Gradual gout attacks?

[Eide]

Hello, all.

I had my very first gout attack recently, on Thursday January 14th, in the big toe of my left foot. Or should I say, that’s when it culminated. There had been a gradual build-up all week, which I initially attributed to my new boots not having been walked in yet. I was able to go to work on that Thursday without too much discomfort, but once I got home and rested my foot for a few hours, the pain had shot up off the scale. The next morning I got an emergency appointment with my doctor, who prescribed 20 mg prednisolone and 3×50 mg voltarene, each for five days, while we awaited the results of the blood tests. The medication worked really well, although the curative effects stagnated at a very tolerably low level of discomfort.

The thing is, however, that as soon as I’m off the meds, the discomfort starts creeping up again. First time it happened, I nipped it in the bud with some more voltarene, which took care of things. Next time, however – because it felt like the pain was in the hallucis muscle and/or tendon (and the swelling was on the underside of the toe, rather than at the joint), I decided to let my body heal itself. Didn’t work, and it culminated in another excrutiating attack, which curiously was not centered around the joint, and no longer the muscle/tendon.

I called my doctor, who postulated it was because I had gone off prednisolone too abruptly. So he prescribed 5 days of 20 mg, and then ever-decreasing doses over several days.

Prednisolone worked reasonably well the first couple of days, but then it stopped working while still on 20 mg, and the pain built up to another attack. I then went back on 3×50 mg voltarene, which very gradually (6 days) brought the dolor levels down to nearly nothing. I kept up the voltarene prophylactically for several days, and resumed allopurinol while I was doing so. On suggestion from my doctor, I switched from voltarene to iboprufenol, but said not to take them prophylactically. So I went off the voltarene, keeping up the allopurinol, and sure enough, the toe started to get more tender again. So as of yesterday, I’m on iboprufenol, after only two whole days without any anti-inflammatories.

Some vital statistics:
Age: 42
Non-smoker
Very moderate drinker (teetotaller since the first flare)
I am overweight (1.75 tall, 93-98 kgs)
Been a heavy coca cola drinker – coke has been my go-to drink for thirst and for dinner (I went cold turkey after the first flare, and done my best to cut out added sugars in general)
Lifestyle: pretty sedentary.
Diabetes: no
In spite of an unhealthy lifestyle, my overall health has been good. Never had a sick day from work until now, and never been on any sort of medication before either. Never done any drugs other than the ones mentioned above.

I have had a slight swelling on the side of my toe joint since this all began, persisting even in the good periods under medication, with a redness that has never gone away, and the area is slightly warmer than the corresponding area on my other foot. I am awaiting my appointment for an X-ray to see if it is tophaceous.

But is it normal for gout to act this way? I have had a total of three attacks within the span of a month (I am possibly building up to a fourth one as we speak), all of them with gradual build-ups. I have been careful with my diet, even kept a food diary where I write down everything I ingest (this has actually been effective at dissuading me from lapsing back on sweets).

Does anyone else have experience with gradual and/or persistent gout attacks? Could it be that I’ve been suffering from one long gout attack since January?

[nobody]

Yes, this isn’t unusual. But…
I was very surprised by “resumed allopurinol”. That’s not a drug that should be stopped and resumed, unless there is a very good reason.
If you’ve started allopurinol a few weeks ago, requiring anti-inflammatories constantly for a while wouldn’t be surprising and not allowing the inflammation to start by quitting them entierly might prevent the need to take large doses for a long period of time (and once it starts, you might find it is best to kill it completely instead of quitting anti-inflammatories when it becomes very mild). Colchicine is often used for this purpose even though it’s arguably not an anti-inflammatory as such because it has different side effects and an effective dose can in many cases be taken daily for quite a while. If you haven’t been told you can’t take colchicine, ask about it. Some people don’t need it but it can be useful when inflammation lasts a long time or keeps coming back.
With all these drugs, dosage matters. So talk to your doctor(s) about using larger doses for a small amount of time and what side effects to watch for. In particular, allopurinol will only work if you take enough and, unlike anti-inflammatories, you won’t feel that the dose is too low. So how much uric acid is there in your blood?

And what’s the basis for your gout diagnosis in the first place?

