Doctor is not sure it is gout.

[Sharron Turner]

My husband had a very intense inflamed wrist and hand this weekend. The doctor gave him a steroid pack and tylenol 3. He has had 3 minor flairs over the last 2 years(he would not go to the doctor for these). His labs showed UA-6.5 that is in the normal range for the doctor, ESR was 23 (slightly elevated) TBIL 1.4 (slight elevation), CRE 1.4 (SE) and GFR was 54. He has early kidney disease, heart disease, well controlled prediabetes, early stage parkinson’s, and incident of a bleed in his esophagus due to medication irritation. He is on coumadin for an artificial heart valve. The doctor has indicated his tests don’t confirm gout, but I am concerned that we avoid another acute episode and possible joint and organ damage. The pain was so bad, he said the only thing more painful he has experienced was when a mortar shattered his elbow in Vietnam! Please chime in and offer direction for us to go in treating him. We are adjusting his diet as he loves his root beer and beef. Thank you.

[nobody]

Hello,
Obviously I can’t tell if this might be gout over the Internet.There are other diseases which might look like gout. But I can tell you that 6.5mg/dl (is that the unit on the lab report?) is enough uric acid for someone to have gout. If the doctor doesn’t understand that normal is irrelevant, ask to see a doctor who understands gout such as a rheumatologist!
Considering all your husband’s health issues, some gout treatments might not be advisable, and the same goes for pain relief. But Tylenol is in my opinion much too weak for a gout flare! There are many types of drugs which can alleviate a flare or simply help with the pain so you should harass doctors until all remedies have been explored. Trying a drug people take specifically for gout such as colchicine might also help with diagnosis.

I could give you some information about diet and uric acid you would most likely not get from doctors but it is probably more important to tailor your husband’s diet to his other health issues and his kidney problem in particular. That said, some changes such quitting alcohol should have no downsides.

[Sharron Turner]

Sorry for the confusion about the root beer. It is a ginger flavored carbonated soft drink in the US, not real beer. It often is made with fructose instead of sugar. The doctor did agree to prescribe 100 mg of allopurinol once a day. We will follow my husbands INR levels to see if there is an interaction between the coumadin and allopurinol. We have a home INR testing meter, so we can stay on top of that. Do we need to worry about the fructose in the root beer? Is there much difference in risk between fructose and cane sugar for uric acid production? I am pretty sure we will never be a candidate for naproxin or other heavy duty anti inflammatory medications due to bleeding concerns. Will a steady diet of anti inflammatory foods like the black bean juice, sunflower seeds and your gazpacho recipe help out in a flair? I am pretty sure we can get the rescue prednisone pack, but I need a plan to try to put out the inflammation when and if a flare happens. I assume we will be at risk for a flair since we are starting the allopurinol.

The doctor wanted to do a SUA test in 3 mos, but is agreeable to one in 30 days to check on liver and kidney function. It seems if I can learn enough to make suggestions he is at least will to consider them. Do you think a rheumatologist is more appropriate with other health issues we have to take into consideration?

I appreciate your help. Your website has been a great resource for me.

[nobody]

Thanks but this is Keith’s site, not mine.

Yes, starting allopurinol can potentially be a trigger but this issue is somewhat overblown. I’d say it’s less of a concern if several blood tests have produced results in the 6.5mg/dl range in the past.
What really matters is that allopurinol takes a while to work, even when the dosage is adequate. So people’s expectations must be tailored accordingly. And if the “this can trigger flares” message works better than the “you’ll need to take this every day for a surprisingly long time before flares stop”, I can’t blame people for going with the former.

There are other anti-inflamatory options than naproxen-type drugs or prednisone which has its own risks. A rheuma could perhaps help but considering the special concerns with side effects and interactions, a few doctors may need to discuss the issues among themselves.
Any drug your husband was or will be taking for other problems (blood pressure in particular) should also be evaluated for adverse effects on uric acid.
Dietary anti-inflammatories could easily be more dangerous than the drugs. They’re typically fine for healthy people but I would be very careful in this case.
You also need to have a real painkiller on hand if at all possible. Don’t let the doctors look the other way! They don’t feel the pain and don’t see it in their numbers so you sometimes have to be an annoyance.

You should evaluate the diet as a whole instead of focusing on one thing like fructose but in this situation I would quit all sweetened drinks, regardless of sweetening agent. It’s hard enough to settle on diet which is both nutritious and uric acid friendly without complicating the matter with products which have no nutritional value.
I have no idea what would or would not be appropriate for this kidney problem but most gout sufferers should drink a lot of water and avoid diuretic foods, drinks and drugs. So unless you know that an additive is safe, beware.

Good luck!

[Cezar G]

Besides medication a strict vegan diet, very low in fat including oil would definitely help – no more root beer fructose or red meat. It seems that your husband can benefit greatly from a healthy diet and lifestyle to complement medical treatment.
Dr Neal Barnard is one of the ethical medical doctors presenting scientific evidence about these topics
https://www.youtube.com/watch?v=BnHYHjchn6w.
Many conditions will reverse or pause their progression even though the change might be really hard.
Good luck!

[nobody]

I was hoping Keith (or a deputy of his) would delete this but in the meantime…
There is evidence that many vegans have high uric acid which increases their risk of gout in the long run. Low-fat diets are likewise dangerous even if they might lower the risk of attacks in the short run.
Do not use quack videos as a substitute for medical research or expert opinion, people!

