uric acid excretion rate test and exercise

[dj2424]

Hello,

I’m a long time gout sufferer who was diagnosed recently. I hope to share my story someday. For now I have an upcoming rheumatologist appointment in less than 2 days and as someone who exercises frequently I had a question about how to ask for a urine excretion test before starting allopurinol or other urate lowering medication.

This is my understanding:

I should request 2 tests where I collect my urine for 24 hours. One day with normal activity, and one day including strenuous exercise.

Now if I’m found to be an underexcreter of uric acid I can take probenecid on my exercise days and I don’t have to take anything on my rest days. Please correct me If I’m mistaken.

The question I have is: What if I’m found not to be an underexcreter? What do I do in this scenario?

I don’t have much information to provide in regards to my uric acid numbers as I have only one from a little over a year ago. That was taken a couple of weeks after a bad attack on my knee when it was measured and showed a result of 9 mg/dL and unfortunately have not had a proper follow up until now. I just want to make sure I do this right before I start taking long term urate lowering medications.

Thank You!

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[nobody]

Hi!
I think it’s a good idea to do these tests if you can because information is always useful, but taking probenecid is another matter. And it’s more important to get more blood tests (notice the plural!).
The preferred medication for uric acid is allopurinol regardless of whether you’re an underexcreter or not. And taking no drug on your rest days is probably a fool’s errand, though more blood tests would be needed to ascertain the matter. If you end up taking both allopurinol and probenecid for instance (which is doubtful), perhaps you might take probenecid only on your exercise days. I don’t know that anyone does that but it sounds less crazy than taking nothing on your rest days.

[dj2424]

Thank You! I think I’ve misunderstood how this urine excretion stuff works in regards to strenuous exercising so let me backtrack.

I wanted to know if there’s anything I need to be aware of regarding strenuous exercising at the start of taking allopurinol for the first time and once I get into the debulking stage. How should I proceed? Should I even get a urine excretion test? Should I just refrain from exercising at all until I pass the debulking stage and not worry about the urine excretion test to make it easier although I prefer not to?

I plan on taking allopurinol everyday for the long term but I wanted to get an idea of how to incorporate my usual strenuous exercising once I start the medication and for the long term moving forward after that.

Thank You!

[nobody]

If you tolerate allopurinol well, taking a high enough dose will probably take care of all your uric acid problems. If not, the drugs which help with excretion might be an option.
Strenuous exercise is generally not recommended while you still have symptoms, and something like probenecid might indeed help in that regard. But you probably simply need a strong enough allopurinol dose to cover your special needs. There’s little point in trying to take a different dose on the days you exercise because it’s metabolized quite slowly anyway.
The most sensible approach in my opinion is to start by seeing how allopurinol works for you and only think about other drugs if it doesn’t work very well.
But it makes sense to do the excretion tests (along with blood tests) before starting any drug if that’s possible. The doctor might not want to bother with this but even if allopurinol is all you need, the information may be useful to decide on a dose or in determining if you would benefit from other drugs as you get older.

I also think it makes sense to take it easy with your exercise at first and make it progressively more strenuous if all goes well… experiment and see what works and what doesn’t!
“Debulking” could take such a long time that you probably don’t want to keep your exercise minimal for the whole process.
And unless you have a kidney problem requiring you to limit your fluid intake or something, always take care to drink enough water considering your body’s needs at a particular time. Mild dehydration is perhaps the best-known trigger of gout.

[dj2424]

But it makes sense to do the excretion tests (along with blood tests) before starting any drug if that’s possible. The doctor might not want to bother with this but even if allopurinol is all you need, the information may be useful to decide on a dose or in determining if you would benefit from other drugs as you get older.

Can you explain to me what the results for this test could potentially tell me that would be anything different from a SUA test? The more I know the better I can justify it if asked why by the doctor whom I’ll see tomorrow. 🙂

Thanks!

[nobody]

You want to do more than one SUA test.

The more uric acid you’re excreting, the better allopurinol is going to work. In particular, if your excretion increases along with your SUA or even more (relatively) when you’re exercising, that would suggest you do not need a particularly low SUA treatment target. If the tests suggest you’re having trouble excreting on the other hand, you might initially require an especially strong allopurinol dose so as to provide a buffer both for your exercise and for the “debulking”.
The data will also provide a baseline which may be used to interpret the results of the same test if you were to repeat it many years down the road if managing your uric acid became more difficult.
Since allopurinol is metabolized quite slowly, you’d need to suspend the treatment for quite a while in order to get a clean result after having started the drug which is why now is the best time to obtain this information.

The trouble with testing your urine is that uric acid is also excreted in other ways so you will only get a partial picture of what’s going on in your body. Still, I think some information is better than none.
Others might not want to burdened with data they can’t put in a formula and that they’d rather do guesswork based on symptoms.