[Eide]

Yes, here’s the thing about my prescription of allopurinol:

In my consultation following the results of the blood tests, I was prescribed 200 mg allopurinol a day – and that’s it. No mention of colchicine or anything else to be taken in combination. At that time I still didn’t know much about gout, so I had no reason to question anything my doctor said. When I had my second gout attack, I called my doctor for another consultation. He told me to immediately stop allipurinol because, he said, it had no effect during an attack (maybe he meant because of the other drugs I’d be taking to bring the attack down?). At this time I had been on allopurinol exactly one week.

By my third consultation, a little over a week ago, I had done my homework. This time I was going to suggest colchicine myself, but he beat me to it. However, what he suggested was that I might take colchicine instead of allopurinol. I tried to point out that the two drugs were usually prescribed together, but it is difficult for a layman to argue with an expert. In the end, where we landed, was that I was to resume allopurinol and take ibuprofen if and when I had flares. I asked if I could have a prophylaxis with respects to these flares, and he said, “allopurinol is a prophylaxis.” I said sure, in the long run with respects to uric acid levels, but he insisted it was a prophylaxis for the flares as well.

I tried to tell him I got my information from the Norwegian Medical Association (I’m in Norway), but naturally professional pride will prevent a doctor from conceding the point to a layman – I didn’t expect he would, so I didn’t force it. But hopefully I will have prompted him to do a bit of reading-up for my next consultation. If not, I’ve got print outs from the Medical Association, and if that doesn’t help, I’m seriously considering changing my GP.

I should perhaps add that my doctor is in his 70s, and the notion to halt allopurinol during flares might be an obsolete medical advice from the old days. Since most every source I’ve come across stresses that one should not stop taking it, I get the impression that such is the case.

I have kept a meticulous log of all drugs and dosages I’ve taken, and so far this is how much allopurinol I’ve taken:

Jan 28 – Feb 3 (8 days) (200 mg)
Feb 19 (16 days hence) – present. 11 days and counting. (200 mg)

As for voltaren in the same period, this has been entirely on my own recognizance. Dosage and duration as follows:
Feb 9 – Feb 18 (10 days): 3×50 mg
Gradual improvement until Feb 15th, after which improvement stagnated at a negligible level of discomfort.
Feb 19 – Feb 21 (3 days): 2×50 mg
Discomfort stayed the same in this period. There was certainly no increase.
Feb 22 – Feb 25 (4 days): 50 mg
My foot didn’t get worse during this period, either. The toe joint was only tender under certain exertions of the toe (eg. when taking off my right boot, by pressing down on the boot’s heel with my left toe). It was not tender to the touch, in spite of the (minute) swelling of the joint itself. I figured “this is as good as it’s going to get”, and went off voltaren, because I didn’t want voltaren in my system if and when I started ibuprofen.

Since my adventure with gout commenced a month and a half ago, I have taken:

prednisolone: 17 days (4+5 days 20 mg, 8 days gradually smaller doses)
voltaren: 28 days (5+6+17 days)
ibuprofen: 2 days (started yesterday)
no anti-inflammatories at all: 11 days (3+6+2 days)

Side effects so far: None that I have been able to detect.

My uric acid level per Jan. 15 was 513 mmol/l (should be 8.55 mg/dL by my calculations). I have not had any blood taken since. I am waiting till after my X-ray and/or four weeks of allopurinol (counting from Feb. 19th) to book my next appointment – whichever seems most prudent.

The basis for my initial gout diagnosis was that blood test, following the emergency appointment on Friday 15th. The evening before I was not able to move my big toe at all, neither with its own muscles or with digital manipulation, for unfathomable pain. It didn’t take long for the missus to persuade me to get that doctor’s appointment first thing. Gout was, of course, suspected right off the bat, but it was the blood test that secured the diagnosis. It does run in the family, too, although my father didn’t get it until his 80s (but then he has always been healthier and more active than I). My brother isn’t diagnosed, but he gets what might be gout flares about once a year, in his ankle. But he takes a few pain killers and that’s that.

My apologies for being so verbose. And thank you for your reply.