[Sharron Turner]

Thanks for all the information. In a past life I was a registered detitian, back in the 80’s, but have not practiced or kept up with profession publications. My dear hubby has a strong preference for sweet foods, but has still been able to keep his prediabetes status maintained as he lost weight shortly after his first elevated blood sugars were found 10 years ago. He has started the low level allopurinol and is checking his blood clotting rate (INR level), as coumadin is attenuated by it’s use and we will probably have to adjust that down and following up with other blood test to observe his kidney function. The anti-inflammatory drugs will be a difficult issue as it can interact with his coumadin meds(for an artificial heart valve) and the concerns about bleeding issues. We will boosting vegetable consumption, and he is currently drinking about 4 oz of tart cherry juice daily. I believe this attack may have been brought on by an infected puncture wound from a rose thorn and then on top of that an oral infection under an old crown that resulted in 2 different antibiotics being prescribed at the same time. He is rather frustrated about this new condition as he really tired of all of the other issues he deals with. Amazingly he is pretty vigorous considering all he has to contend with and I hope to keep him that way. Many people follow very restrictive diets, but they are hard to adhere to and most people usually modify them after a period of time or abandon them all together. Eating a balanced diet has always been a challenge for my husband, but he was really shocked at the ugly gout pictures I showed him to try to get his attention to realized he could have some bad effects over time. I appreciate the efforts that have gone into this site and the education I am getting about the Gout condition. Now I am trying to find foods without high fructose corn syrup so he can have some of the things he wants to have in moderation along with other the dietary adjustments. Thanks, again.

[Sharron Turner]

We just got some new lab tests for the kidney specialists, so we don’t have any liver values we do have UA and other measures. Chuck has been on 100 mg allopurinol for about 20 days now and his UA is now 5.1, down from 6.5 mg/dl and his kidney function is unchanged with a eGRF at 47 which is stage 3a kidney disease. He is experiencing shoulder stiffness daily and a little continuing pain in the right wrist, where he had his last attach a month ago. He is drinking cherry juice daily, reducing his sweets and sweet beverages somewhat and eating pineapple and some more fruits and vegetables. We will hopefully meet with his primary physician soon to see if he can have something for his joint pain. He currently is only allowed acetaminophen for pain due to bleeding concerns. While he is only taking 100mgs of allopurinol it seems to be reducing his ua well. Is this considered a good rate of reduction. Does UA drop fast early in the treatment and level off or does UA levels fluctuate? As he is already having shoulder discomfort, would a higher dosage of allopurinol increase his shoulder pain? And is an increase in dosage called for with his reduction at the rate we are experiencing?

[nobody]

This UA drop must be confirmed by further testing but is a good sign.
A higher allopurinol dose might help (especially considering this kidney problem) but we don’t know how fast its metabolites are eliminated in this case so increasing the dose could conceivably do more harm than good. It looks like 100mg might be a sufficient dose (combined with a reasonable diet) if not the dose that allows for the fastest recovery. Someone who understands both the parmacokinetics and this kidney disease might be able to venture a guess or reference relevant studies…
The main thing he apparently needs is drugs targeting inflammation or pain anyway. Surely the bleeding concern is an issue with COX inhibitors, not all drugs. Taking lots of acetaminophen without testing liver values is dangerous by the way.

[Sharron Turner]

Just to add information, the lab report has the last 18 months UA values with the 2 tests in 2019 running at 5.9 and 6.3mg/dl. So the 10/30/20 at 6.5 was a slight increase. And now we have the 5.1 result on 11/17.

[Sharron Turner]

Thought I would post an update. Latest UA level is 4.1. Hubby is on 100mg of allopurinol and drinking the cherry juice still. Eating pineapple very regularly along with yogurt and some other dairy and avoiding soft drinks and no longer having the occasional beer. Wrist is feeling much better, with a little pain if you rub around the initially inflamed area. His main issue now is his left shoulder pain, but the doctor doesn’t think this is related to gout. The shoulder pain began shortly after he started the allopurinol and feels a lot like a rotator cuff type pain.

If anyone has anything to add about the shoulder issue, please post.

We are continuing to take the allopurinol and are thrilled his uric acid is dropping so quickly.

Thanks!

[nobody]

I’ve naturally had shoulder pain linked to wrist pain before I took a UA-lowering drug. So far as I know, it’s pretty common to develop shoulder pain when you have a wrist issue. And you can definitely get gout in the hands.
Whether actual gout in the shoulder is plausible considering these UA values is another matter. But during the initial phase of treatment, UA crystals are known to wander so I don’t think the notion can totally be ruled out even though there are more plausible explanations.
If this shoulder problem is indeed secondary to the wrist issue, anything that relieves muscle stress might help (as well as very mild exercise). If it’s bad enough, seeing a physical therapist might be advisable (though if it seems very bad one should of course first rule out serious problems).
Also note that topical anti-inflammatories might be somewhat effective for hand inflammation and should be much less prone to causing stomach issues than pills. Even if the hand isn’t painful anymore, mild inflammation there could still be causing arm and shoulder stress.

I hope the liver and kidney function values are as good as the uric acid values! Ideally you would want to stick to the 100mg but if it’s too much for your husband’s system, it looks like a slightly lower dose might still be effective (if further blood tests keep returning such low UA values, that is). During the initial phase of the treatment, it makes sense to use a dose that’s a bit too high anyway.

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