[Keith Taylor]

I’ll leave a quick answer for now. Because I think the level of interest in PDF files is much lower than I once expected. So I’m trying to spend less time on topics that interest me. Then I have more time for topics that help others.

Remember that PDFs are copyrighted documents that normally cost $30-$60 each to access legally. I’m bending the rules by making them available to members. Whereas previously I threw away the rules by making PDFs available to anyone. That was a decision that cost me plenty in server resources as every PDF robot on the planet sucked the life out of my website response times. Fortunately, I never had other penalties for infringing copyright.

I’m going to close the current PDF library soon. Because I want to encourage collaborative research projects and personal projects where members share their findings.

So I’d love to hear other people’s thoughts on PDF files for gout research.

Finally Cory, I want to clarify why I believe this is a matter that needs to be discussed in this forum rather than private email. Because the reason I provide any part of this service, including PDF files, is to help people understand gout more so they can work with their doctors better. So discussions about how GoutPal operates are just as important as personal gout questions. Hopefully, I will clarify that with better documentation on my contact form soon.

[Keith Taylor]

Maybe I was being too light-hearted, so sorry about that. But in my mind, you were asking me to comment on a page of crap. So I should have taken more time to explain why it was crap.

However, the simple truth is that urea comes from proteins and uric acid comes from purines. In some circumstances, uric acid breaks down to urea, but that is not relevant to human gout.

As far as I’m concerned, there is no connection. Except that I’ve seen gout sufferers post urea test results in the forum instead of uric acid results. So I guess the similarity of name must cause confusion.

My biggest worry is that a poorly-written, misleading article relating to uric acid now has a link from a high-profile gout forum. So do you mind if I remove that link?

[Keith Taylor]

Sorry I missed this @d-q

When I spotted it I was on a beach in Minorca. So just laughed at the first line and went for another swim. Now I’m back and the Autumn blues might be arriving. But I’m not going to Fall into that trap [pause for Intercontinental Laughter]

I’m thinking of contacting the final website you refer to about a page explaining the difference between d_q and keith. Simply put – you believe crap like that and I believe other crap 😉

[Keith Taylor]

The idea of only taking allopurinol “as required” is new to me and goes against everything I’ve learned so far. But I’m always willing to learn more.

However, I’d need a lot more information before I was convinced of the validity of this approach. For example, full medical history including uric acid test results, additional tests for uric acid excretion rate, height and weight (with significant weight change history) and diet details during non-allopurinol and allopurinol phases.

I’d like to say more. But I’ll wait to see if there is any input from other readers first, as this is an old question.

[Keith Taylor]

You should post your uric acid test results here.

[Keith Taylor]

I apply a different set of standards to home uric acid testing compared with regular blood tests. Because in the home setting it’s extremely important to try to minimize the number of variables that might affect your results outside the lifestyle changes you are trying to measure. But this is probably overkill for standard lab tests.

In particular, uric acid blood tests should always be accompanied by liver function and kidney function. As far as I am aware, kidney function tests are one of a few blood tests that call for fasting before the test. So that fasting period is supposed to eliminate any unusual impact on results from recent food intake.

Of course, you might argue that large portions of red meat 24 hours earlier might impact the uric acid test result. But so might many other factors (eg weather, exertion, etc). So you get to a point where you have to decide if you control gout or gout controls you.

In my opinion, arranging uric acid tests around your eating plans puts you in the latter camp. But that’s just my opinion.

[Keith Taylor]

Generally, allopurinol is preferred over febuxostat (Uloric) because it is cheaper and has a longer track record. However, uric acid treatment has to be managed on an individual basis. So some each gout patient has to consider:
– ethnicity.
– reaction to starting dose.

For certain ethnic groups, rheumatologists recommend a screening test for the presence of a specific genetic variant. So consider allopurinol screening for Korean, Han Chinese, and Thai racial groups, and discuss with your doctor.

Allopurinol Starting Dose
In all cases, allopurinol starting dose should be no higher than 100 mg per day. Then your doctor should test your blood after 2 to 4 weeks. Tests should include kidney function and liver function as well as uric acid. Because that allows your doctor to see if allopurinol is causing any unwanted blood abnormalities. Also, your doctor should ask about any other side-effects you might have.

If all is OK, your doctor will increase the allopurinol dose gradually until you reach your target uric acid level for dissolving old uric acid crystals (debulking). Of course, each dose increase must be accompanied by the same 3 blood tests.

If blood test results or other symptoms indicate a problem with allopurinol, your doctor should consider switching to febuxostat (Uloric). In which case, the starting dose should be 20 mg per day. Then slowly increase as with allopurinol.

If febuxostat also presents problems, you are in a tiny minority of cases that are harder to manage. But not impossible. Because uricosurics might provide a solution. Otherwise very low-dose allopurinol with tiny incremental increases has been shown to overcome adverse reactions. But I’m not aware of any similar cases of slow introduction of febuxostat.

[Keith Taylor]

Hi @satish-nelakurthi @gouthelp

Thank you for adding great gout questions, and responding to replies.