[nobody]

My GP even told me at one point colchicine was the same thing as allo! The relevant specialist is called a rheumatologist. I wish I could say they are always knowledgable about gout drugs… but still, trying a random rheuma is a much better bet than a regular doctor.
The main point in seeing a rheuma in my opinion isn’t even to get the treatment right but to make sure another joint disease isn’t mistaken for gout. A single uric acid blood test (especially if the result isn’t that high) in the context of a single gout-like episode can’t establish a gout diagnosis. Ideally you want crystals to be detected in the symptomatic joints, either with DECT or joint fluid aspiration. A simple ultrasound could help tell what’s going on though some doctors favor MRIs. But none of this is strictly needed if there a pattern of repeated flares with the right features along with several uric acid tests. Even though gout is the most likely explanation for your symptoms considering your family history, you don’t want another problem to be missed. As you point out, doctors are often so arrogant that it makes them dangerous…

It’s correct that allopurinol is unlikely to help with a flare but that’s not a reason to stop it since interrupting treatment could easily cause a second flare soon afterwards or simply cause the flare to last longer.
You understood correctly that allopurinol is typically not effective as a prophylaxis in the short run, though it could in principle work early in the treatment if the dose was large enough and if the disease was caught early enough.
Ibuprofen or Voltarene on the other hand can work nicely as prophylaxis if you tolerate large enough doses well but for some people these drugs are seriously problematic when taken for too long.

You don’t need to wait 4 weeks after restarting allopurinol to get your uric acid checked unless the number of blood tests you’re allowed to get is limited somehow. The value after 2 or 3 weeks would be instructive enough and I would in any case recommend more tests a few weeks afterwards considering the results are sometimes randomly off (in my experience anyway).
You don’t want to suffer pointlessly on an allopurinol dose which is too weak. 200mg works for some people but others need more. The sooner you your dose right, the sooner you’ll get better (if this is gout).

If you do indeed have gout, you should get your brother to get his uric acid tested and to show his ankle to a rheumatologist next time it acts up. Gout is a disease best treated early!

[Eide]

This is all very good advice. The reason I figured 4 weeks is because I’ve read a second test should be taken 3-4 weeks on the initial dose of allopurinol, to see if an adjustment of the dosage is recommended.

Of course, different sources give me different figures – for just about everything. Some suggest starting with 50-100 mg of allo, others say 100-300 mg for an initial dose. All in all, I was dismayed to learn just how little clinical testing has been done for a disease which has been known since ancient times. A lot seems to be based on received knowledge and anecdotal evidence. We haven’t even properly identified the mechanics by which alcohol hinders uric acid from being excreted, we have just accepted that it does. And the same goes for most dietary recommendations. My heart sank when I read that tomato products were the fourth most commonly reported gout trigger, but it doesn’t seem to have affected me adversely.

And vitamin C and dairy products are supposed to be good for lowering uric acid levels. But wait: that’s just for healthy people. For people with gout, vitamin C apparently has no effect in lowering uric acid. Presumably the same is true for dairy.

I will book another appointment to have additional blood drawn – and I’ll ask to have my blood pressure taken while I’m at it (I have never had my blood pressure taken as an adult). But I’ll wait until after the X-ray – besides, my previous consultation was just over a week ago, I don’t want to be “that” patient.

Thank you kindly for your replies so far.

[nobody]

Dairy works. That’s one of the few things we know. We understand some of the mechanisms at least. I wouldn’t compare that to the matter of vitamin C. But rather than distinguishing between healthy people and people who have gout (a dicey proposition), I’d distinguish between people on medium/large doses of allopurinol (and similar) from most people. If you’re taking enough allo, diet will hardly matter except for avoiding triggers during the early phase of therapy.
Since you seem concerned about that, the one thing that would most likely trigger you is dehydration. So anything that makes you leak a lot should be avoided. Anything that makes you pee or sweat a bit more than usual can probably be mitigated by drinking more water. As for the rest (such as a few tomatoes), that’s a matter of avoiding stuff that triggers your immune system and that’s a pretty personal matter which in some cases may include gluten and whatnot. If you don’t notice tomatoes doing anything, no worries.

[Eide]

Can’t say I’ve really noticed the effect of dairy. I’ve been a fairly big consumer of dairy before my gout (whole milk, fat-free yoghurt, cheeses), to a heavy consumer after (skimmed milk, fat-free yoghurt and cheeses). Skimmed milk makes up a significant portion of my daily fluid intake.

