[Keith Taylor]

You need to be aware of the context of that PubMed reference (The Crystallization of Monosodium Urate). Because it is focused on lab principles that affect how and when uric acid crystals form or dissolve. But for practical gout treatment, we need to make uric acid safe. So the guidelines that I refer to in my earlier reply (British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of gout.) make it clear that 350 μmol/L is safe but 300 is safer. My interpretation of that is that if you struggle to get down to 300 because of other factors then 350 should be OK. But 300 is better. Which is presumably why your rheumatologist suggests increasing the dose.

Obviously, febuxostat always needs to be checked with liver function tests. So make sure you get that irrespective of staying on 80mg or switching to 120mg per day.

I agree with Nobody on the uric acid excretion test. What’s the point if your excretion rates are affected by febuxostat? Maybe the doc has some comparative results for febuxostat patients?

[Keith Taylor]

Hi James, thanks for the update.

I’m also of the opinion that your strange 413 μmol/L uric acid test result is within the bounds of usual variations (How Your Uric Acid Level Changes). Because there are lots of other factors at play here, besides the action of febuxostat (Uloric). For example, time of day, time since last meal, amount of exertion. But also the fact that uric acid crystal debulking is not a linear process. So a cache of crystals that have been well hidden by immune reactions and subsequent mineralization/calcification/etc can spontaneously dissolve and temporarily raise uric acid levels. As Nobody notes, this often happens months after getting uric acid safe.

I’d go as far as saying that linear trends in uric acid test results are highly unlikely. So I tend to ignore the highest and lowest. Then look for average trends.

On colchicine, I’m also in agreement that 4 days seems about what you would expect to stop gout pain. But colchicine does not act on existing inflammation, as it restricts inflammation spreading. So I would support it with naproxen to get faster relief.

[Keith Taylor]

To reflect changes to my organization of gout and alcohol information, I’ve renamed this topic (from “Possible Beer and Gout review”). Because I believe there is a specific way that gout sufferers should manage alcohol consumption.

First, you must ask if you drink more than national guidelines. If so, you have an alcohol issue, not a gout issue. But you can choose to perceive it how you like. Because the second question is crucial.

Second, do you have a uric acid treatment plan? By which I mean a phased target for uric acid control that includes monitoring by a blood test. That plan can be dietary, herbal, or pharmaceutical. But if you ain’t got targets or you ain’t got regular tests, you ain’t got a plan.

We know from my first contribution to Alcohol and Gout Research, Does Alcohol Affect Gout, that alcohol affects people differently. So you need to compare changes in alcohol intake with changes in uric acid blood test results. Then you can tell how alcohol is affecting your gout. But for completeness, you should also log daily gout symptoms. Because alcohol might affect gout pain differently from how it affects uric acid.

Finally, I just checked Allopurinol And Alcohol and found some research that alcohol can affect the way allopurinol is processed in our bodies. So I’ll put a link here to the research soon so that we can discuss it prior to updating that article.

[Keith Taylor]

Update for Craig ( @craig-schadt ).

I hope you’re still visiting GoutPal, Craig. Because I found a source of Kirin Tanrei Double Platinum purine-free beer at Rakuten Global Market. Unfortunately, this product was out of stock when I looked. But, it’s worth checking to see if new stocks arrive. Note that this is the global site, not the USA site which doesn’t sell specialist goods.

The company is a global shipper for Japanese products. So while browsing their catalog I found:

• Japanese beer Ryoma 1865 – alcohol-free and purine-free.
• Asahi-style free (FREE STYLE) purine zero 500 ml – 6% alcohol.
• 350 ml of Sapporo Goku Zero – purine-free, 5% alcohol.

Which is your favorite Purine-free Beer for Gout?

The catalog has many more purine-free beers, especialy zero-alcohol. But some are restricted from international shipping.

[Keith Taylor]

Thank you for your feedback. However, I’m not clear what exactly you are referring to.

