Am I on the right path?

[Ron Avery]

First and foremost THANK YOU Keith for maintaining such a resourceful website. I feel like I have empowered myself with the knowledge I need to overcome this dreaded disease.

I am a 51 yo male. Gout was first suspected on my big toe when it flared up in fall 2010. Since then I have had episodes in both ankles, feet (metatarsals) and heel/ Achilles. Each time it was put to tendinitis due to the fact I play a lot of squash & ball hockey. These occurred once or twice a year.

Well, starting just before Christmas it started on my right foot then my left ankle, right foot, right ankle, left ankle, last Thursday and left knee Sunday. So it has been an on & off ordeal for 7 weeks.

Both knees started with a tenderness just below the knee cap just a little off center. Over the next 24 hours they ballooned so there was 10% mobility and pain at 10++ with any movement. Also, cramping at times. Are these gout symptoms ? Also, are fever/chills and sweating at night normal ? Right knee pain is greatly reduced but still swollen and mobility is about 60%. Left knee is still behind because it flared up more recently. Right ankle is still swollen and there are twinges of pain when I walk in my ankles and right foot. I have been on the couch for the past 6 days only able to move with a cane & pain and unable to work.

I have been taking Naproxyn like candy and Tylenol for pain. Last week, I had my UA tested and it came back at 503 (8.46) kidney & liver function normal.

So I saw my doctor today and she prescribed Allopurinol 200mg/day and Colchicine 2 x .6mg/day until I see her in a month. She also said to take the Naproxen & Tylenol extra strength as required. I have an appointment in a month for blood work and to re-assess.

I think I’m on a good path to control my gout but would welcome any input. I’m supposed to go to Vegas March 5 and would really hate to cancel on my buddies.

Thanks again.

[Keith Taylor]

Hi Ron, you are doing everything right!

Your description of gout symptoms is quite common, but other people reading this should note that symptoms do vary from person to person. Anything from dull ache to raging hot pain is ‘normal’ for gout. The fever comes because your immune system is fighting invading uric acid crystals.

I’d recommend one colchicine before bed, and the other in the morning. When you support that with Naproxen and Tylenol, I’m certain that you will enjoy your Vegas trip. March temperatures might be a bit low, so make sure you avoid prolonged exposure to cold. Also, stay hydrated. Any fluid is fine – just drink until your pee is pale straw color.

Ron, you’ve made life easy for yourself! 😀
Enjoy Vegas and send us a photo of your winnings!

[Ron Avery]

Hi Keith,

Thank you for your prompt reply.

I still have some pain and stiffness/limited mobility in both knees but they are getting better. Should I continue taking Naproxen to get the swelling down or save it for any future attacks since I’ve started on the Colchicine ?

Also, if I’m just on the Allopurinol and Colchicine daily and I do get a flare up do I increase the colchicine temporarily (and to what dosage) and hit it with Naproxen as well or just the Naproxen ?

Thanks,
Ron

[Keith Taylor]

Colchicine stops inflammation spreading, but does not reduce it. If inflammation is significant or unbearable, take naproxen.

Never ever take more than two colchicine per day. It poisons your immune system. That’s good if it it just enough to slow inflammation (2 per day), but bad if it kills you 9more than 2 per day). Also avoid colchicine if you have an infection, or are exposed to infectious people.

Naproxen can reduce inflammation by itself, but it is more effective for severe gout pain if taken alongside colchicine.

The 3-pronged approach is always effective:
Colchicine to stop inflammation spreading
Naproxen to reduce inflammation
Tylenol to block pain.

If attacks are not severe, then not all three are required. For most people, preventative colchicine during the early days of allopurinol treatment prevents gout flares. If they do happen, the other 2 elements of your pain control package allow you to stay mobile.

For other readers, please note that your choice of anti-inflammatory and pain-blocker can be different from naproxen and Tylenol. Discuss your options with your doctor, but always insist on the maximum dose, as gout is not something to treat lightly.

[Keith Taylor]

Not sure if I answered you completely, Ron.