All research I have been able to find re: the effects of dairy on uric acid levels have included healthy subjects only. With respects to vitamin C, there is certainly literature suggesting vit. C helps prevent gout in the first place, but I have found one article that has specifically targeted patients with established gout:

https://onlinelibrary.wiley.com/doi/full/10.1002/art.37925

The sample size was not tremendously huge (40 individuals), but the methodology seems sound enough:

Patients with gout and an SU level >0.36 mmoles/liter (6 mg/dl) were recruited. Twenty patients already taking allopurinol were randomized to receive an increase in the dose of allopurinol or to commence taking vitamin C (500 mg/day). Twenty patients who had not been taking allopurinol were randomized to start receiving either allopurinol (up to 100 mg/day) or vitamin C (500 mg/day). Levels of plasma ascorbate, creatinine, and SU were measured on day 0 and week 8.

As you can see, 10 subjects who had not yet commenced allopurinol were given 500 mg vitamin C in place of it – and it had no effect in the initial 4 weeks. Adding allo after 4 weeks had some effect after the next 4 weeks, but not nearly as much as those who commenced allo and then increased dosage of allo after 4 weeks (fig. 3).

[Eide]

It could be that gout patients need a higher dose of vit. C for it to be effective, and it could also be that vit. C has effect only a certain time after a flare has subsided. It seems strange that gout patients should be immune to some of the effects of vitamin C, but who knows. There is still a good reason to take vitamin C while on allopurinol regardless, however, as vit. C increases plasma ascorbate, and so reduces the risk of oxidative stress from use of allopurinol. Apparently.

Oxidative Stress from Use of Allopurinol – Is There a Reason for Patients with Gout to Take Vitamin C?

Anyway, yeah… “anything that makes you leak a lot should be avoided.” I’ve never gone to the bathroom so often as after I started taking allopurinol. In the leaflet it stresses the importance of water, 2-3 litres a day, which to me is an extreme amount. I can push myself to 2 litres, but with all the water I’m taking I feel like I’m going to the bathroom all the time. I have found that diet sodas help me retain water better than water. Water seems to be… water purging. If I try to push the 3 litre mark especially, it leaves me feeling bloated and my urine will be crystal clear. Even with 2 litres, my urine is often clear. It is never dark these days. Before gout, I could easily make do with 1 litre of fluid in a day. If I drank more, it was because of my sweet tooth. I’m trying my best to spread the fluid out for the whole day, and to drink less after 8-9 in the evening (to avoid having to get up in the night so much). I am gradually finding a good balance, though. I think 3 litres is probably excessive for my body size, so if I manage 2, I’m satisfied. My food diary has proven essential to help me get all the fluid I need, from all sources.

[nobody]

You can’t reliably tell people who have gout from healthy subjects and you don’t need to do unreliable dietary research on the effects of dairy to know that it has an effect since you can ascertain its main effect (purines, or rather the lack thereof) in the lab.
But this is irrelevant to most allopurinol users anyway.

As to the first vitamin C study, such a study was unlikely to find anything conclusive since it is obvious it can not reasonably be compared to allopurinol and uric acid numbers are often especially noisy in gouty individuals requiring many more subjects or measurements (especially if you’re not careful about when and how the blood is drawn).
As to the other study, the important thing when it comes to oxidative stress is as usual allopurinol dosage. Considering how many people take an incorrect dose, studying things which make little difference like vitamin C seems borderline irresponsible.
Full disclosure: I don’t take large amounts of vitamin C unless I have an infection (and even then, very rarely).

Going to the bathroom often may be the best thing you can do to support allopurinol in the early phase of therapy. Obviously you shouldn’t go overboard with water but it doesn’t sound like you do. Assuming you don’t have some kind of kidney problem requiring you to limit fluid intake, 2 litres isn’t much unless you’re not counting other fluids or there’s a lot of water in your food.
For what it’s worth, I drink a good bit more (mostly plain water since I don’t do sodas) because it feels good and my mouth feels dry otherwise yet my GP hasn’t recommended drinking less (except inasmuch as it might interfere with my sleep as you point out).
After your gout symptoms are mostly gone, if drinking makes you pee quickly, that may be a sign you don’t need to drink that much.

