Gout with normal uric acid levels?

[Stephanie Mahlke]

I’m new to this forum.

I was diagnosed with gout in 2014 by a podiatrist after getting an x-ray during what appeared to be an acute gout attack. The pain in my big toe was so intense I was unable to walk without crutches for a couple of weeks even on painkillers. I started taking whey protein several months before the attack and noticed I could not stand for long periods of time without my hips and feet getting sore. I put off going to the doctor until I had that attack.

Now other joints seem to be affected, my right thumb, and right hip. My hands sometimes get real stiff in the morning. I decided to get a uric acid monitor to see just how much uric acid I’m dealing with. I’m pretty sure I’m pricking myself correctly but the uric acid was at or below 3 mg/dl the two times I tested so far.

Is it possible to have gout without the hyperuricemia? Or are the crystals going straight to my joints for whatever reason?

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This long discussion about gout with normal uric acid includes experiences and other related topics. Including:

• Normal Uric Acid But Still Have Gout.
• Gout Without High Uric Acid – Maybe Pseudogout.

[d q]

Hello Stephanie,

Whilst what you describe sounds like gout, I am little unsure about getting a diagnosis from a podiatrist. My podiatrist is fantastic and extremely talented but I would still probably get checked by a rheumatologist first. I think the best way to approach this would be to;

Visit your GP and get a proper blood test done. Based on those results seek their opinion and ask to be referred to a rheumatologist. They will further assess to see if gout could be the cause and then either a) Ask you to make a few lifestyle changes to see if they can lower your uric acid levels (if they can be controlled in this way) or b) they will put you onto medication.

Now in answer to your questions;

Now other joints seem to be affected, my right thumb, and right hip. My hands sometimes get real stiff in the morning.

Generally gout starts in one place and spreads over time to other places as the condition progresses. Attacking multiple places at once normally occurs later when nothing is done to control UA levels earlier.

Gout Without High Uric Acid – Maybe Pseudogout

Is it possible to have gout without the hyperuricemia?

Hyperuricemia causes gout over time. The most similar pain condition to gout without high uric acid levels is pseudogout which is a build up of calcium instead. However, I would not trust a prick test to give you an indication of your UA levels. You should have a blood test followed by another blood test 2 weeks later or so to get an idea of your UA levels. It is not uncommon to find low UA levels whilst you are in this midst of an attack either.

Or are the crystals going straight to my joints for whatever reason.

I am not too sure I understand this question but crystals will accumulate in joints over time. It is when these crystals break away from joints that the immune system reacts and causes you the pain you feel.

Get seen and tested properly first (preferably by a rheumatologist).
You’ll be in a better position to make choices and we will be in a better position to help too.

Take care 🙂

[Jean Clyne]

Definitely possible to have gout with normal uric acid levels, I do as well, my doc says that is quite common, on the other end, a person can have high uric acid levels and not have gout. Mine is in several different sites, ankles, toe, Achilles tendons, various finger joints. 6 mos on allopurinol took all swelling out of Achilles tendons, took soreness and swelling out of other areas as well. Side effects from it caused me to go off it however still take anti inflammatory, cox 2 inhibitor, called celebrex. If I take black cherry juice, alkaline lemon based water, I have been totally symptom free for past 4 months. Total vegetarian diet works too. I kept a food/symptom diary and that really helped me initially to correlate symptoms to diet. Sugar is the other culprit. If the whey based product bothered you, you might be lactose intolerant to milk products. Is there any added sugars to this product? Sounds like something in that supplement is causing your body’s reaction.Good luck.

[Jean Clyne]

Other thoughts, questions I have might apply to you as well. Is there a connection with gout and poor circulation in hands and feet? Overall high levels of inflammation? High histamine levels in body caused by certain foods or other allergens? Does a hereditary connection make it more likely to get gout with normal uric acid levels?

