Recurring gout

[Jeffrey]

Hi there – As background, I got my first gout attack about 5 years ago in the big toe – very painful stuff. After managing my diet for a few months, the gout attacks stopped. For the next few years, I became complacent (drinking beer, eating seafood and not drinking cherry juice – not in excess though).

About 5 weeks ago, I got another gout attack, the first one (I think) for a few years, this time in my left ankle. Since that first attack, I’ve had about 4 attacks since, all on the left ankle joint. All these attacks were quite mild (compared to the first time I got it) – I ate naproxen and colchicine immediately and the pain was gone a few hours later. There is little to no swelling in my ankle and I was able to continue on walking etc.

Since the first attack, I have paid careful attention to my diet again (no alcohol, no red meat, reduced meat, drank cherry juice etc) plus drank cucumber/celery/lemon/ginger smoothies daily. I am wondering why I am still getting these attacks, almost weekly since the first one, albeit relatively mild. Could it be that I am eating something that I think is low in purines but is actually a gout trigger? I have not been able to go get my urid acid levels tested as we are currently in a lockdown due to COVID.

Is there anything you can recommend/suggest as next steps for me? It’s quite frustrating that I am making a significant effort with diet and lifestyle yet the attacks are still coming on. I should also note that prior to the gout attack (which has always occurred early in the morning), my ankle would feel very stiff the night before, and the joint would be sensitivity to touch (but I can still walk and there is no pain otherwise). Also wanted to note that in all attacks since the first one 5 weeks ago, it had rained the day before the attack and was very cold outside (could be just a coincidence?).

Any advice is appreciated.

Thanks

[nobody]

Hi,
Obviously I can’t tell if what you have in the ankle is indeed gout. And assuming it is, I don’t know if what you’ve been eating or drinking was a major factor. So if we pile assumption on top of assumption… it’s what your diet and lifestyle over the years that matters most, not what you just consumed.
People often overthink triggers and whatnot because they want a convenient explanation for their troubles and a quick fix but gout is a slow disease. The way to beat it is to consistently maintain the amount of uric acid in the blood at a safe level. And the longer you’ve allowed gout to fester, the longer it’ll take to go away. Once it’s fully developped, you’ll keep getting symptoms for a quite a while even if you did everything right. People often get confused and fail to treat their gout because they’re not rewarded for doing the right thing but it simply takes patience.
So the first step is to measure that uric acid… do you know how high yours is?

That said, since you said “red meat”, I suspect you might have the wrong information about purines or indeed about what affects one’s uric acid more generally. You could research this for yourself or sak for some help in this regard but really, what you should focus on first is your uric acid numbers (procuring the past ones as well as a plan to monitor this number more closely in the future).

Yeah, the cold is not your friend (and neither is heat if it brings about mild dehydration).
You might also want to try a different way to take colchicine in order to put an end to this string of attacks. Other drugs might also help but I think it’s the safest one to deal with recurring low-level symptoms. But again, this would at best be a kind of bandaid. You really need to focus on the underlying problem!

[Alan Straub]

When I have a gout attack, I eat nothing with a heartbeat, except dairy for five days. No red meat, no fish, no chicken, etc. Dairy is fine but no flesh from anything with a heartbeat….

[Jeffrey]

Thanks for the information Nobody. The last time I had my uric acid recorded was probably about 18 months ago, and it was at the higher end of the normal range – 0.49 mmol/l.

What did you mean about taking colchicine a different way? I am now basically taking 1 or 2 at the first sign of an attack (i.e. when the ankle starts to feel stiff and there is some pain). I try not to take too much.

Agree that it will be a slow burn to get my uric acid down to safe levels. Do you think the cucumber/celery/lemon/ginger juice daily will help with this? I’ve read online that it helps.

Thanks

[nobody]

The normal range for uric acid is irrelevant to gout. 0.49 is unfortunately way too high but that reading could be a fluke. Do you have older numbers that would confirm that value is usual in your case?

Taking colchicine at the first sign of an attack may be too late (depending on how your attacks work and on how good you are at noticing and recognizing the early signs). Colchicine works relatively slowly and builds in your system so to speak. Recurring attacks are in my mind a sign of ongoing inflammation to begin with which suggests you can’t rely on feeling that an attack is over anyway. So you could perhaps try to take colchicine every day for a while, and taking more on top in case of an attack. But you should run this plan by a doctor before taking way more colchicine than you’re used to. I don’t know your medical situation and I don’t even know how much colchicine there is in “1 or 2”.
Colchicine dosage in controversial and it works differently for different people. My point isn’t to recommend a particular dose but to suggest experimenting within the bounds of what’s safe for you. My rheumatologist told me I could take more colchicine than I ever did but it is a dangerous drug and not everyone should take as much as I did when experimenting.

The effect of such a juice will be different in different cases but I don’t think it would do much provided you already had a decent diet.
In any case that’s not going to fix 0.49 mmol/L if that’s a typical value for you. The only quick fix for that is a drug such as allopurinol. In some cases it is the only practical solution. Dramatic lifestyle and dietary changes can sometimes do wonders but if you already have a decent lifestyle and diet, there may not be that much room for improvement. Certainly supplementing a bad diet with basic foods or vitamins is unlikely to make a big difference.

Finally, you shouldn’t be getting any attacks Alan! I don’t eat corpses myself but that’s not going to fix gout in most cases. Attacks are a sign your usual diet is wrong or that your gout can’t be fixed with diet.
Note that if you fundamentally changed your diet recently, that’s a different matter because it can take a very long time for the attacks to go away once you’ve allowed your gout to fester.

[Jeffrey]

Thanks nobody. I also previously got a test which showed 0.45. I think given it is quite high, I may have to obviously get it taken again and speak to the doc about allopurinol. I was hoping to do this naturally but may be past that point now.

Thanks for the advice. If you think of anything else that might be useful or something I can do, please let me know

Cheers

[nobody]

I’m not sure what exactly you mean by “naturally”. Whatever you had in mind, anything as effective as allopurinol could also be harmful, and the downsides of allopurinol happen to be better-understood.
Once your gout is cured, you should have plenty of time to experiment with ways to quit allopurinol (or a similarly effective alternative) while keeping your uric acid under control. Failure at that stage would be much less harmful than failure now.
So I would recommend focusing on the precautions people should ideally take when it comes to allopurinol and similar treatments: making sure you indeed have gout, making sure you don’t have known conditions or genes that would potentially make allopurinol very dangerous to you and planning the careful monitoring of the effects of slow dose increases (starting with a very small dose).
We know who (that is, people who have East Asian ancestry) should get what genetic test before trying allopurinol for instance. But what do we know about the dangers of berberine to this or that group or even about the common metabolic diseases that a seemingly healthy diet might trigger in a small number of people?

There would be lots of other things you could try but would they amount to distractions at this point?
If you’re willing and able to decisively address the cause of gout, doing that ASAP is what would best protect you in the long run against worse attacks, the lasting damage they might do, the indirect effects of impaired mobility (there’s a reason doctors recommend regular exercise!) and the side effects of anti-inflammatory treatments which are merely dealing with the symptoms.

[Jeffrey]

Thanks nobody, appreciate the advice

[Author]

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