[Eide]

So I’ve been waiting for the summons to my X-ray (or ultrasound) appointment, and started to suspect my doctor had forgotten to book one for me. I called the X-ray wing of the hospital, and sure enough, nothing was booked. So at least I called my doc and booked an appointment to have my blood pressure taken, as well as new blood tests. That’s for Thursday the coming week. If the swelling persists by that time (and I have no reason to believe otherwise), I will ask him to book an appointment then. There may be as much as a 10 week wait to x-ray extremities, so I changed my mind about waiting until after x-ray for my next consultation.

[Eide]

Just got back from the doctor’s. My blood pressure was 158/100, which is uncomfortably high. Now I wish he had taken my blood pressure before I started allopurinol, because I do not know if my elevated BP is due to either allopurinol, all the NSAIDs I’ve taken, or both. He didn’t mention any conflict with allopurinol today, and I didn’t think to ask (the leaflet in the allo packet lists it as a cautionary note). He cautioned me against NSAIDs, however. I’ve already taken 100 mg allo this morning – I’m thinking about skipping the one for this evening until I’ve checked.

He seemed much more diligent when it came to my blood pressure than he was with my gout – after all, he never booked any follow-up appointments for my gout, they have all been on my initiative. Taking my blood pressure, too, was on my initiative. But with my elevated blood pressure, it seemed like he was more in familiar territory.

[nobody]

The forum discarded my reply so I’ll be very brief: your kidney and liver function numbers also need to be checked because you started allopurinol. And gout often impacts blood pressure indirectly, something many doctors neglect.

[Eide]

They drew more blood today, so we’ll see what it says. The ECG was also “not bad”, according to the nurse who administered it (I didn’t think to ask for actual numbers at the time). My follow-up is on the coming Tuesday, I guess I’ll know more then. But with the quantity of voltarene and lately ibuprofen, I shouldn’t be surprised if that has been a major contributor. My toe was acting up again just yesterday, so I had a hefty dose of 1200 mg ibuprofene (400 at 6 hour intervals).

I tried to press the issue about colchicine, but the doc said he wanted to check with the rheumatologist first.

[Eide]

Ok, I thought I’d wait until they were done with all things blood related before posting an update.

Good news: I don’t have high blood pressure after all. They had me wear one of those blood pressure monitors for 24 hours, and my average is 126/74.
My kidney function is tip top.
I also don’t have diabetes.

I am, however, vitamin D deficient, and my cholesterol is somewhat high.

And for the uric acid levels, which they didn’t actually test until I nagged them about it:

296 mmol/l, or 4,9 mg/dl.

That’s just after four weeks of 200 mg allopurinol a day. So that certainly sounds good, but my foot isn’t any better. Things that rush to my mind:

1. The first blood test – which revealed high uric acid levels – was taken the day after my foot was at its worst. I was still in agony when they drew blood. Could the elevated levels be explained by the infection, perhaps?

2. I have not been able to identify any food stuffs that trigger an attack. Instead, it comes back as soon as I’m off anti-inflammatories. Just ever so slightly the first day with no drugs, and then just a little bit more on day two, and a lot more on day 3. I am able to prolong this period if I use ice and paracetamol, but only anti-inflammatories have had any success in reducing all the symptoms. But they never go away completely.

3. I’m thinking this may not be gout at all – or if it is, it must surely be tophaceous. When swelling is minimal, there remains a hard swelling of the joint which, but for comparison with the other foot, might look like a normal part of the joint.

What say you?

I have an x-ray scheduled for April 6th, and an appointment to a rheumatologist April 29th.

[nobody]

If I understand correctly, you have only two uric acid values: one before taking allopurinol and one while on 200mg/day allopurinol. If so, there is no need for another explanation for the first “elevated” value. People who have gout typically only get good numbers while on a medication which lowers uric acid. That’s why they take the medication!
Getting the amount of uric acid in your blood right doesn’t fix gout right away because abnormal amounts of old uric acid can remain in the rest of your body for months or even years after the starting the therapy.

I’d say tophaceous gout is unlikely in your situation but it’s the rheumatologist’s opinion which matters, not mine
In the meantime, the X-ray may show something if it is not gout.

An ongoing gout attack sometimes behave as you describe: few symptoms as long as you take anti-inflammatories but they progessively come back if you quit taking the pills. I’d give colchicine a try in your situation because it’s slow acting but can put gouty inflammation to rest or at least keep it at a low level without having the same side effects as regular anti-inflammatories.
Alternatively, try a higher anti-inflammatory dose before stopping because you want the inflammation to stop completely rather than being merely moderated or there’s a good chance it’ll come back.
Something else you could try while the symptoms are very mild (but this works for some joints and not others) is a topical anti-inflammatory instead of a pill.

