Gout attack recurrent

[Don Ro]

Hello,
My first attack at the big toe was in December after being dehydrate from working in the field and drinking couple beers at night. My uric level was at 7 which was normal high. Doc descripted me with Indomethacin. I only drank it when I couldn’t tolerate the pain. I stopped drinking alcohol, changed my diet to almost no meats, drinking celery juice, cherry juice, and a lot of water. After 1 month passed, I started to run and exercise and the toe was swollen up (2nd attack). This time was less painful so I took the left over Indomethacin. somehow the drug didn’t seem to work but the pain wasn’t agonizing. It got better after 2 weeks, I started chasing my little boy around the house and the toe flared up again (3rd attack). Once again, the pain was at level 3-4 not too bad. It was just uncomfortable to walk. I went back to the Doc and he gave me Prednisone. The pain and swollen were gone away after a week of taking the drug. 2 weeks later, I drank beers again (3 beers in 1st night and 2 on the 2nd night). My toe was swollen up again 3 days after that. it is still swollen now but pain level is 1-2. Is it something else or still gout? Should I taking Allopurinol? Why do I keep getting the flare-ups? Is it the beer or the exercise that caused the flare-up?

[Keith Taylor]

Hi Don, or with your avatar should I call you SuperDon?

Your introduction to gout is similar to mine in many ways. Except I got a definite gout diagnosis (eventually). Back then, there were no agreed guidelines for gout treatment. But the consensus was to let the patient choose between uric acid treatment, preventative pain control, or pain relief as required.

That’s a simplification but it should be irrelevant because doctors now have guidance on when to treat with uric acid lowering drugs. And everything you say tells me that’s what you need.

So unless you have reasons not to, I think you should make an appointment with your doctor to start a uric acid treatment management plan. [Edit: Don, as nobody pointed out below, “treatment” implies that you start some form of medical therapy immediately. But I intended to encourage you to start the consultation process about resolving your uric acid problem. Your doctor has a wide range of options. We can discuss those options as you wish. Sorry for any confusion.]

What are your thoughts on that?

By the way, you described “uric level was at 7 which was normal high”. But I would describe 7 mg/dL as Warning/Dangerous https://www.goutpal.com/449/uric-acid-concentration/
Bearing in mind that uric acid blood test results tend to be understated during gout attacks, I lean towards “Dangerous”. So it makes sense to avoid delays.

[nobody]

Hi,
How do we know that Don has gout? And if he does, how do we know he requires uric acid lowering drugs?
Maybe there is a basis for a gout diagnosis that Don hasn’t disclosed. Mabye Don has had more than one uric acid test. But we can’t assume.
My opinion based on the information above: this is premature. Don’t take dangerous drugs based on the most likely cause and treatment but start by getting more tests. The relevant medical speciality is called rheumatology. Start by getting an appointment with a specialist if at all possible.

[Keith Taylor]

We don’t know that Don has gout. We do know that he has hyperuricemia. In which case he should discuss that illness with his doctor and agree on a plan.
Thanks for pointing out that I wrote treatment plan when management plan is a better term. Because the “treatment” they agree on could be further tests, wait-and-see, or something else.
I will correct that now.

[Don Ro]

@Nobody – Thanks for the feedback. Perhaps, I should retake the uric acid test.

@Keith – Thanks for the information! Doc never explained to me about the treatment plan just descripted pain med. Perhaps, I should talk to him about what to do next.

[Keith Taylor]

Cheers Don,

Doc never explained to me about the treatment plan

It’s a common problem. The guidelines say that treatment should be an agreement between patient and doctor. With both parties playing their role. But no one reads the guidelines 🙁

[nobody]

There are other tests that can be done to rule out other diseases as well as to make sure this is gout. Some of these tests are in my experience only ordered by specialists.
But doing the uric acid test again is by far cheaper and easier. So whatever else you do, doing it again is an easy choice when the first result was only slightly higher than we’d like. While you’re at it, do make sure that result really was 7 and not 0.7 or 700 (both of which would be much worse than 7).

[Don Ro]

My mind is still thinking about how did the gout flare up 4 times on the same toe within 3 months.

[Don Ro]

I was wondering if I need to take any inflammatory pill for my flare up. The big toe is still swollen but doesn’t hurt only when I walk or put pressure on it. This is a second week of inflammatory. If I don’t take the pill, could urate acid damage my joint or any future damage?

[nobody]

Both indo and prednisone are anti-inflammatories. If the effect of whatever you’re taking now isn’t satisfactory, show the swelling to your doctor and ask whether the dose should be increased or the medication changed.
Assuming this really is gout, my guess is that the risk of lasting damage is low if there is only pain when you are putting weight on the joint(s) as long as you are able not to put weight too often on the joint(s). I suspect the risk of lasting damage would increase progressively over the years if you were to keep suppressing symptoms with drugs without adressing the root cause.

