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The crucial, and constantly overlooked, issue for gout sufferers is that once you have had one gout attack, you cannot tell if subsequent flares are a sign of you getting worse or better.
It is a well known fact that allopurinol can provoke a gout flare. This is the absolute best treatment for gout when administered properly, yet it still causes some initial problems until it has done its job.
What people fail to realize is that any therapy, including improved lifestyle, has exactly the same effect if it is benefiting you by lowering uric acid. There is no way to tell easily if your gout flare is caused by new uric acid crystals forming or old ones dissolving.
You might get a sense that old crystals dissolving seems to affect more joints than new ones forming, but this is far from universal. The best chance of judging the effects of any actions you take is to test blood for uric acid. This is not easy, as levels fluctuate from day to day, and through the day. However, you can get an idea of the risks of uric acid crystals forming, and, after a few tests, you may also see trends that you can attribute to positive or negative lifestyle changes.
On balance, you are likely to get more benefits than disadvantages from exercise, but try not to get dehydrated.
There is, perhaps a group 1.5
These are people who attempt to control their gout by lifestyle changes but recognize and work towards the 6mg/dL goal.
Even without medication, there is still a professional role (or better still obligation) for your doctor to work with you and monitor what is happening.
This means uric acid tests at least every 3 months, preferably tracked against weight loss. It also means a clear plan to achieve a BMI of 21 – no mean feat for most of us.
Gradual weight loss is the main thing you can do – 1 or 2 pounds per week. Also look at lowering iron. Finally look at purines, but do not make your life a misery, or you will never stick to it.
All the time – keep hydrated.
You are definitely not alone in being of this mindset. The problem with this mindset, which is encouraged by many health professionals, is that it only makes sense if accompanied by clear goals.
Cloud the issues with purine mumbo-jumbo and groundless alcohol bans and you have the recipe for disaster that probably caused this topic in the first place.
As long as you make uric acid management your first priority, and pain control your second, you have a chance of success. Unfortunately, most doctors do not put enough emphasis on the uric acid priority, so it is up to you to insist.
Getting down from 232 pounds, unless you are a giant, is a huge undertaking. However, if you can see that a few months of progress is giving you uric acid lowering benefits then you will be much more inclined to keep going.
Report your weekly weight loss here – I’m sure I speak for all of us when I say that we will encourage you. And you, in turn, will inspire others.
zip2play said:
People with gout are divisible into two generalized categories:
1. Those that control their uric acid to 6.0 mg./dL usually with allopurinol and have no further acute attacks no matter what they eat or drink.
2. Those who do not use drugs and try this that and the other between attacks and then this that and the other to stop the attack until the next one.
It if from group 2 that you wll see all the nostrums, food remedies, and do's and don't.
Interesting point.
I guess I fall into #2 – but I am new to gout. I have the hope of controlling it by diet and losing weight if possible (currently 232). I am saving the drug option for later if #2 doesnt work out for me. I guess I would like to be an optimist that I have the power to control this myself. I dont think I am the only one out there with this mindset.
What an excellent series of interesting posts.
I'll try and summarize this as there are great lessons to learned.
Or perhaps it's better left “as is” to show the true spirit of the forum without my interpretations?
From “Does hyperuricemia affect mortality? A prospective cohort study of Japanese male workers:”
These results showed that hyperuricemia has a strong association with the RRs [relative risks] of death in all causes, coronary heart disease, stroke, hepatic [liver] disease and renal [kidney] failure, and indicated that serum uric acid seems to be a considerable risk factor for reduced life expectancy.
More importantly, the recent “Allopurinol and mortality in hyperuricaemic patients” concludes:
Our findings indicate that allopurinol treatment may provide a survival benefit among patients with hyperuricaemia.
I've moved this here as it was posted in a topic “Food to Lower Uric Acid”, to which it has no relevance. I realise that conversations can easily wander off topic, and try not to moderate unless absolutely necessary, but this really adds nothing to the debate.
Yes, Jack, the world is not perfect.
Yes, tophi can appear pretty much anywhere, but it is vital that any abnormal growth is checked immediately by a qualified medical professional.
As well as agreeing with zip2play about the salt.
Tavery said:
To give you an image of me…I am a 40 year old white male. 6 foot, 234 pounds (on the edge between overweight and obese). I have no health/physical problems that I am aware of. I sit at a desk all day and havent been exercising much in the last few months but my weight has been holding steady for a couple years now.
p.s. When I saw the doctor on the first attack they said my uric acid level was “on the high side of normal” (before all my diet modifications) and I wasnt a candidate for frequent recurrances.