Where did you get your research from that a vegan diet is so high in purines?

Please can you clarify where you read this exactly. Then I can help you and others by explaining clearly why a vegan diet is NOT high in purines.

yeast extract and MSG are two of the worst things for gout

Again, please can you clarify this. Because it sounds like one of those made-up so-called facts that we see on many Internet sites. But I cannot find any real evidence to support that assertion.

I agree with you on the value of gout sufferers avoiding processed foods. But the problems are not restricted to vegetarians and vegans. Also, I believe there are many additives in processed foods that are worse for gout sufferers than the two you mention. But I won’t expand on that until I’m clear about exactly what we are discussing here.

[Keith Taylor]

Hi Sian,

That’s a great response from Nobody and here are my immediate thoughts.

I can see from your first message (Guidance on febuxostat, colchicine, and NSAIDs) that your husband’s uric acid levels have been 250-300 since around December 2017. Unusually, your rheumatologist’s advice at that time was to aggressively increase febuxostat dose to 120mg. So that resulted in uric acid of 149 μmol/L in January this year.

Personally, I’m a fan of such an aggressive approach to reduce the time for uric acid debulking. But that has to be something that is agreed by doctor and patient. Because a thorough risk assessment of high-dose uric acid treatment is important. Also, we’re all concerned about the long-term effects of febuxostat compared to allopurinol. So, it is important to leave the consultation with enough information for you and your husband to be happy that he is getting the right uric acid treatment at the right dose.

With respect to GFR, I’ve learned that it tends to decrease with age and with gout. But studies indicate that both allopurinol and febuxostat tend to raise GFR. So I’d ask your new rheumatologist if she/he knows of any evidence to show which is best. I’m aware that other factors influence GFR so there might not be a definitive answer.

Is low GFR caused by gout, age, or something else?

Unfortunately, none of us can assess the length of time it takes for all old crystals to dissolve. So, as Nobody says, “it’s too early to rule out residual gout as the cause of some of your husband’s symptoms”. However, there is a faint hope that your new rheumy knows where you can get access to a DECT scan for gout management. If so, please tell! Because that’s the Holy Grail for assessing how uric acid treatment is really progressing.

[Keith Taylor]

I just added a summary to the beginning of this topic which I repeat here. Because this topic attracts lots of interest. So I believe you should read relevant facts before adding to our discussions about controlling persistent gout pain.

Gout swelling won’t go away.

See Heat Or Ice For Gout Relief. Because this compares two ways to reduce gout swelling.

Gout pain gone but still swollen.

See 3 Unusual Signs Of Gout. Because this looks at unusual aspects of swollen joints.

How long for gout swelling to go down?

How long does gout flare up last? Because this explains the factors that affect how long for gout swelling to go down.

After reading those facts, you can continue the discussion here. But it is usually best to start your own new gout topic.

[Keith Taylor]

Hi Bruce,

This isn’t a personal recommendation – just a couple of Rheumatologists that list gout as a specialty around Duluth that I found from Google Gout:

Fernandez-Pokorny, Ana M.
MD ACR Fellow Member, Female
INSTITUTION
The Duluth Clinic
400 E Third Street 3rd Floor
Duluth, MN
55805
US
PHONE
218-786-8888

Dr. Stephen L Hadley, MD
RHEUMATOLOGY ASSOCIATES
1000 E 1st St Ste 203
Duluth, MN 55805
(218) 249-6960

Dr Hadley also consults at:
RAINY LAKE MEDICAL CENTER
1400 Highway 71
International Falls, MN 56649
(218) 283-4481

Please let us know how you get on. Because I’m very interested in listing doctors who have helped gout patients.

[Keith Taylor]

To clarify, the timings I mentioned are just a guess really. Because, in the absence of a uric acid DECT scan, it is almost impossible to tell when all old crystals have dissolved.