Slight imbalances in your body could cause uric acid to accumulate in one area over time and when your body finally reacts to this accumulation, that can precipitate more accumulation at the same location. The reaction itself is partly localized as well.
As a result, it’s not unusual for gout to affect the same joint(s) several times in a row and/or for several months. At the same time, it is also not unusual at later stages of the disease for the pain/redness/sweeling to move between different joints.

[Don Ro]

Just want to follow with an update. I took the Uric test 2 days ago and the result was 9.3 mg/DL. No attack, no pain unless I put pressure on it, or perhaps it’s coming. I’m confuse and not sure of what I’ve been doing is the right approach. No alcohol and my diet is mainly soy based food. Also been taking cherry tart extract and drinking celery juice. What I’m confuse is why my uric acid is higher now then when I had my first attack. Before it happened, I was eating high purine foods and drinking beers everyday. Perhaps, something wrong with my liver.

[nobody]

This is looking a lot more like gout. Obviously, I can’t diagnose you and we don’t have much data to go on because this is still early days but 9.3 is a more typical result for gout sufferers. The variation in test results is also suggestive rather than confusing, even typical around the time of a gout attack (see my previous comment about precipitation)… assuming of course this indeed was a gout attack.
We could go over more comprehensive dietary recommendations if you like but this 9.3 result suggests that you’d better focus on a powerful treatment which would reduce the amount of uric acid in your blood. It would be worth re-testing in a few weeks to make sure that wasn’t a fluke, and you would ideally also get a uric acid excretion test (very few people seem to get one because it’s not useful in most cases). But even a single 9.3 is suggestive enough considering you weren’t consuming alcohol.
Let us know if you want us to go over the precautions best taken (but often neglected by doctors) regarding uric acid lowering drugs even though we don’t know yet if you’re going to take any.

Right now, I’d dial down the unwarranted confusion and book another doctor appointment to discuss whether your latest blood test is enough evidence to move on to uric acid lowering drugs or the diagnostic instead needs to be ascertained with a rheumatology appointment, joint imaging or even joint fluid aspiration.
In case you can’t get that appointment quickly, I would also book another blood test before the appointment so that the doctor might have three rather than two test results to work from.

[Don Ro]

Thank you for the quick response! I can feel the attack is coming. The toe is aching and hurting when I tap on it. Any good suggestion for preventing the attack? What I was confuse is that I thought my diet was to focus on lower the uric acid but evidently not. What are the chances of the test result was a fluke? Also what is the uric acid excretion test?
Yes, please go over the precautions best taken uric lowering drugs! When taking the drug, can I stop after awhile or need to be taken for the rest of my life? I have a podiatrist appt end of this month for the foot issue. Do you guys have or know a good diet plan to reduce the uric acid level?

[nobody]

Sorry for not replying quicker but I had no network.
It’s probably too late to prevent the attack but to make sure it doesn’t get worse than it needs to be, take as much indomethacin (or similar) as you are allowed to. Maybe give your doctor’s office or your pharmacist a phone call about how much you could take if you’ve never discussed this with them. Make sure they understand you are asking about a one-time thing, not how much you could take every day.
Also, the following is less important but drink plenty of water, rest your affected joint and make sure your blood can flow freely into and out of the area (elevate it close to the level of your heart or simply lie down if needed).
I’ll address the other stuff later.

[nobody]

So, diet and drugs…

I’m not sure what you meant by “was to focus on” but the issue here is that, while the effects of dietary changes are different in each case, they are highly unlikely to be sufficient to deal with the troubles of a patient who tests as high as 9.3. While that value could be a fluke, it more likely reflects a problem serious enough that it could only be slowly improved with dietary changes rather than solved entierly (or in a timely manner).
I do not know that decent dietary advice is available anywhere outside of Japan, let alone a complete dietary plan deserving of being called “good”!
If you wanted to try to address your uric acid problem through diet, that would require a thorough assessment of your metabolism and health risks (including mental health risks) because a diet which helps one person may harm another. There are as you might have guessed simple general principles you could try to follow and which would be helpful for many gout suffers but I don’t like to spell them out in full to people who might not be serious about mitigating the risks involved in following a restricted diet because gout pain as well as the debilitating effects of chronic gout are bad enough that they might drive someone to behave unreasonably.
You evidently already know the most basic things to avoid already. At this stage, I would only add that avoiding the consumption of significant amounts of sugar would be helpful in many cases, as would the consumption of generally recommended amounts of vegetables and the maintenance of adequate hydration through the day as well as the year (by drinking enough as well as by avoiding diuretic drugs, drinks or additives). If you aren’t lactose intolerant, also consider consuming plenty of skimmed milk or products made from such (and of course proportionally reducing your consumption of other nutritious foods in order to keep your diet balanced). And finally, be aware that single-celled organisms such as spirulina or yeast as well as some mushrooms can be even more harmful to gout suffers than animal flesh. That’s not the whole picture but I think the above information is pretty safe to share.

