Uric Acid Crystals Lifecycle – 5 important questions

[d q]

Hi Keith / Patrick, I’ve done as much research as possible reading websites and trying to piece together what goes on in the body before, during and after a gout attack and I am really confused about all this crystallisation process. I thought I’d ask a few questions and hope your responses can help me and potentially others who are also slightly confused in the technicals.

1. Assuming uric acid is high in a patient and crystals form, do these actually get trapped in joints or do they get consumed (coated) by white blood cells? I can’t seem to understand what happens during the crystallisation process. If they are coated by white blood cells, why aren’t they then removed from the blood by the kidneys or stool? If they are not removed then what is it exactly that is getting trapped in the joints? surley it’s not the now coated crystals?

2. Now Allopurinol lowers the levels of Uric Acid so assuming they are coated by white blood cells then why would they dissolve? Why would allopurinol have any impact on ‘already’ ingested or coated crystals? It’s wrapped up already and should bare no impact?

3. When (if I understand the above answers) crystals do get stuck in joints, is the consuming of these crystals by the white blood cells the actual pain we endure? If so when they are consumed (coated) do they remain coated and stuck in the joints ready to dissolve again when uric acid concentration levels drop therefore getting the attack in the same place? If not then what is causing the pain during the attack? The Crystallisation or the dissolve? It’s so confusing? Or maybe I’m slow and dumb:)

4. If 380 ummol is dangerous because that’s the level of concentration required to form new crystals and dissolve existing ones (depending on the answers above), what is the deciding factor of dissolving or crystallisation? Is it body temperature? Cold = Crystallise or Hot = dissolve?

5. If gout and crystal forming around joints takes many many years then why after an intense 1 or 2 years of allopurinol usage and complete removal of crystals does it only require a few months for a new attack to occur?

Sorry for the time it may take for you guys help answer the above.

Thanks everyone, I’m sure you’ll help us ‘techies’ or those who are really interested in gout understand the confusing bits further!

🙂

[Jay]

Hi all.
Can anyone advise me on how long it should take to reduce uric acid to safe levels through diet alone.

About 5 weeks ago a blood result came back at 0.44 mmol. I immediately changed my diet, eliminating 95% of meat and fish intake, staying hydrated at all times, completely abstaining from beer and having a breakfast (I never used to do that).

My latest blood test shows I am at 0.38mmol (which is still too high – being above 0.36mmol). So a 0.06mmol drop in 5 weeks.

Can someone help, I’d really appreciate it.

[Lance]

Thanks dq, you’ve covered 3 or 4 questions on my bucket list! I found the UDRP Pain Pathway article helpful in explaining the lifecycle of uric acid in a user friendly way. Anxious to hear the science behind the concepts!

[d q]

Hi Lance, I’m glad this post might be helpful to you.

I’m extremely anxious of what the experts have to say too!
I’ve been completely confused about the above and would love to get the insights as to how it all works in more details.

Thanks everyone 🙂

[Keith Taylor]

Again, quickly, then I’ll return for more detail if needed.

1) Osmosis! Crystals, coated or otherwise won’t pass through most membranes that stop your entire body falling out of your arse. Apologies! – I’ll look up the right words later.

2) More osmosis. All to do with organic compounds reacting to differential concentration. It’s molecular. Somewhere in the old forum there’s an explanation I gave to an inorganic chemist who refused to believe it could happen. I’ll find it when I return. (try searching for combinations of urate, monosodium, crystals, organic, inorganic, chemistry, hansinnm, zip2play)

3) Inflammation is all about the immune system calling for reinforcements. I’m discussing it ith myself at the moment in http://goutpal.net/forums/topic/free-fatty-acids-ffa-and-gout/#post-2872

4) Temperature is often the main factor. But, there are others. I just can’t think of the main ones now. They cease to matter if you get below 300! (Sorry to harp on, James).

5) Because your rheumatologist is an idiot. I.e. it is simply not true. (maybe search for ‘allopurinol vacation’). [Quick check – yes it’s there! 3rd result – Is allopurinol a lifetime drug?]

Tell me which bits need better explanation.

[d q]

Hi Keith,

Thanks for your response mate. I’ve got the general gist to what you explained but still a little confused.

1. Ok I think I understand, but I’ll wait for the right words when you have time.. Thanks 🙂

2. Osmosis makes sense on this one. Concentration levels outside the coated crystals meet levels inside and therefore will move to the less concentrated zone (blood stream) exposing the now dissolved crystals as a result UA levels increase in the blood I assume.

3. I’ve read your discussion and love it thanks. I think I may have something to add to this one. My thesis is reasonably straightforward. They dissolve with the lower levels of UA and then the UA levels would naturally increase in the blood because of the dissolution of the crystals increasing the overall UA level once again which in turn may or may not cause new crystals. Depends on the UA level when they dissolved (thus another attack may occur)..?

