January 9, 2017 at 9:20 am #2376
I have been on allopurinol 300 for a year now, started in January 2016 and have had three blood tests and all indicate my Uric acid is below 5.0. The last reading in December was 4,2. During this year I had a gout flare in June and the doctor said it was due to my body clearing the crystals because of the now low Uric acid and to avoid a new attack he gave me colchicine 0,5 to be taken as a prophylactic for 6 months. I did fine and by December my level was 4,3 and finished using colchicine. It is now January 2017 and yesterday I had a gout attack (as usual on the right toe) and I am taking now Indomethacine and hope to control this attack.
My questions are:
– is it possible that after 1 year on allopurinol 300 and readings below 5 I am still clearing crystals and can still get an attack? How long does this process take?
– should I go back taking colchicine as prophylaxis? I am afraid I could get another attack.
BTW: I am 61, normal weight and walk 5 miles every day and eat sensibly.
Any ideas? God bless.
January 9, 2017 at 1:44 pm #2377
Thanks for all that information. I know it’s heartbreaking if this happens when you are doing everything right. You are lucky to have a doctor that seems to understand gout well. His explanation is correct. And, I refer to that uric acid crystal clearing process as “urate clearance”. Or, reducing the uric acid burden. But, it can’t answer your “How long does this process take” question.
Truthfully, nobody can. There are too many variables. But, I have made up a ‘rule of thumb’. Like all such rules, it is a little vague. I tell recovering gout patients, like you, to expect urate clearance to take about one month for every year you have had gout. Then, the only truth is “the lower your uric acid, the shorter the period for urate clearance”
Because of that, I personally chose to go for maximum dose allopurinol, in order to minimize the time at risk. My doctor gave me full support in that, but I had to try with 3 others before I found a doctor who understood the biology.
So, using my rule of thumb for your urate clearance period. I’m going to guess your gout started when you were around 30. But, I guess your symptoms started many years later. You started allopurinol in January 2016. But, your uric acid will not have got down to 5 immediately. I’m going to guess April 2016. Therefore, my rule of thumb says, 30 months of urate clearance takes you to October 2017.
Obviously, that’s all speculation. There might be a particularly well-hidden cluster of crystals that trigger a small attack on New Years Day 2018. We just don’t know. As I’ve said, you can reduce the risks of an attack. But, it’s always best to be prepared.
If you are the type of person who listens to your body, you’ll recognize the early twinges of an attack. In that case, there is no need for prophylactic gout pain therapy. That also applies if you are confident that you can control an attack quickly, once it starts.
If not, prophylaxis for a few weeks/months might be the answer. But, you have to weigh up the pros and cons with your doctor. Personally, if I was opting for prophylaxis, I’d also insist on an allopurinol dose increase. That might raise the risk of a flare in the short term. But, it would reduce the period of time that prophylaxis was required.
Again, there are no rules for how long it takes. So, I’m going to make up another rule of thumb, on the spot. If you get uric acid down to 2, change the rule to one week of risk for every year of gout. It’s very hard to be precise, but I hope this explains the controllable elements.
That should give you the information you need, Maurice, to improve your gout treatment plan. But, if you need me to clarify anything before you see your doctor, just ask. In particular, I’ve had to guess at things like current allopurinol dose, uric acid test dates and values, etc.
I’m here to help you make the right choice for you. And, we can discuss it whenever you feel the need.
January 11, 2017 at 11:45 am #2384
Keith: first off let me thank you for a very well explained answer. Makes a lot of sense and you are awfully good at guessing… right on the money.
Let me then pick your brain a bit further: my Uric acid level has been below 4,5 since Feb 2016. A month after starting allopurinol 300 it went from 7,0 to 4,1. So I’ve been clearing crystals for a year now but according to your guesstimates, I could be clearing for 20 months since I have had gout for 20 years now. Therefore I could stay put for 8 more months -in theory- or increase the Allopurinol dose and get faster clearance. I am tempted to use colchicine as prophylactic and up the dose. What would be your dose of choice? 400? 500? Don’t worry, express your thoughts and I will run it by my doctor. This is the only med I take, my health is fine otherwise.
January 12, 2017 at 3:49 pm #2386
Hey, thanks Maurice. It’s nice to get some positive feedback.
My dose of choice might shock you, but there is logic behind it.
First, I started allopurinol properly with a low dose, and increased gradually. Also, I’m not in one of the racial groups that are advised to take a genetic screening test before allopurinol. I say this, not in answer to you. But, other gout sufferers will read this, who are concerned about allopurinol side-effects. I’m not susceptible to any such side effects. So, I see no limits to allopurinol dose.