The problem lies in clumps of crystals coated in almost impervious coatings. I recall one recovering GoutPal member who went over a year with successful allopurinol treatment. Then he got a short-lived attack in the knee. So, it pays to keep the pain meds on hand until you reach the point where you can’t remember why you have them.

[Keith Taylor]

1. Very important to stay hydrated on allopurinol. Does it not say that on the label?

2. Gout recovery is a slow process. My rule of thumb is around a month for every year of excess uric acid. But you didn’t suddenly develop gout 9 years ago. Rather, you suddenly noticed gout that had been developing for a few years. So it’s difficult to guess without your medical history. Nonetheless, I shall guess at 15 years, and further guess at 15 months for full recovery.

You can consider yourself to be free from gout after 6 months without a gout flare, as long as uric acid stays below 6 mg/dl (but always best to aim below 5).

So, Adrian, I would say everything is progressing for you as I would expect. And the real issue is why do you believe that migratory pains are *not* typical of gout?

By the way, “moderate” is quite meaningless – you can choose from Safe, Borderline, Risky, or Dangerous uric acid levels. 8 mg/dL is Dangerous, so keep taking allopurinol. If you want to recover faster, consider 6 months on a higher dose.

Finally, how much are blood tests for kidney function and liver function compared to a glass of wine?

P.S. Yorkshire sky is blue today (again) 🙂

[Keith Taylor]

It would be easier for me to respond if you gave reference to the information you are asking about. But I’ll try to explain the rheumatologist video. I assume it is a general gout video rather than one targeting obese or other malnourished people.

Except for secondary gout, most uric acid imbalance is genetic. So lifestyle might be a contributary factor but it is not the starting point for treatment. Therefore diet can contribute to your gout management plan. But it should not be the foundation of your plans.

Why can’t I say tofu? Not that I was going to.

[Keith Taylor]

Thanks, nobody

I think there are some general principles:
– With gout, uric acid will definitely affect all joints eventually. That’s been proved with DECT scans and explains nicely why uric acid patients get flares in previously unaffected areas when crystals start dissolving.
– Inflammation generally tends to spread around the body. I’m much less knowledgeable about these processes. So I guess the main issue is what causes inflammation in the first place? Then, how does it spread to other joints?
– The healthy human body is well balanced in terms of symmetry and I guess we’ve evolved to get the most of joints working in harmony. A sports physiotherapist would probably be best to give examples of this. So, when a weakness affects one joint, others have to work harder to compensate. Eg, gout in the fingers might induce repetitive strain injury in the wrist if you have to change your typing style.

There might be more. But ultimately, each case has to be considered on its own merits.

As I type this, I’m thinking of a 9th possibility, which is much less concrete. Because I’ve noticed that after prolonged periods of gout pain, I seemed to be much more sensitive to pain elsewhere in my body. I’ve not researched this, but it might be that intense pain in one joint makes us unaware of other joints being affected. Then, as pain subsides in one joint, we notice more in another. Of course, this is more likely during uric acid treatment. Because attacks when lowering uric acid tend to affect many joints. Whereas “standard” gout attacks from new crystal deposits rarely affect more than one or two joints.

To bring this slightly back on topic (no pun intended), the spine is central to all other joints. So, this phenomenon of “spreading joint pain” is most likely to result in back pain.

Finally, all of this depends on context. Because, as I just hinted, the behavior of gout pain is completely different at different stages of treatment.

Thanks again for your magnificent contributions to this forum, nobody. You are a true friend to gout sufferers everywhere. Also, a delightful resource for answering the trickiest of questions – nobody knows!

[Keith Taylor]

I’ve republished this page at 7 Ways Gout Causes Back Pain. Because as part of a bigger picture, the main issue with gout back pain is many people don’t believe it exists.

So gout sufferers become victims as either:
– They don’t believe they have gout, so don’t seek uric acid treatment.
Or
– Their doctor doesn’t believe in spinal gout, so they get the wrong treatment.