Drugs which lower uric acid can in principle be discontinued but, unless perhaps you have made significant lifestyle changes, that would naturally bring back the problems which drove you to take the drug in the first place. That’s why these drugs are often considered lifetime drugs, not because you would become addicted to them or something. Since gout is a slow disease, it sometimes takes a long time to come back after it’s been thoroughly cured so you might end up being able to take breaks from such a drug safely if you wanted or needed to.
There are four main precautions to take with uric acid lowering drugs:
-first, your health risks and in particular your kidney and liver function need to be evaluated ahead of time and followed up as you begin taking one of thses drugs (for instance, the most common uric acid lowering drugs can raise the amount of alanine aminotransferase in the blood non-lineraly with respect to the dose so it’s best to have a baseline value and see if taking a small amount of the drug seems to affect that blood test result before moving on to stronger doses)
-second, you should be aware of the signs of the most serious adverse reaction so that you might report them to a doctor in a timely manner should you notice them (or indeed get yourself to the ER if need be)
-thirdly, it’s important to take a sufficiently strong dose as well as to avoid taking an excessively strong dose… but it’s impossible to put a number of that before trying a drug so you’ll have to get several uric acid tests to make sure a particular dose is right for you (the safest way to proceed again being to start with a small dose before increasing it incrementally if it turns out not to be strong enough)
-finally, there is a genetic test for an especially dangerous form of allopurinol intolerance common among people who have some East Asian ancestries (if you are at risk, consider taking an altrnaive drug if the test is unavailable to you)
This might sound scary but most of these drugs are actually quite safe for most people. However they are a slow cure to a slow disease while doctors often give people dangerous drugs to people in urgent need. As a result, many doctors aren’t always appropriately cautious when there is no emergency which is why I’m trying to give you the tools necessary to make sure resonable steps are taken to ensure your own safety as much as is practical.

[Don Ro]

I’m really appreciate the information. they are very helpful. When I said my diet was focus on lower uric, I meant avoid eating food that is high in purine. I do drink a lot of water (10-12 16oz glasses) and tea. I don’t need to go to urgent care yet because the pain is not as painful like other gout suffers described (hope it doesn’t get worse). Probably won’t take any drugs if it’s not needed. It has been like that for last couple times. The pain level lvl is 3-4. This is the part that confuses me. My recent attacks weren’t so painful. Is it normal of the gout attack?

[nobody]

There are a few things here :
-yes, you should avoid consuming very many purines (although it’s more complicated because there are different purines which have different effects) but it sounds like you might not understand what that involves or achieves
-the main purpose of anti-inflammatory drugs isn’t pain relief (that’s what analgesics are for) but to prevent further damage and stop a self-sustaining (and potentially accelerating) process, and failure to take enough anti-inflammatories for long enough might cause an attack to lack longer than necessary or even to come back
-pain can be caused by the damage done by a gout attack rather than by ongoing inflammation
-I can’t tell what you call 3-4 pain level (how is your scale calibrated?) but it is normal for gout pain to vary and more specifically to peak during the first phase of an attack (whether we should call less intense pain following more intense pain a separate attack or part of the attack which caused the more intense pain is mostly a semantic issue)
-gout can cause chronic low-level pain lasting a lot longer than you’ve experienced so far but that seems to be common only at later stages of the disease

Bottom line: as long as any swelling or redness/hotness affecting much of the foot (as opposed to some small red dots for instance) remains, anti-inflammatories are indicated to the extent that you tolerate them well.

[kyiv stoner]

Seems interesting. Thanks!

[Don Ro]

Update:
Went back to podiatrist last month and she said that i don’t have gout. What i’m having is two bones at joint are rubbing that cause inflammation. That explained why every time i exercise like running or applying pressure to the big toe, it flared up. I ate beef and drank again and no flare up.

[nobody]

Earlier I asked: “How do we know Don has gout?”. Now I have to ask: how do we know he doesn’t? What tests has this podiatrist done to rule out gout?
Flares aren’t directly caused by eating beef and drinking but by an excessive amount of uric acid in the blood. If you have enough (as many do), you’ll get flares even if you never drink or eat beef.
And you had one uric acid test come back with a very concerning value which implies you might be at risk of developing gout even if you current foot problem has a different cause…
So I would recommend that you see a rheumatologist if possible and regularly monitor the amount of uric acid in your blood in any case. I think you should also try to determine why you have so much uric acid in your body because, while that is most likely not a sign of an emergency, that potentially has serious implications besides gout.

[Don Ro]

You bring up a very solid point. Podiatrist was looking at the X-ray image and with the information i provided on the exercise and with the shoes. When my toe was swollen, my uric acid level was 7. Second test showed 9 when my toe wasn’t swollen and low uric acid diet. Gout flared up when the uric acid crystallized. I think i will need to see a rheumatologist. Thanks for the recommendation and your forum.

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