I think your doctor is wrong about your risks. “The high side of normal” is a dangerous place to be once you have had an attack. It is vital to keep checking blood to make sure uric acid stays below 6mg/dL. Many people have higher levels, yet never develop gout. You have shown that you are susceptible, therefore this is important to you.
Why risk the chances of increasingly painful gout attacks? The whole point of managing gout is to control uric acid so that it stays below the danger level.
If yours is not too high, you may be able to control it with sensible diet, gentle exercise and gradual weight loss. But you must get uric acid levels checked regularly to make sure you remain risk free.
CC_Alaska said:
Well…there's another way to diagnose it: Tuff it out this time and if it's Gout; IT WILL RETURN….probably about a year or so from now when you have completely forgotten about the first incident. Sorry…thats my tongue in cheek humor.
So CC_Alaska had it right then!
3 days is about the normal time for a gout flare to clear up by itself, particularly in the early stages of gout. Of course, this does not prevent more attacks happening, so that consecutive attacks appear as one long continuous gout episode.
The longer your gout goes untreated, the worse it gets. More joints become affected, and attacks become more frequent. The buildup of uric acid crystals in the joints leads to permanent, crippling, joint damage.
.61 is a very high reading (this converts to 10.25 mg/dL using my uric acid level conversion).
It is important to get on the allopurinol as soon as you can to get your uric acid under control before irreversible joint damage occurs.
It is vital that allopurinol is introduced properly, and monitored frequently to ensure that uric acid levels are kept below .35mmol/L. I cannot stress this enough – doctors frequently issue allopurinol without proper backup, and if you do not take enough to get your uric acid down to a safe level, then you are simply wasting your time.
You can get brilliant GPs who are well versed in the latest gout treatments, and you can get some who haven't really taken much notice since med school. The former will know that you need a well monitored plan for keeping blood uric acid below 6mg/dL, with appropriate pain control until existing uric acid crystals have dissolved. The latter will often tell you to take 300mg allopurinol for the rest of your life, and leave it at that.
A rheumatologist is much more likely to understand gout, but as with all professions you get good and bad.
Go with whoever gives you the clearest and most confident explanation of how they intend to achieve the plan shown in bold.
Thanks to all for your replies. What are your thoughts on using a rhuematologist v gp for gout advice and guidance? Is this the right path to take?
I am struggling with baking soda as it gives me diahrea – not as bad as colchicine though! Not sure how that will go in Africa. Unfortunately, my recent gout attack has still not subsided (but has relented on my big toe) and has moved to the side of my foot, and my fingers and wrists are getting a hell of a workover also.
The advice I keep getting and reading is to start on Allopurinal when the gout has stopped. But my gout hasn't stopped in a couple of years. In fact, the pain is unbearable if I stop taking dicloflenac. So, presumably I start taking allopurinal any time now – well, when I return from Africa that is?
Great news Charley.
Please remember to get a uric acid test at least every 6 months (unless doctor advises more frequently).
Thank you Iain – your post is a powerful reminder of the crippling effects of gout if it is not treated properly.
What absolutely horrifies me is the fact that you have been treated with allopurinol and febuxostat, and your uric acid remained high. I realise that it is too late to prevent joint damage, but surely the doctors can get your uric acid levels below 6mg/dL to prevent further gout flares and more joint damage?
Have you had your urate clearance checked (24 hour pee test)?
vegetarianGuy said:
My doc did say that as I dont have major swelling getting fluid out of my toe joint won't be a simple thing. Any views on that? Will it be super painful?
Based on sucking up info from all over the web it seems Peas, Cashew nuts, beans and lentils are a no no for me.
As you know, I am not a doctor, but I simply cannot see how inflammation makes joint aspiration easier. Synovial fluid occurs naturally in the joint – it is not the result of gout, but something everyone has. (forgive me if there is some disease that causes people to lose synovial fluid – as a layman, I assume everyone has it). In my experience, the procedure is painless – I was still waiting for it to happen when the doctor had finished.
I believe that this should be done by a rheumatologist, but I appreciate the difficulty of this if your doctor will not refer you. I can think of 3 options, and I hope others will chip in (but please remember this is a UK situation where seeing an administrator is at least one thousand times easier than seeing a specialist):
- Ring NHS Direct for advice (I have never tried this)
- Join BUPA or similar private health scheme (I have never tried this)
- Feign agony and job-threatening inability to walk at the nearest hospital (I wasn't faking)
The danger of “sucking up info from all over the web” is similar to drinking from the toilet bowl when parched. Yes, you will quench your thirst, but you also risk sucking up the shit.