Therefore, I’d be very pleased to get comments from gout sufferers who have experienced either of these.

Also, I’ve noticed a few topics about back pain during uric acid treatment. I believe this is part of the issue where flare-ups occur in previously unaffected joints as old uric acid crystals suddenly dissolve. So, I’m now wondering if I should update again to “8 ways gout causes back pain”?

[Keith Taylor]

Thanks Patti

“I took the how acidic are you test…one of the ads. It led me to another site that was highly marketing supplements. Just so you know.”

That reminds me of one of my first personal “Gout Gamechangers” that I missed from my list. Because when I first got my gout diagnosis I Googled about gout every day. Then, I checked marketing claims and soon realized that the majority of Internet gout information is bogus. So I started GoutPal as a way to organize my personal gout research. Currently, I’m working to make my gout and uric acid information more accessible to all gout sufferers.

Anyhoo, I see the over-hyped marketing claims for gout products and services as a learning opportunity. So, when you see something dodgy, it’s good to discuss it here. Then, you and I can learn more. But even better, thousands of other gout sufferers read our information. So they learn to avoid these gouty marketing scams.

[Keith Taylor]

Although posts about antacids and gout are infrequent, this topic certainly attracts a lot of attention. In particular, there is lots of interest in Pepto Bismol, Tums, and other antacids associated with gout.

Of course, my primary concern is to ensure that I have covered all the facts about antacids and gout on GoutPal.com. But I don’t think I’ve achieved that, except perhaps for Pepto Bismol and Gout.

I think the main reason for this is that antacids are produced in many different forms. Which makes sense as I learn about the wide range of gastrointestinal diseases they are designed to serve. So, I was particularly interested today to read a new investigation into antacids and gout.

Yuan, Shu, Zhong-Wei Zhang, and Zi-Lin Li. “Antacids’ side effect hyperuricemia could be alleviated by long-term aerobic exercise via accelerating ATP turnover rate.” Biomedicine & Pharmacotherapy 99 (2018): 18-24.

This study first makes the point that Proton Pump Inhibitors are one group of antacids that are infamous for raising uric acid. Because they slow down ATP turnover, which is a new topic for me to investigate in relation to gout. Even more interesting given that we regularly discuss exercise, is the news that this effect is alleviated by long-term aerobic exercise which promotes ATP turnover.

There’s always something new to learn about gout 🙂

[Keith Taylor]

“Regarding the results I have no doubts..they are correctly 100%.”

Really Rich, 100%? I have several doubts. Because:
1. I remember from earlier discussions you are traveling around Europe where the scale used for blood test results is hardly ever mg/dL.

2. None of your results actually state mg/dL. Because your first 2 results in your list have no scale. Then you say mg followed by mg/do, neither of which are valid scales for uric acid blood test results. Finally, you end with ml/dl, which is again meaningless.

3. I have wasted much time over the years trying to investigate gout at low uric acid levels outside the USA. But wherever people have bothered to check they have *always* returned with corrected results in mmol/L.

So, Rich, please can you double-check the scale used in your test results. Then compare them with the different scales used for measuring uric acid levels. Also, if you have the actual lab reports, perhaps you could photograph them and send the pictures to me.

[Keith Taylor]

Loni, if gout is solely caused by a primary disease such as one of those you listed then it will be resolved. But managing secondary gout is not that simple. Because there are 2 great unknowns:

1. Is your primary disease the sole cause, or do you also have gout?

2. How long will it take to correct the underlying cause?

In both those cases, you run the risk of serious harm from excess uric acid. So it makes sense to get uric acid safe now. Then, when you recover from the primary disease you can start a controlled, safe withdrawal from uric acid treatment.

Coincidentally, I wrote about reasons for managing secondary gout today in a different context. I’d appreciate feedback to say which explanation is clearer.

[Author]

Posts