I always felt that the best approach was minimum pain control consistent with mobility. I.e. if I can walk with a little discomfort, then I don’t need more drugs. This is something you get a feel for if you try to be aware what your body is telling you.

Until allopurinol has got rid of the bulk of old crystals, you might experience some discomfort. Naproxen will help, but might not remove it completely. If the pain stops you from doing something, then best to treat it. However, try avoid being fixated by pain. A good walk, or other ways of getting out and enjoying yourself will take your mind of residual pain.

The most important thing is to get uric acid down to 5mg/dL, or lower. Then you know that any pain will be short-lived, which gives you more confidence to get on with your life.

If I’m not making myself clear, please keep returning to ask questions. I’ll give you all the support I can to make sure you get complete control of your gout.

[Ron Avery]

I really appreciate your genuine concern for me and everyone on this forum. I will keep posting updates as to my progress.

I am the same way. I’ll only take pain meds if I really have to. I’ve always been very active so not being able to play squash or exercise at the gym really has me down. Once my joints feel better I hope I can get back at it.

I have a question about diet. I eat a fairly healthy diet ( or so I think). Lots of fruit and veggies, red meat maybe once a week, chicken & salmon moreso & pork once in a while. I drink very little soda pop and drink water like a fish. However, a lot of the veggies I like are on the high purines list and I typically eat beans, lentils and peas at least once a week each. I also enjoy my alcohol & beer but typically no more than 2 drinks a day unless I’m with friends on the weekend or up at the cottage then that number goes up substantially. Should I alter my diet now at the beginning when I’m trying to get my UA down or should I keep eating normally so that the Allopurinol dosage I take gets adjusted to the right level to keep my UA level below 5 based on my diet ?

What I’m trying to say is if I were to adjust my diet now to a very low purine no alcohol diet then 200mg of Allo might get and keep my UA at say 4.2. If I don’t adjust my diet then my Allo may have to be increased to say 3-400mg to get me to that same 4.2.

I do not want to live a teetotalling strict lifestyle. Life’s too short and I enjoy food and alcohol too much !

What are your thoughts ?

[Keith Taylor]

Thanks, Ron 🙂

Exercise generally is good for gout, but you do need to be careful about over-stressing joints that might be weakened by the presence of uric acid crystals. Maybe swimming or walking to keep up the fitness levels for when you do feel like squash again. Also, somebody at the gym might be able to advise you better on this – maybe an exercise plan that avoids joint stress. There’s evidence that tendons etc recover once uric acid is under control, so the future looks bright.

There’s an awful lot of stuff written about gout diet, but I’m moving towards a simple view.

If you eat a diet that is generally considered to be healthy by modern nutrition standards, it is almost the best you can do for gout. There might be some tweaks you can introduce to lower the reliance on allopurinol, but attention to basic health is more important than purine control.

My reasons for saying this is that a modern healthy diet is very low in animal purines. Despite widespread repetition of vegetable purine information, we now know that vegetable purines do not affect gout. My simple basic diet approach ticks almost all the right boxes for a good gout diet. Beyond that, personal tweaks for individual diet management need to recognize what that person likes (or hates) to eat.

I’m trying to find time to expand the best simple diet into some practical guidelines. The foundation is:
Eat Food. Sufficient. Especially Plants. (EFSEP)

It’s my take on a similar theory about nutritionism:
Eat Food – not food-like substances. Essentially, it is much healthier to eat whole, natural foods, compared to highly processed meals that sound like food. If you look at labels, focus on the ingredients. If you wouldn’t order a plateful of an ingredient, don’t buy the product that contains it. There are some gout specifics that have been highlighted, such as High Fructose Corn Syrup. More generally, we know that toxins can increase uric acid, and many food additives are toxic to a degree. Added iron is significantly associated with gout.

Sufficient – overeating is bad for general health, and terrible for gout. It is usually worse than excess animal purine intake. Why? Because our own flesh produces uric acid as it metabolizes, just the same as purines that we eat. Overweight people have a significantly higher source of uric acid, and a significantly higher risk of gout.