Perhaps I should make my warnings clearer in “Foods High in Uric Acid – a Surprising Myth.”
As uric acid results from purine breakdown, many have assumed that all purines are equal. Yet vegetable purines are no longer seen as serious as a source of gout. Unfortunately, other than statistical reviews, there is little hard analysis of the real effects of digesting particular foods.
The only way to test this is to take a reading just before, then 2 hours after, a meal. To find a true correlation, the “meal” would need to be one single food item, and it would need to be repeatable. Perhaps it is no wonder that studies like these never get done. I might try it myself – a bowl of lentils for lunch everyday could be just what I need
vegetarianGuy said:
Do you think I should stop taking Berocca?
Gout pal what do you make of my reading spiking to 490s during the pain and lowering to 420s as the pain has eased. Should it not be other way round? Urea near the joint so reading lower during pain?
I am not body builder or anything like that
I don't take any protein shakes or suppliments either to get big.Yes I will see a Rheumatologist. Are they the absolute specialists for Gout or is there a chance that they are not too bright?
Are Arctic Medical's urea readings reasonably accurate?
I was worried about too much iron, but it is not in Berocca, so you should be OK.
Uric acid readings do fluctuate, so I would not read too much into it from 3 readings. The tendency for uric acid in the blood to go down when crystals form is common, but not absolute. By the way uric acid [C5H4N4O3] is not the same as urea [CO(NH2)2]
I'll stop looking out for you on Worlds Strongest Man
I can't attest to individual brightness, but yes – rheumatologists are the gout specialists. They also deal with other inflammatory diseases, so should be in the best position to distinguish gout from other diseases.
The uric acid meters have been shown to be very accurate compared to full size lab machines. The only problem is getting the test right. Only two simple reminders:
- Wash and dry hands before use.
- Make sure the drop of blood is large enough to fill the circle on the test strip.
The holder (it's actually called a lancing device!) is included with the meter, but you only get 5 lancets, so best to get a box with your order.
Come to think of it, lancing device is probably better than pricker!
I’ve just done a bit more delving into the white blood cell and diet issue. It is difficult to find much relevant, conclusive work, but I did see that “Adherence to the Mediterranean diet attenuates inflammation and coagulation process in healthy adults” shows a link between higher white blood cell count and the Mediterranean diet.
The author’s definition of such a diet is:
- Daily consumption of nonrefined cereals and products (e.g., whole-grain bread, pasta, brown rice), fruits (4 to 6 servings/day), vegetables (2 to 3 servings/day), olive oil (as the main added lipid), and nonfat or low-fat dairy products (1 to 2 servings/day)
- Weekly consumption of fish, poultry, potatoes, olives, pulses, and nuts (4 to 6 servings/week), as well as more rarely eggs and sweets (1 to 3 servings/week), and monthly consumption of red meat and meat products (4 to 5 servings/month)
- Moderate consumption of wine (1 to 2 wine glasses/day)
- Moderate consumption of fat, and a high monounsaturated to saturated fat ratio.
So zebra just once a month
Allopurinol does not increase uric acid – it reduces it. The painful gout flares from this process arise because old uric acid crystals that were hidden by the immune system in a protein sheath become “visible” again when that sheath falls away as the crystals dissolve. These flares are no different from the ones caused by new crystals forming, but they do tend to affect many joints at once.
These flares are not totally inevitable, but are common enough to be expected. In fact, the people that do not complain of gout flares during the first sew months of allopurinol are probably amongst that massive percentage who do not take the correct dose of allopurinol.
Dosing is vital, and you are only weaned on to it to check that there are no serious reactions. These reactions are very rare, but as with all medications, it is wise to tread carefully.
Some doctors do not undersatand the significance of dosing, opting for a “standard” 300mg dose and leaving it at that. This is usualy a complete waste of time. The best way is to start with 100 mg then increase this over a few weeks to get the right dose to bring uric acid below 6mg/dL Therefor you need blood tests every one or two weeks in the early stages.
I'm not certain that one month will be long enough to get this dosing right, so you should check this with the doctor.
With gout this serious, dietary adjustments are not likely to have much impact – unless you have been on a total no fruit, no veg, just mountains of fish and meat diet. Eating more fruit and veg, particularly dark coloured varieties, can help as they increase your natural anti-inflammatory and anti-oxidant intake. They should also help boost your immune system, which will help you recover from gout flares more quickly. The best dietary advice is to lose weight slowly if you need to, and keep well hydrated at all times.