[dj2424]

Wow. Thank You for that clear and concise explanation. Google couldn’t come anywhere close to answering my question and was even more confusing to say the least. I will definitely try to convince my doctor now to order this test for me before starting allopurinol.

I will definitely now request my doctor for a 24 hour test to be conducted twice once my current flare stabilizes and goes away. The first one on a regular day without any exercising for at least 24 hours prior. The second one a few days or a week later after exercising. Now for this second one should I collect the urine within a set number of hours right after exercising? If so how many? And how quickly should I turn it in to the lab after collecting it or do I have a buffer for the urine to sit uncollected until I can turn it in say the next day?

[nobody]

I recommend you also get your blood tested (or test it yourself) at least once each time you’re pissing in bottles.
But I don’t know what the effects of exercise are precisely or for that matter the extent to which adequate fluid intake balances them. I don’t even know how fast the kidneys work or if there are differences between individuals in that regard.
So I really can’t say what the best time would be to carry out these tests. It makes sense to me that you ought to pissing in bottles both on the second of two rest days as well as immediately after exercising strenuously but I can’t be more precise. For all I know you should rest more than a day before the resting test. Hopefully your doctor will know (assuming they see any value in such tests) but trial and error is always an option…

The doctor’s office or the lab should tell you how quickly you must bring the urine. This may depend on what else they want to look for in your urine.

If your flare doesn’t resolve quickly, it’s not strictly necessary to wait until it’s over.

[dj2424]

Hello,

Just wanted to post an update. The new Rhumetologist appointment went horribly wrong. It’s one of those practices with lots of doctors that have a large foot traffic and ended up waiting as twice as long as the actual time I spent briefly with a PA followed by the doctor. I was so rushed that when the PA blurted out that they were so far behind while I was speaking, I almost walked out of there at that point. They wanted to order x-rays that they wanted to do right there to eliminate “some other things” which I declined. I obviously and sadly didn’t even get the chance to bring up urine excretion. They at least ordered SUA test along with a kidney/ liver workup and prednisone for my current flare so that there I guess was only silver lining. I’ve already started looking for a new doctor.

I guess I’ll be like Keith and other people here before I find a doctor that suits me. I’ve found it hard in general finding even non specialty decent doctors here in Arizona.

Quick question and a bit off topic: Can you explain to me why 5mg/ dL is the targeted SUA level by everyone here and not 6? All my research online and everywhere else including most medical professionals target the higher number. I only bring it up because the useless doctor I saw and during the rare time I could speak, asked about this and she replied that 5 is a level targeted only for people with tophi and extremely resistant to most treatments.

[nobody]

You don’t need fancy medical care if you know for a fact you have gout. In that case, any doctor should be able to order SUA tests and write you an allopurinol script. No specialist is required unless you do not take well to the usual treatment or the diagnosis is doubtful.

As to targets, it is not the case that everyone here targets 5.
The 5 target is simply for people who aren’t served well by the 6 target… which is another way to say that that your target should be the one that works for you, not 5 or 6.
But we don’t know ahead of time what target will be good for you so you need to start somewhere… and since people can often achieve 5 without side effects, it’s arguably a better place to start than 6 in many cases. It’s also better to err on the lower side at first because that provides a buffer against “debulking” and it’s less risky to try a higher target once gout symptoms are mostly gone.
Most doctors don’t have time for this and only want to know if the number is OK or not. You don’t want to recommend 5 (or even lower) to everyone because of the risks involved with any medication but you also need to let busy doctors know that 6 isn’t always good enough, hence the variations on the “but target 5 in severe cases instead” theme you find printed on lab reports and such.
5 isn’t ideal for people with sizable tophi by the way. Side-effects permitting, you want a much lower SUA to treat that.

[dj2424]

I actually did not know if I had gout or maybe pseudo-gout for sure until yesterday. My results from a past ER visit where they completed a joint aspiration were “misplaced” at the time. They were finally able to provide it to me just yesterday.

The pathologist report states:

“(Crystals, Synovial Fluid, Pathology Review)
Crystals present demonstrating negative birefringence, most consistent with urate crystals”

I ironically actually went and got another joint aspiration done at a different location the day before Thursday because I wasn’t sure if the ER would ever locate the results. They did so a day later but either way once I get the results from the latest one sometime next week and if that matches the above report as expected, I can without a shadow of a doubt move forward with my treatment plan.

Next step- finding a physician that would be willing to work with me on getting the 2 urine excretion tests done before I start taking allopurinol.

I know I’m being somewhat overly cautious here but I truly believe that if I’m starting a lifetime medication, I should do so knowing the complete picture before just diving straight into it. Plus I’m not going to lie- it scares the the crap out of me but each day gives me more confidence that I will someday come out the other side all the better for it.

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