In the UK, maximum advised dose is 900mg per day. In the USA, it is 800mg per day. Gout PAtients should note that this is not a medical maximum. Under medical supervision, with appropriate liver and kidney monitoring, a specialist might prescribe higher doses.
In short, my dose of choice is 900mg per day. Then, once visible tophi have disappeared, and pain symptoms have gone for six months, the dose can be lowered. At that stage, you can be almost certain that the uric acid burden has dissolved. So, all you need is an annual check for uric acid, liver function, and kidney function.
Of course, a doctor might feel that there is no reason to go for the maximum dose. In that case, I would ask for evidence that a lower dose is better.
Essentially Maurice, it boils down to what you are most comfortable with. You are clearly on the road to recovery. So, it’s up to you if you want to proceed with caution, or race ahead. Either way, it’s a good place to be, compared to most gout sufferers.
January 14, 2017 at 10:23 am #2405
Thanks again Keith. I am totally convinced about your strategy to control gout and clear the crystals.
My take/strategy is this: I will start again the colchicine 0,5 as prophylaxis and after a week or so will up the allopurinol dose from the 300 I take now to maybe not 900 but to 600. In three months I will have a blood test and check UA level; hopefully it will be under 4.0. I will take it from there.
In any case, how do you go about upping the dose from 300 to 600 ? Weekly increases of 100? Incrementally? Or just double it in one go? What is your experience with this? The actual dose of 300 sits very well with me; no side effects whatsoever. And also, should I split the 600 in two takes (breakfast and dinner)?
Thanks again for your efforts in summarizing these matters for us. Great help!
January 14, 2017 at 2:47 pm #2409
Maurice, I can’t tell you how happy I am with your positive tone. I’m looking forward to you posting a message in future that you are free from gout. And, I hope you’ll return to encourage other gout sufferers to follow in your footsteps.
As for the allopurinol dose increase, I went from 300 to 600 to 900. That sequence fits the tablet size. 2 weeks after each dose increase, I had blood tests. Uric acid test confirmed that my uric acid level continued to fall. Kidney function and liver function tests confirmed I had no side effects. Those 3 tests are important for all gout sufferers at least once a year. And, they should be repeated whenever medications are changed. Changes include new medicines, or dose increases.
Any new gout patients reading this should note that my 300mg allopurinol dose was preceded by 100, then 200mg. And, if you are of Han Chinese, Thai, or Korean descent, you should get a genetic screening test before starting allopurinol.
There is no advantage from splitting allopurinol doses during the day. Allopurinol breaks down very quickly in the body to oxipurinol. Both help reduce uric acid production. Oxipurinol stays in the body for up to 2 weeks. The implications of that are:
1) It doesn’t matter too much if you miss one day (but try with all your might not to!).
2) Blood test results need 2 weeks after dose changes for results to be accurate.
Good luck Maurice! It sounds like you are well on the way to becoming a Gout Champion. 🙂
April 23, 2018 at 9:43 am #6949
Hello everyone (specially gout guru Keith):
I wanted to touch base and tell you where I am now. It’s been 16 months (since Jan 17) on allopurinol 600 which has allowed me to keep my UA readings at a steady 3.1 and I have been 10 months without a single flare. Hurray! I believe I have been clearing crystals long enough and I could lower my allopurinol dose, correct? I don’t want to take more than necessary. What should be the goal now? Lower the dose to 100 and keep monitoring UA level and make sure it doesn’t get higher than let’s say 6.5? Is this a sensible approach?? I don’t think I need to stay forever on a 300 dose should I?
Of course whatever I do I will continue to eat sensibly and stay away from seafood, beer, red meat etc. as much as possible.
Any ideas on strategy to use once we believe crystal clearance has been achieved?
April 23, 2018 at 10:51 am #6950
nobodyParticipantŦallars: Ŧ 508.73
The generally recommended maintenance target is 6, not 6.5. After clearing all their crystals, some people are apparently able to substantially exceed that value for months or even years without experiencing gout symptoms but that is obviously risky.
Perhaps you could try taking 200mg (two 100mg pills) for a month or two and see what test results you get on that dose. It may be prudent to lower your dose slowly (or that may be a pointless precaution, I don’t know).
April 24, 2018 at 10:36 am #6955
Thaks! Will try 200 mg and see where it goes from there..
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