishing but in medicine, psychology and so forth a distinction is often made between researchers and clinicians. And clinicians are supposed to heed guidelines regardless of whether they are peer-reviewed.
        I’ve had this conversations with too many denialists for my comfort (not just in medical matters: climate denialists for instance will also argue for peer review against subject-matter expertise).

      • #10380
        Eide
        Participant

        I’m actually glad you mentioned climate deniers, Nobody; I had a paragraph about it myself in an earler post but decided to cut it. Climate deniers, while they often claim to cite peer review, they invariably misquote it, quote it out of context, or flat out lie about what’s in it. The peer reviewed climate science itself is pretty solid, and always in stark contradiction to climate deniers’ claims.

    • #10377
      Chris Clemmons
      Participant

      And to your earlier response, Allopurinol is not cherry picking. It’s the most widely prescribe drug aimed at lowering uric acid levels in gout sufferers.

      There are 9,200,000 gout sufferers in the United States. 0.2% of them is 18,400 people, who would experience Steven Johnson Syndrome or experience severely negative outcomes with the drug. Of those 18,400, approximately 4,600 would die. So, to my original point, try what you can first, before seeking pharmacological remedies, and be cognizant of the risks those pharmaceuticals pose.

      “The most commonly used urate-lowering antigout drug, allopurinol, is associated with rare (affecting ~0.2% of patients), but severe, hypersensitivity reactions that are fatal in 25% of cases.105 Pharmacogenetic studies have shown a strong association between HLA-B*5801 and allopurinol-induced Steven–Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) in Korean, Han Chinese, Japanese, Thai106–110 and European populations.111 A meta-analysis based on these studies showed that patients who expressed the HLA-B*5801 allele had an 80–97-fold increased risk of developing SJS or TEN in response to allopurinol compared with patients who did not express the allele.112”

      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3645862/

      Finally, no one is cherry picking, other than you, who dismisses peer reviewed research out of hand over your own personal bias. You’re welcome to your opinion, as I had given in my initial post on this thread, and you’re welcome to disagree w/others opinions by substantiating your disagreements, however you have yet to actually substantiate anything from what I can tell in this conversation, and have instead mischaracterized my statements multiple times. For instance, drugs like colchicine means drugs intended to treat inflammation, not NSAIDS, but you brought up NSAIDS because its an easy straw man to dismiss my claims out of hand, once again.

      It’s likely that you know more about your own condition than most doctors do, as most doctors have a general set of rules/guidelines to follow that mainly operate on trial/error, due to the genetic variability in patients. There are over a dozen different genes that code for gout, and the combination of them impact what treatments will work, and which wont. They also impact how you respond to each of the different medications available.

      Gout is a condition that needs a considerable amount of additional research, and having humility when discussing said condition is desperately needed.

      • #10379
        Keith Taylor
        Participant

        I can’t ignore…

        There are 9,200,000 gout sufferers in the United States. 0.2% of them is 18,400 people, who would experience Steven Johnson Syndrome or experience severely negative outcomes with the disease. Of those 18,400, approximately 4,600 would die. So, to my original point, try what you can first, before seeking pharmacological remedies, and be cognizant of the risks those pharmaceuticals pose.

        Those 4,600 would only die if they were treated without acknowledgement of professional standards. No one dies from 100 mg allopurinol.

        On the other hand, pathologists are failing to detect deaths from untreated uric acid. Because it is not standard practice to test dead hearts for uric acid crystals.

        You will not die from properly administered uric acid treatment. But you might die from crystal induced organ failure while you are wasting time with poor diet and irrelevant academics.

        I have another anecdote regarding death and gout. But I will save it for another day.

      • #10383
        nobody
        Participant

        Thank you. But for completeness: I’m not sure how much allopurinol it would take to kill the most vulnerable but 100mg would already be a pretty serious dose for some patients and you can start with less (as some guidelines mention). More importantly, even though allopurinol has more common potentially deadly side effects, people with East Asian ancestry should get a genetic test or simply use febuxostat instead… something I have told people time and again on this forum. Every single easily avoidable death is one too many.
        I’d also wager the more serious risk for most gout sufferers is indirect (by the way of lifestyle, obesity and so forth) rather than organ damage.

        Even more importantly, people such as Chris who do not understand gout aren’t able to tell if a treatment worked (whether it be pharmalogical or not) and too many doctors do not care.

      • #10388
        Chris Clemmons
        Participant

        My apologies. I missed the dosage of 100mg, as it wasn’t stated in 4 of the 5 of the studies listed. Thank you for pointing that out Keith.

    • #10385
      Ted Pimentel
      Participant

      As someone who is new to gout, I am having difficulty differentiating the positions of each person on this thread. So far as I can tell, both are advocating drinking lots of water (and perhaps doing way with alcohol, drinks that are diuretics and drinks that are sweetened with fructose). Is the point of contention about whether to start uric acid treatment sooner vs. later? If so, what is the “medical standard of care”?

      • #10387
        nobody
        Participant

        Sorry for all the meta stuff. Yes, water and so forth isn’t controversial (in most cases).
        And yes, when to start uric acid lowering drugs is the real issue. It’s more complicated than just the standard of care because there are the difficult matters of diagnosis and relucatance but as far as I can tell, the standard is unsurprisingly: in the presence of recurring symptoms and hyperuricemia resistant to lifestyle intervention, start allpurinol or febuxostat if there is no suspicion that the patient is especially at risk for serious side effects.
        Some of the problems include: failure to evaluate this risk rationally, useless lifestyle advice, failure to follow up said advice with regular testing, failure to follow up the symptoms and failure to identify said symptoms. I would also add: failure to refer to a specialist in the absence of clue.

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