4. I’m almost positive and agree that temperature is a big factor as my attacks generally start after a hot shower and not as often in the middle of the night. Potential increase in blood flow to the feet when showering which in turns cause a little expansion which may or may not dislodge a few crystals and an immune system attack is also imminent. What do you think on that idea..?

5. I’ve read that article before but it doesn’t seem to explain why it takes such a long time to build up and once they dissolve with treatment why it doesn’t take too long before they build up again and cause joint pain. I’ve had high UA for over 15 years and only got gout 2 years ago so it took 13 years to build up crystals and deposit them in joints and if I stop allopurinol it will only take a few months or let’s say maximum one year for an attack to flare up again. How does that work? Unless I’m understanding your article completely wrong..? 🙂

Thanks For everything Keith 🙂

[Keith Taylor]

Hi again James,

I think this is a big subject that you have broached. Because, I can’t help thinking that it involves explaining something like the life-cycle of uric acid crystals. So, that would highlight factors that affect formation, location, duration, and resolution. Therefore, it’s a big project. But, I already have one massive project at the moment which is to complete the reorganisation of practical tips for different types of gout sufferer.

Now, I’m not shying away from this. But, I have to think of the value it will give compared to the time taken. So, I have 2 ways to tackle projects that involve explanations beyond a simple short question and answer session.

1. Create a suggestion to publish on GoutPal.com. That can be an enhancement to an existing page. Or, it can be a new page. Either way, you need to browse existing suggestions. Then either comment on a suitable suggestion. Or, start a new suggestion. Because, It’s Your GoutPal.

Or, 2. Create a personal plan to learn what you need to know. Although I assumed that service would mainly be used for treatment plans, it’s equally suited to learning plans. But, you have to start a personal gout diary first. Because, I have to create a meaningful space where we can run question and answer sessions to meet your goals. Ultimately, this might be a better option. Especially if you want heavy involvement in the direction of the project. Because whatever we produce, I can adapt for the millions of anonymous gout sufferers reading GoutPal.com.

I won’t lie. Both of these options require some effort on your part James. But, you don’t seem frightened to get stuck in.

Uric Acid Crystals – Too small to be sharp

Finally, for point 5, which I think is relevant to everyone on allopurinol. Irrespective of wanting to learn about uric acid crystal lifecycles.

Let’s imagine you recover from gout with allopurinol. It is true that uric acid crystals will start to grow again as soon as concentration breaches the crystallisation point. But, if you’ve had a good clear out, you can last for years without having another gout flare.

So, in the report attached to http://www.goutpal.com/1629/is-allopurinol-a-lifetime-drug/ Perez-Ruiz claims over 4 years. But, note this is entirely dependent on getting uric acid below 300 μmol/L during treatment. Then, the time depends on what it rises to when you stop allopurinol. Therefore, once again, we see that gout has to be managed on an individual basis. Who’s to say that you couldn’t last 13 years if you do 3 years on maximum allopurinol? Or, maybe you have to do 15 years on maximum allopurinol and 13 years off. It’s just a numbers game that nobody can predict. All we know is that uric acid crystals will form again if uric acid rises above crystallisation point.

However, before gout flares become obvious, the uric acid crystals cause a lot of damage. So, if DECT was more widely available, it would be easy to get an annual check that would tell you when to restart allopurinol. I hope that day is not too many years away. When uric acid control stops being a guessing game, and starts being managed based on exactly what is happening in our bodies.

[d q]

Hi Keith, I’ll certainly work on a suggestion letter and the reasons why I think it would be great for the public to view. As a secondary gout sufferer I think I can help with other people who have my condition and as a result have gout. 🙂

[GoogleUser2]

Dormant Gout Crystals

I’m in need of some direction (I’m guessing from Keith, but would appreciate any personal stories with similar details).

I am a former gout sufferer. I know that is the envy of all who are currently fighting their personal bout. I had multiple occurrences over a three year period. I apologise for the lack of precision on the details (it was my hope that I could reference my diary to provide sme data, but have had no luck).

I believe my last gout bout was at least two, maybe three years ago – first bout maybe six years ago now. I was prescribed Allopurinol and colchicine for flares. Around two years ago my prescription lapsed and I never refilled.

My question is – I have never made an effort to “purge” UA crystals. There has been no prolonged allopurinol dosing with the express intent to “dramatically” lower my levels. I tend to maintain 5.5-6.5 levels. I am not overly anxious to trigger gout-like symptoms, but if I can be convinced this will be something that will impact my activity down the road – I would consider taking action. I’m 51, fairly to very active – could lose 15-20 lbs.