[nobody]

Jean, in my opinion your should use actual numbers instead of “normal uric acid levels”. How “normal” is defined changes from place to place and changes over time as well. It can also be defined higher for men than women. But gout pays no heed to what anyone defines as “normal”. It’s the numbers which matters.
The diagnostic criteria I’ve seen imply that gout is common when uric acid is on the high side of the “normal” range (depeding on how it’s defined). But gout is not expected when uric acid is on the low side of the “normal” range.
And if you have’t been tested regularly, you don’t know how high your uric acid has been for the last few years and therefore how likely it is for you to have gout. Gout isn’t caused by the uric acid in the most recent test result.

And yes, it makes sense that poor circulation, hereditary factors and so forth might contribute to gout.
Studies have shown that other factors have an impact as well. The amount of uric acid in the blood is very important but it’s not the whole picture.

I have nothing to add to DQ’s answer to Stephanie’s original question.

[Jean Clyne]

In Canada, normal uric acid levels are defined as between 150 and 400 umol/L. So far mine have been tested every 6 months, due again soon as well. Results were 308, 339 and after 6 mos. of allopurinol dropped to 258. Next results will be after 6 mos. off the drug, only going with more of an alkaline diet and increased levels of black cherry juice, around 300 to 400 mls.per day aND higher dairy intake. Symptom free during this time so it will be interesting to see what levels are.I have been on total vegetarian diet with very little sugar for 2 yrs. now.

[nobody]

So all your tests were done while you were on a “total vegetarian diet with very little sugar”? In that case, it could be that your symptoms were caused by older desposits.
My understanding is that gout is unlikely when the highest test result is under 360. But that reasoning assumes that tests were repeatedly performed before the subject started a diet or any kind of urate-lowering treatment.
339 on a serious diet is high enough for uric acid to have plausibly been in the danger zone before the diet. Since people seem to react differently to diets, it’s not a given… just plausible.

[Stephanie Mahlke]

Thanks for your replies. It turns out that the test strips were defective. After that initial 3 mg/dL reading I got “Lo” readings. I then tested my husband, who would be expected to have a UA within the test strip range, and he was “Lo” too. I returned the strips and monitor to the seller. It looks like I’ll need to see a doctor who would measure my uric acid level during a time I’m not having a gout attack. Also find a monitor and test strips that I don’t have to have shipped to me. The other day I woke up with a really sore thumb joint that I could not bend all the way. The night before I had a little red wine, which is not an all the time occurrence. I’m thinking whatever I have is hereditary since my mother got affected by arthritis at a young age (30s or 40s). It looks like I’ll need to revamp my diet big time since I’m so young and it seems to be getting worse quick.

[Keith Taylor]

Wow! My 3 pet peeves in one post. 🙁

1. Podiatarist
Now, I’m sure there are some good ones. But I mainly see the bad. Because most do not understand uric acid control. Also, the worst podiatrists allow tophi to grow. Then butcher the bunion and post meaningless unhelpful videos on YouTube.

OK, I’m squeamish and hate seeing operations. But I hate needless suffering even more.

2. Normal Uric Acid
There is nothing exceptional about normal uric acid. Yet it makes my blood boil. Because Normal is a statistical term that roughly translates to everyday language as average. You have average uric acid levels. So that’s OK.

No, it isn’t OK!

Average people get gout. I do not want you to be average. Because I want you to be safe.

3. Unnecessary Home Uric Acid Testing
Here’s a little GoutPal story.

When GoutPal was young, he loved to tinker with cars. So, as soon as he got his first car, he learned to strip it and fix it. Then, he got adventurous and bought an automotive multimeter after reading something in one of the many magazines he half-understood.

But, the multimeter readings only confused him. Until a real mechanic pointed out that all he need do was ask for a battery check when refueling. So GoutPal learned a lesson about leaving some complicated things to experts.

Except he didn’t learn.

Because years later, GoutPal started a website to learn about his gout. He didn’t understand normal=average. Also, he didn’t understand many other important things about gout. But he still wasted several days of his life learning how to use a home uric acid tester.

So now, before you buy a uric acid test kit, I advise:

Convince yourself that you can learn and apply consistent strategies for using the meter in the exact manner described in its instructions.

Uric acid test meters are not toys. These instruments need a consistent, adequate blood sample of the correct size which may take practice to achieve.