D deficiency is common in overweight people. Do you have a gallbladder issue as well? Are your liver function numbers good? Both obesity and D deficiency are associated with NAFLD.

[Eide]

Getting the amount of uric acid in your blood right doesn’t fix gout right away because abnormal amounts of old uric acid can remain in the rest of your body for months or even years after the starting the therapy.

That’s good to hear, actually. And I’m still taking the allopurinol, in case I gave you the impression that I stopped. I was just a bit suspicious that my uric acid levels should have been lowered that much so soon. I guess there is no need to increase the dosage, at least, unless my body develops a tolerance.

I’d say tophaceous gout is unlikely in your situation but it’s the rheumatologist’s opinion which matters, not mine

I figured that’s what it’d have to be, if it lingered even when uric acid levels had reached target levels. Given my present predicament, I am relieved to hear I’m wrong.

I’d give colchicine a try in your situation because it’s slow acting but can put gouty inflammation to rest or at least keep it at a low level without having the same side effects as regular anti-inflammatories.

I’d love to give colchicine a try, but my doctor has been very unaccomodating on that point. “That’s for the rheumatologist to consider” has been the reply when pressed.

I have so far not had any side effects of either voltaren or ibuprofen, though I switched from the former to the latter because I feared the long term effects of voltaren more.

Alternatively, try a higher anti-inflammatory dose before stopping because you want the inflammation to stop completely rather than being merely moderated or there’s a good chance it’ll come back.

When my foot has been really bad, I’ve been at the maximum recommended dose for nearly a week straight. When I was on voltaren, that was 3×50 mg a day, and for ibuprofen it’s been 3×400 mg a day. I do not wish to go above that without a doctor’s go-ahead. And my doctor already thinks I’m taking too much ibuprofen: he says I shouldn’t use it prophylactically, but when and as necessary when I get symptoms. But as that’s pretty much a constant thing, it’s a catch 22.

Something else you could try while the symptoms are very mild (but this works for some joints and not others) is a topical anti-inflammatory instead of a pill.

I have recently started to use Voltaren Forte. I haven’t really been very consistent in using it, as it says to apply at 12 hour intervals – and that’s difficult to manage when I work irregular hours. But it hasn’t had as good an effect as pills.

D deficiency is common in overweight people. Do you have a gallbladder issue as well? Are your liver function numbers good? Both obesity and D deficiency are associated with NAFLD.

My liver values were normal. I don’t know what values from my tests pertain to the gall bladder, but my doctor hasn’t said anything about it.

[nobody]

A single good test isn’t enough to establish that the dose is sufficient but yes: your prior should now be that 200mg/day is more than enough for you.
Keep in mind that lots of factors influence uric acid so major changes in weight, lifestyle, diet and so forth might require a dose adjustment. It seems that people such as ourselves who take a relatively low dose remain more sensitive to such changes. I might for instance take a slightly larger dose depending on the weather or what I eat.
But perhaps you’d find you would do well on a slightly lower dose and with a somewhat higher average amount of uric acid in your blood. You’ll have to fine-tune by ear because, while test results are of course much better than having no data, they are only a rough guide (or at least that was my rheumatologist’s opinion).
For the next few months however, if you indeed have gout, you’ll probably get pretty random symptoms and test results will probably be your only reliable guide. 296 mmol/l is fine for this stage. Best wait until symptoms are gone for good before experimenting with higher values.

I’ve never used Voltaren but I’ve used liberal amounts of generic topical dicolfenac more like every 5-6 hours. Not that I expect it would do much good for a big toe joint… I found it only works acceptably well for smaller joints (but it might for better on others than on me).

You’d know if you had serious gallbladder issues, as they are rather painful. Without such issues and with normal liver numbers, I guess there’s no reason of suspecting malabsorption of a number of other vitamins or to recommend a bunch more tests. The combination of being overweight and living at a high latitude is more than enough to explain a D deficiency.
And regular D supplementation probably reduces the risk of developing NAFLD anyway (and perhaps of developing gallbladder issues as well).

[Author]

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