I think you have had great replies from Nobody and d_q. So it would be good if you summarized each of your questions, saying what you have learned and how it has helped you. Then, you should start new topics with any outstanding questions. Because it’s always better to have separate topics for each question unless they are closely related. Meanwhile, I want to focus on the bigger picture.

I am just dreaded thinking if I will be stuck with this inflammation and pain forever. How can I be sure I am going in the right path?

In short:
– Gout does not last forever if you treat it properly.
– You are on the right path when you and your doctor have a schedule for uric acid treatment. But that takes time. So you also need a strategy for dealing with gout attacks until most of your old uric acid crystals have dissolved.

Now, I know that every time you ask a gout question, you get more questions once you learn the answers. That is how the learning process works. But it can soon lead to confusion from an overwhelming number of questions. Which is why I put the plan first. Because that gives you a framework to improve your knowledge and then improve your treatment plan.

More importantly, it gives you a timescale. For example, an average time for gout recovery is about 6 months once you get uric acid below 6 mg/dL. At that time, questions about prolonged or lingering gout pain make sense. But before then, you are just experiencing usual gout recovery symptoms. So the question has much less value than something like “how can I stop the pain in my big toe during my uric acid debulking period so that I can walk without a gouty limp?”

Because then you can focus on effective short-term pain control while also being aware that:
a) Your long-term need to control gout is good because you have uric acid below 6 mg/dL.
b) You have considered that good footwear is essential to minimize damage to gout-weakened joints.

So, returning to your latest comment. First, I should point out that you need to play an active role in setting a short-term uric acid target. That is the target for the “debulking period” when you get uric acid low enough to dissolve old uric acid crystals. Then when you reach that target and go for 6 months without a gout flare, you can consider yourself gout-free. At which time your doctor can adjust your allopurinol dose to maintain a safe uric acid level.

My view of a good target during debulking is aggressive. Because I believe in the maximum allopurinol dose to get rid of uric acid crystals as soon as possible. But that is only acceptable when kidney function and liver function blood test results are OK. In conclusion, each gout patient must discuss this target with their doctor and agree a dosing/testing schedule that achieves uric acid debulking safely.

The decision on a safe uric acid maintenance level can wait until you have gone 6 months without a gout flare. However, I believe 5 mg/dL is safest. But individual circumstances might mean you have to settle for 6 mg/dL.

Finally, we have to address that big toe pain issue. So I see 3 possibilities:
1. Recurring gout pain because you have only just started to get uric acid under control.
2. Joint damage from gout.
3. Other arthritic condition.

If it’s option 3, it’s beyond the scope of this website. But as there is no other explanation at the moment, let’s assume it is gout-related.

For option 1, I believe a steroid shot should have controlled this, but I’m not personally experienced in steroid use. Generally, the approach is:
a) Stop inflammation spreading (colchicine).
b) Reduce existing inflammation (NSAIDs such as ibuprofen, naproxen, etc).
c) Block residual pain (paracetamol or other compatible pain relief).
So you need to discuss this with your doctor to find the combination that works best for you.

For option 3, there is some evidence that gouty joint damage can be reversed when uric acid is treated properly. Unfortunately, this is one of the areas of gout management that needs further research (Chhana, Ashika, and Nicola Dalbeth. “Structural joint damage in gout.” Rheumatic diseases clinics of North America 40, no. 2 (2014): 291-309.).

In conclusion, I think you are on the right track with allopurinol. But you might make better progress if you set a lower uric acid target with your doctor. Beyond that, you should keep asking questions here. Also, consider doing a daily posting of your gout symptoms – even if it’s just a report of “no gout symptoms today”. Because then you can look back to see exactly how your gout is improving.

[Keith Taylor]

Hi Kevin,

Gout and Sausage Fingers

I found several reports suggesting that gout is associated with sausage-like swelling in the fingers (dactylitis). But I don’t know how common it is. So it’s impossible to say if your case is gout-related or something else. Because a third report I looked at suggests that the usual tests for getting the right diagnosis are:
1. Trauma
2. Cellulitis
3. Osteomyelitis
4. Rheumatoid “variant” disorders (psoriatic arthritis and Reiter’s syndrome)
5. Gout
From:
Forrester, D. M. “The “cocktail sausage” digit.” Arthritis & Rheumatism: Official Journal of the American College of Rheumatology 26, no. 5 (1983): 664-667.

So it’s possible you have something as well as gout. But it’s up to you and your doctor to decide if its worth doing further tests now. Or better to wait for a few months to see if dissolving old uric acid crystals resolves the problem.

Febuxostat Dose

80 mg seems very high to me for a starting dose. So given you have had a reaction, I suggest starting with 20 mg febuxostat. But you should discuss this with your doctor. Also, note that pill-splitters are easy to find online and in pharmacies if the smallest pill size is 40 mg.

After 2 weeks you should get retested for uric acid with kidney function and liver function tests. Then discuss increasing your febuxostat dose slowly achieve your uric acid target.