Perhaps I should start a course to help gout sufferers “learn and apply consistent strategies for using the meter“. $200 for the course. Then at the end, you get to choose between a free home test kit or equivalent value in professional blood tests. Any takers?

Also, perhaps I should amend my test kit page to make the buying choice easier to understand?

Why do you buy a Uric Acid Meter?

[Simon Duvivier]

Some interesting posts here. I have used a meter for a couple of years now and have noticed that individual consecutive results are not especially consistent. What you should do is plot the results on something like an excel spread sheet and then insert a trend line. A typical trend line would use the moving average of the last 6 test results. (excel will do this automatically for you) In this way you get a more consistent plot with odd highs and lows blended out. I think this will show the long term picture better and whether the blood urate level is trending up or down.
Now a couple of questions:
1. Gout crystal appear in the blood above a certain concentration. When the concentration reduces the crystals re dissolve in the blood and the gout disappears. The crystals will be more soluble in a warm solution rather than a cold one. Therefore you should bathe the affected area in hot water rather than ice it as is sometimes recommended????
2. How quickly will a gout trigger – beer for example – appear as a higher urate level in the blood?
3. If you take a sample of blood from a zone affected by gout will this show up as a higher urate level on the tester? Is it important where you take a sample for testing?

[nobody]

Crystals would normally form very slowly. In the blood, they are quicker to dissolve. Trouble is, crystals are often not bathed in blood. They are for instance found in joint fluid.
Ice does reduce inflammation a bit. It brings fast relief but, as you note, might make the problem worse. Anti-inflammatory pills are more powerful than ice anyway if you can take them.

[Stephanie Mahlke]

I’m back. I had a doctor test my uric acid level and it came back “normal” 4.6 mg/dL. They also tested me for rheumatoid arthritis and other autoimmune disease. Imagine how nervous that made me! Tests are negative so I guess it is a case of polyarticular gout with “normal” uric acid level. Doctor says to take curcumin, cherry extract, and a lot of vitamin C to help prevent gout attacks.

[nobody]

4.6 is pretty low. Gout is unlikely (but not impossible) at that level. I need to take a drug which lowers uric acid in order to get test results that low.
It’d be worth re-testing your uric acid in a few months if the symptoms persist. And if the second test is low as well, you may want to consult a rheumatologist (that’s the appropriate medical specialty) instead of simply assuming you have gout.
Joint pain can have other causes besides autoimmune diseases by the way.

[Jean Clyne]

Normal Uric Acid But Still Have Gout

Your number is in high normal, I also have numbers in normal range, 308,339,258 and 361 but still have gout.

My doc say to not get hung up on just the numbers but rather the symptoms. Here in Canada they are starting to not test for uric acid levels because you can have high levels with no gout, low levels with gout, everyone is different.

Lots of low fat dairy is good for lowering uric acid levels as well. If you keep getting more attacks you may have to go on an anti-inflammatory such as indomethacin or celebrex. That really helps me.

A drug like allopurinol may be needed to remove old buildup of uric acid crystals from your joints that are causing the attacks. Lots of info on this site to help you.

[nobody]

4.6 isn’t “high normal”. It’s low. Your uric acid on the other hand isn’t low. You had one low test while taking a drug that lowers uric acid. All that number tells us is that the drug works on you.
If some people in Canada find uric acid numbers too complicated to bother with, that’s their problem. We all understand that “you can have high levels with no gout, low levels with gout” but that’s no reason not to make use of the data we’ve got. Likewise, smoking isn’t recommended even though you can smoke without getting cancer and get cancer without smoking.

[Jean Clyne]

I don’t understand your post, nobody. Cdn values call “normal” as between 150 and 400 umol/L for what it is worth. All of my values are between 258 and 361 so how is that high? I am hoping rheumatologist appt. this week will provide additional insight. Now many docs here aren’t testing ua levels at all, don’t really understand that one, you would think the more data a person has would be valuable in a diagnosis

[nobody]

361 is a touch higher than recommended. No big deal. I wouldn’t call that “high” but unlike 4.6, it’s high enough for concern. Once you develop gout, you’re far from safe if you test at 400.
If you had many tests done since you quit allopurinol and the highest was 361, that would be one thing. As things stand, your uric acid could conceivably be slowly increasing or simply chronically too high and we wouldn’t know. Your uric acid definitely not scary high and won’t kill you but in my opinion, a little gout is too much.