Let me know if there is additional information that you need to help make my decision. Thanks

Luke

PS. would really value the details in my diary – even if you need to copy and email them to me Keith – I would be most appreciative.

[Jean Clyne]

Interesting, you are similar to me, I wonder if you got rid of enough store of ua crystals while on allopurinol to leave you symptom free now? If you made dietary changes since the time of your bouts then maybe now your system is not building up high levels of ua. Here in Canada many docs are no longer testing blood ua levels but needling affected joint to see if there is crystal buildup. I had a friend recently diagnosed in that manner. If you remain symptom free, why would you treat with drugs that have bad side effects for many users. It would be different if you were still having attacks, you would need to deal with it but ” if it ain’t broke, don’t fix it?” If I develop bad gout symptoms again, will go on uloric but right not am able to control with diet. Vegetarian, black cherry, lots of dairy and alkaline , no sugar, lots of walking, warm socks all the time are working. Will it last, don’t know but the side effects from allopurinol were horrible for me, I couldn’t stay on it. I am waiting for rheumatologists appointment, will be interested in that input.

[nobody]

Hi Jean!

“If you remain symptom free, why would you treat with drugs that have bad side effects for many users.”

Because, once the symptoms come back, they will probably not go away as soon as you restart allopurinol (or an equivalent). And for many users, the drugs used to treat the symptoms have even worse side effects.
The costs and risks involved in infrequent but regular blood tests aren’t negligible but are in comparison quite small. If you can pass the blood tests with a careful diet and natural preventatives such as cherries, there will be no need for you to take allopurinol or Uloric.

[Jean Clyne]

Thanks, nobody. My doc has now referred me to a rheumatologist which will likely take 9 mos to a year . I will be interested to hear what he/she has to say or recommend. So far 5 mos off allopurinol and symptom free, hope it lasts. Ua levels now at 361 so still within what they consider normal here, for what that is worth!

[nobody]

361 ought to be fine as long as the results are consistently around 360 (or lower) as opposed to randomly switching between 360 and dangerous values.

[d q]

361 ought to be fine as long as the results are consistently around 360 (or lower) as opposed to randomly switching between 360 and dangerous values.

This is indeed very true. It’s about a range of results and not the individual result (Although the ad hoc tests can be very helpful too). Take it from me.

[nobody]

@Luke:
Based on your old diary, my guess is that you have a good shot at keeping gout at bay without recourse to allopurinol if that’s what you want. As your doctor said, your uric acid was never very high in the first place. You’ll need to keep monitoring it however and you may need to go back to allopurinol as you get older.
In the meantime, if your highest test result since your stopped having attacks has indeed been 6.5, while you should be OK you should also be aware you might have a very small safety margin. A diet which lowers uric acid and/or weight loss might turn your borderline test results into reassuring ones.
If you allow gout symptoms to come back, you may not be able to get rid of them as easily as you could have prevented them.

[chris mousel]

SUA Dr. Unimpressed by Gout Crystals

Hi Just an update. My original question was answered beautifully. Had no real track record of labs, no diagnosis ever given. The symptoms I was experiencing seemed to be crystal resolving- but completely unknown.
Well I had an episode of painless swelling to my right knee. Unable to bend, joint felt unsteady. 10 cc of fluid was drained from my knee and yes no more question about.
Gout crystals found but ” not a lot “.
I don’t know whether to laugh or cry?
The doctors are still not impressed!
Thank You to the forum , because you helped me understand what was happening. I don’t know what the future holds but I’ll remain on the eating journey I began and go one day at a time.
My last crystal dissolving event was in September of 2018; lasted about 14 days which was not fun and this knee swelling event is the latest.
I did get a steroid injection to the knee and function returned pretty quickly.
I guess more lab work to follow being done in one week.

[nobody]

“Not a lot” of crystals is consistent with the SUA test results you’ve posted. And “not a lot” is too much.
Furthermore, while we do not know how high your SUA used to be, that you have any crystals with a SUA tests coming back under 7 also suggests gout (crystals do not form so easily in the bodies of people who do not have gout).
Keep getting your SUA tested! Nearly every test should come back with a value under 6. If it doesn’t, you should consider medication or possibly eating a lot of foods known to lower uric acid.

Rest assured to you are not the only one in a “laugh or cry” situation! Here’s a model for self-reinforcing medical malpractice:
Start by neglecting and misdiagnosing patients who have mild gout.
Then, when a patient with mild gout annoys doctors enough to get some tests done, their result will be different from the results of the gout patients the doctors are used to. Use this fact as an excuse to dismiss the patient with mild gout.
And so the next time a patient with mild gout shows up the doctors will have no experience in diagnosing or treating them even though there are many other patients with the same problem.

[Author]

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