Especially Plants – most of your food intake should come from plants in the form of fruits, vegetables, grains, nuts, etc. This is true of diets that have shown to be associated with better health, such as alkaline diets and Mediterranean style diets. The beauty of this is that there are loads of free resources to help you plan tasty meals. Also, you can change gradually. I’m now at a point where I rarely cook with meat, and when I do, it is as a flavoring, not a main ingredient. Traditional Chinese food is very strong on this idea. It can be hard to change the habits of a lifetime, but new discoveries with simple healthy eating goals are much easier to follow than boring low-purine diets. I eat more meat when eating out, but even then, I’m finding myself drawn more to vegetarian options. I’m aware that it can be quite hard to be totally vegetarian, as missing important nutrients might be unhealthy. However, with occasional meat, and mainly plants, I know I’m doing my gout good. This type of diet produces alkaline urine, which is much better for excreting uric acid.

The alcohol issue is fraught with difficulties, and debate. The science is confusing and occasionally contradictory, and this reinforces my belief that you have to take a personal approach. Commonsense certainly plays a part. If you drink heavily every day, that’s not good for gout, but also not good for general health. If you drink moderately every day, or heavily occasionally, this is less likely to have an impact. If you suspect alcohol is impacting your gout, it is important to analyze your situation carefully.

You need to distinguish between inflammation and uric acid levels. Alcohol might affect both, but you need to be certain. This involves carefully recording uric acid levels and any signs or symptoms of gout. You do this during a period of normal drinking, then during a period of abstinence, and keep repeating the pattern. In order to reach a fair conclusion, you have to do this many times. Personally, I find life is too short, as you say. Anyway, I always found that my gout felt better after a few pints, and I prefer to live my normal life, and accept whatever allopurinol dose is best to keep me safe.

As an aside, I find some of the official alcohol guidelines very restrictive. I’m ‘guilty’ of my own interpretation – e.g. 1 Unit = 1 Pint. The most useful part, for me, is at least 2 alcohol-free days per week. For me, I keep this as at least 3 alcohol-free days, and usually 4. I find that without that, I tend towards low-level inflammation, which may or may not be gout related. Also, I now find that drinking on more than 2 consecutive days induces depression – a personal observation, and nothing to do with gout.

I hope this helps, Ron. I’ve covered quite a lot of ground here, but feel free to ask about any of the detail.

[Ron Avery]

That’s very comprehensive, thank you. It’s how I try to live my life (for the most part). I believe the more a food is processed the worse it is for you. The more it’s in it’s natural state the better. Living day to day and adhering to good eating and drinking ( no more than 2 units a day and at least 2 days a week no alcohol) practices does not concern me.

I’m more worried about the occasional weekend where friends come over on Friday night and we have 4 or 5 units to drink, Saturday night it’s out to dinner with other friends to a steakhouse where not only is the smallest steak 10oz but a couple of Martinis and 2 bottles of wine are consumed between the four of us. Then we’re invited to a family bbq on Sunday where 8-10 beers are consumed that afternoon/evening. Don’t get me wrong, this is not the typical weekend for me but they do happen 4-5 times a year with that type of consumption. Throw in a 4 day trip to Vegas with my buddies where drinking in the norm 24/7, a yearly one week trip to the cottage where there is daily consumption and I wonder…

1) Will this all lead to a spike in UA level that causes a flare up or will the Allopurinol keep it in check ?

2) From what I understand flare ups occur because of the deposits of UA in the joints that have accumulated over many years. Since theoretically a big bulk of these crystals that have been deposited in the joints should be cleared out after about a year of being on Allopurinol, and having your UA level below 5, there should be plenty of “room” to hold any new crystals that may temporarily form after a binge and spike in UA until the Allopurinol can catch up and get rid of it. Therefore there shouldn’t be a flareup. Does this make sense or is it wishful thinking ?

3) I don’t want to live in fear that a crazy weekend once in a while is going to result in a flareup. I’d rather take an extra 50-100 mg of Allopurinol to guard against that. Makes sense ?