[Jean Clyne]

So today I got my long requested rheumatologist appointment which raised more questions than it answered. Because right now I have no hot, red, swollen joints in active flare mode, and when I have had joint pain, there was very little redness and swelling, mainly just pain, the doc is wondering if I even have gout. More blood work today, xray of both hands and feet and ct scan getting booked to see what is going on? He has prescribed colchicine for me to take if I can initiate a gout flare and see if it works on it. I am not looking forward to this, but after 2 yrs on very restricted vegetarian diet, I guess a meal of roast beef, big slice of the sugary cake and a bottle of sugary pop will see if it initiates a gout attack as it would have done in the past. Also was tested for rheumatoid arthritis, he says I definitely have osteoarthritis. Wonder if it could be pseudo gout, some kind of food allergy response to meat and sugar? No answers, just more questions?

[nobody]

If you mostly cured your gout through your diet, it’s only to be expected that the remaining symptoms would be very difficult to diagnose. An immune reaction to something inside a joint would need to be quite strong before redness and swelling become apparent. Full-on gout is very strong.
Gout is a slow disease. You might need to eat meat for years before you get full-on symptoms. And it would likewise take a long time to make them go away after that. So you don’t want to develop typical gout symptoms!
Since you did take allopurinol in the past and your uric acid tests at 361 even though you are on a “very restricted vegetarian diet”, as long as you haven’t eliminated gout as a culprit for your symptoms I think it would be prudent to remain careful about your diet and to keep monitoring your uric acid.
You can of course eat roast beef and stuff once in a while, whether it be as a test or for a social occasion. It takes a lot more than one meal for uric acid to do much damage.

And in case you weren’t aware: people who have had gout in the past develop osteoarthritis more often than people who never had gout.

Like you said, no answers (or at least not yet)…

[Jean Clyne]

Thanks, nobody, it is a shame I think that it takes so long to get gp to refer me to specialist. I’ve spent the past 2 years working really hard to get this under control so now, no obvious symptoms. Even when I had attacks, I took the anti inflammatory celebrex, that I already had for occasional use for osteoarthritis pain as soon as I got symptoms so likely was able to only get a relatively mild attack with pain but only some swelling and no redness. I know that gout will tend to migrate to joints already damaged by osteoarthritis, that only makes sense. This might be difficult to diagnose. I hope the ct scan will provide some answers as to what existing damage is present if any. The thought of trying to induce an attack and then seeing if colchicine stops it is rather horrifying to me. The rheumatologist doc didn’t think it was rheumatoid arthritis but did blood test for it anyways. I might be waiting a while for a ct scan so answers might not come for a while, thanks as always for your comments.

[Stephanie Mahlke]

I think I forgot to mention that I’m going to get another checkup in August. If the uric acid is still normal I guess I’ll keep on taking curcumin, cherry extract, and vitamin C supplements to keep from getting an attack of whatever it is that’s ailing me. Whatever it is it’s slowly spreading to new joints. Now in my large toe, fingers, thumbs, hip and back! My fingers and thumb get stiffer, and sometimes throb, even after drinking just 2 ounces of wine. Seafood makes my big toe twinge a little. Gout? Very odd though at my uric acid level. The question is will taking the supplements be enough to keep other joints from getting stiff and achy.

[Jean Clyne]

You sound much like me with the random pains in different sites. When I finally got a rheumatologist appt. he looked at my now normal looking joints, said it doesn’t look like gout, well no, not now after 26 mos of no meat or booze taking anti inflammatories and getting everything under control. Xrays and blood tests showed no rheumatoid arthritis which is good, shows osteoarthritis which I knew, am waiting for ct scan to show if there are uric acid deposits in joints or not.I get the feeling this doc thinks it is all in my head, but if it is not gout then what the heck caused all those symptoms and joint pain when eating meat? Are symptoms from lupus?fibromyalgia?leaky gut? allergies?

[Author]

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