There are different figures given for the saturation point of uric acid. This can also be raised by higher pH and higher temperature. The figure quoted by Roddy and colleagues in “Concordance of the management of chronic gout in a UK primary-care population with the EULAR gout recommendations” is 360 µmol/L. I have seen it elsewhere as high as 400. I can find no evidence to suggest that readings in the 429 to 495 range are anything other than a risk for gout, so where your doctors confidence is coming from is beyond me.
Gout is often hereditary, so that is a a second pointer to suspect gout
That is not to say that you definitely have gout, but you must be a candidate for the joint aspiration test.
I have been in a similar situation. Unfortunately (or perhaps luckily), I was in no position to walk out of the x-ray department, so they had to continue testing until they found the gouty culprit.
Your lifestyle is probably helping to inhibit the full effects of gout. However, if you are genetically programmed for excess uric acid (either as an under-excreter or over-producer) then diet may not be enough. And even vegetarian diets may not be gout optimal. Are you taking supplements? Excess iron can be a real gout trigger. And do not forget that you are surrounded by the meatiest source of uric acid – your own body. In fact one of my criticisms of the “pathway to from purines to uric acid” model from the Google knol that you refer to is the equal weight it gives to food intake and cel breakdown as sources of purine. The former should be tiny print, almost invisible, whilst the cell breakdown emphasis should be large enough to cover the whole diagram. Increasing muscle mass through excessive exvercise is not good for gout, though you have to balance the cardio-vascular risks of too little exercise.
If I were you, I'd see a rheumatologist.
Yes – a little trauma can bring on a gout attack. In fact, my very first attack was set off when I kicked a ball, the point of impact being the end of my big toe – but not much impact at all. My theory is that joints that have been damaged at some time are most likely to get attacked by gout which is certainly the case for me.
vegetarianGuy said:
… Maybe I am just going mad
Then, my friend, you are definitely in the right place
CC_Alaska said:
Don't let her breach the 'Do Not Cross' tape making a 3 foot perimeter around your foot though. I have two bouncy 7 and 10 year old kids that love nothing more than to jump and bump my sore toe!!!! I'm in the process of constructing a titanium metal box to encase the foot for these occurances.
Make it bigger. Put the kids in.
Well…there's another way to diagnose it: Tuff it out this time and if it's Gout; IT WILL RETURN….probably about a year or so from now when you have completely forgotten about the first incident. Sorry…thats my tongue in cheek humor.
Good luck…I really hope it's stress or strain from the gym!!!! If not, life isn't over….you just have to ride out a 'toe party' (my name for it) now and then!!! It can be an reason to get the wife to bring you stuff while you watch TV with your foot up on a pillow. Don't let her breach the 'Do Not Cross' tape making a 3 foot perimeter around your foot though. I have two bouncy 7 and 10 year old kids that love nothing more than to jump and bump my sore toe!!!! I'm in the process of constructing a titanium metal box to encase the foot for these occurances.
I hope you all appreciate the humor. I've had diagnosed Gout for 9 years and I still live a happy life. Remember, there are millions of people fighting life threatening diseases at this very moment…Gout is not one of them…glass half full!!!
Take care…..
Definately moves. Mine started 6 years ago in my right big toe then attacked my left big toe once. I just had my first attack in my left knee. I know this sounds crazy, but I'd take it in my knee rather than my feet. At least i could walk stiffed knee'd. I couldn't get a shoe on when my big toes were swollen. The upshot is that i went over a year without an attack…thank the good Lord for that!!!
zip2play said:
So my Dx is tendonitis of the foot, and precisely the “tensor hallicus longus” (I had to look that one up so don't be impressed.
)
Well, I AM impressed
One of my great difficulties, probably natural on a site that is dedicated to gout, is the issue of giving gouty advice to someone who hasn't got gout. Once the idea is there, it is hard not to see the situation as gout looking for recognition and treatment. Perhaps if we had better local diagnostic centres (for all common diseases) and fewer managers who need waiting lists to manage, we would get the answers we need much earlier (A bit of a UK slant, but I know that prompt, accurate gout diagnosis is an issue everywhere, despite different health administration models).
Just as an aside, have you noticed that the more that professionals seek to display their professionalism, the worse service we get? Doctors want to be doctors more than they want to heal, and so our health suffers. Teachers want to be teachers more than they want to educate, and so our education suffers. And don't let me start on politicians (or rather DO let me start on politicians). Sorry, rant over.
For your sake, I hope that you have not got gout, but part of me will regret losing a great contributor – especially one that gives us pictures!
Best of luck with the x-rays.