[Keith Taylor]

Diet Gout Trial in Baltimore

The DIET GOUT (DiGO) Trial is a research program conducted by Johns Hopkins University, Harvard Medical School, and the Rheumatology Research Foundation to find out if a healthy diet can lower uric acid, a risk factor for gout.

You can MAKE A DIFFERENCE by participating in the Diet Gout (DiGo) Trial to help doctors, nutritionists, and patients suffering from gout understand more about foods that lower gout risk.

Gout Sufferers who can participate in DiGo

To Participate in the Diet Gout (DiGo) Trial, you or a loved one must:
> Be at least 18 years old
> Have been told you had or have gout by a health professional
> Not be taking medications to lower uric acid (allopurinol, febuxostat, probenecid)
> Be able to travel to the ProHealth Research Clinic in Baltimore.

For more details see https://www.digotrial.org/
​​

[Keith Taylor]

Thank you for everything Keith, honestly, you are a true gentleman.

Thank you for your kind words, sir. How did you know? 😀

A True Gentleman takes the weight on his elbows!

[Keith Taylor]

It’s been a long time coming @d-q but I finally got a bit further with

Does anyone know anything about Thalassemia and Gout / Uric Acid?

To the extent that I found a slideshow about thalassemia that mentions gout and uric acid. So I used that to illustrate this topic (above).

So despite this being your historic first topic, it looks like we’ve come full circle. Because your most recent posts indicate your strong hope that new medication for your underlying condition is your best chance of curing secondary gout.

I realize I’m a bit slow. But it’s all starting to make sense now! 😀

[Keith Taylor]

Due to the high level of interest in this topic, I had another look for studies about gout and cracking joints. But there aren’t any.

In fact, I had a closer look at the study mentioned in the video above:
Castellanos, Jorge, and David Axelrod. “Effect of habitual knuckle cracking on hand function.” Annals of the rheumatic diseases 49, no. 5 (1990): 308.

Now, that study mentions gout. But only as a condition suffered by joint crackers and non-crackers in that study. So I can confirm that joint cracking does not appear to affect your chance of getting gout. But I also confirm there are no studies of the effects on joint pain.

So the only way forward is to try for yourself. Because the consensus from the reports of long-term effects is that there little or no harm caused by cracking joints. But remember to post your results here.

[Keith Taylor]

Febuxostat vs Allopurinol Mortality

Some die taking these drugs, some die because they decided not to take them

I have an alternate view. Unfortunately, I can’t find the exact studies to back up my theory. But I believe that long-term gout patients generally have a health advantage. Because they are more likely to get regular health checks. So early signs of other health problems should be spotted and corrected earlier. Of course, that assumes the patient has the sense to insist that appropriate tests are done alongside uric acid monitoring.

In my previous message, I mentioned a study that investigates mortality rates. And other studies show different comparisons. But differences are small. And statistics only show averages – not the personal situation where you take better than average care for your own health.

Finally, since we’re looking at comparatives, I think your uric acid levels are good compared to many gout patients. Most studies show that less than 30% get below 360 μmol/L. Primarily because most doctors can’t get past the mental block of increasing dose once patients get average uric acid scores around 400-420. Is it time to worry less and get back to “5 years ago I didn’t know what gout even was and enjoyed work, life (in most cases anyway)”

[Keith Taylor]

Febuxostat vs Allopurinol Comparative Doses

Coburn, Brian W., Kaleb Michaud, Debra A. Bergman, and Ted R. Mikuls. “Allopurinol Dose Escalation and Mortality among Patients with Gout: A National Propensity‐Matched Cohort Study.” Arthritis & Rheumatology (2018).

we estimated that the three febuxostat doses observed during follow-up (40, 80, and 120 mg/day) were approximately equivalent to 300, 600, and 900 mg/day of allopurinol, respectively

That estimate is based on their analysis of the clinical trials results in:
Becker, Michael A., H. Ralph Schumacher, Luis R. Espinoza, Alvin F. Wells, Patricia MacDonald, Eric Lloyd, and Christopher Lademacher. “The urate-lowering efficacy and safety of febuxostat in the treatment of the hyperuricemia of gout: the CONFIRMS trial.” Arthritis research & therapy 12, no. 2 (2010): R63.

But, since these two drugs affect different pathways, I would expect results to vary between individuals.

Apart from that, the latest trends seem to be combining xanthine oxidase inhibitors with uricosurics. Which is explained rather beautifully in the final step of http://changegout.com/explore-gout
There’s also an interesting film on that website.

[Keith Taylor]

And finally (for now)

there are upcoming new medications for my blood condition which could potentially reduce Uric Acid levels naturally as a result

What medication is that @d_q ?

[Keith Taylor]

or some other British republic

Yorkshire?

assuming this forum still works by then

As I get older I think more and more about a legacy solution for this forum when I can no longer support it. So the time for that to start is probably now.

If anyone has any ideas for how that might happen, please start a new topic.

[Author]

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