Again, I want to reiterate that the bulk of the time will be normal eating and drinking.

I’m not sure I quite understand what you mean by inflammation in the context you are using it in. You say that drinking can cause inflammation. Is this inflammation of the joints or some other kind ? How do you quantify it ? In terms of measuring UA levels I have to rely on Drs. visits so they can only happen at best once a month so I wouldn’t be able to gauge immediately what a week or two of abstinence vs drinking does to my UA levels.

My knees are both feeling a bit better and I can walk without a cane…slowly and have been pushing myself to do so. They’re both still quite swollen and stiff with limited flexibility and going up & down the stairs is a chore but I can tolerate the pain now so no more Tylenol for now.

Thank you again Keith for all your help !

[Keith Taylor]

Absolutely brilliant questions and observations, Ron! These are exactly the types of issues I’ve struggled with in the past. Sometimes I’ve worried for years about a particular aspect of gout that I didn’t understand. Then, I’ve seen a piece of research that has allowed me to view gout in different ways. Without blowing my trumpet too much, it’s that type of insight that you simply will not get from most places – because most people do not worry about gout at that level.

There is a simple approach – take sufficient allopurinol and stop worrying. This is a necessary approach for many doctors, but has 2 major flaws:
A. They don’t always understand what “sufficient” means. I won’t rant about that again just now.
B. It doesn’t help patients understand their gout in the context of better lifestyle choices.

I found point B particularly relevant, as once I knew I could control gout, I didn’t want to die of heart disease.

So on to your points, Ron:
Your description of your lifestyle sounds good to me. I say this in the context of someone who believes that life is for living. I do not think that 4 or 5 weekends of the type you describe will seriously damage your health, or seriously worsen your gout. Sometimes we have to accept that gout has more reasons than diet, focus on the positives, and stop over-analyzing. More than that, it is important to understand the exact nature of how gout pain can and does exist.

1) Generally speaking, high uric acid is a result of changeable factors, unchangeable factors, or a mixture of both. Changeable factors include meds for other health problems, environmental or dietary toxins, prolonged bad diet. Unchangeable factors include meds that have no alternative, ingrained bad diet habits that can’t be broken, and most common of all – genetics. It has been proved that a high purine meal will usually produce a uric acid spike, but this will not cause a gout flare. Allopurinol is most effective at lowering uric acid from diet, and about half-effective at lowering uric acid from natural cell turnover. So yes, allopurinol will help prevent a uric acid spike from high purine meals. The latest news is that – if this is just an occasional event, rather than a daily diet problem, then it doesn’t matter.

We now know that a uric acid spike does not trigger a gout attack. Uric acid crystals form very slowly, so a short-lived spike has very little effect. It is the daily average concentration above 6.5mg/dL that leads to extensive uric acid deposits. The startling results of the latest science tells us that uric acid crystals alone cannot produce a gout flare! The inflammation and pain signalling processes are very complex, but they need the presence of Free Fatty Acids(FFAs). By coincidence, FFAs are significantly high in most foods that are also high in animal purines. Thus, we associate a beef dinner with gout attacks, but the truth is far more complicated than simple uric acid spikes.

2)Makes perfect sense, and is not wishful thinking. Some leading-edge gout specialists believe that gout treatment might eventually become a short, annual intense treatment that reduces uric acid to near-zero for a couple of weeks or so. The rapid debulking of crystals in this period removes the risk of gout attacks. Lots of work to be done, but all the latest research supports your theory. On GoutPal, this is now known as Ron’s Plenty Of Room Theory! With more time, I’ll develop a suitable acronym 🙂

3)I hope you can see that temporary additional allopurinol is not necessary. By adopting a strategy that lowers uric acid to 5mg/dL, you have a built in safeguard against uric acid fluctuation. The real issue, shortterm, is how best to manage the debulking period. Once you get that right, you can kiss gout worries goodbye forever.

Alcohol-related inflammation in my context, is about prolonged heavy drinking. I’ve not studied it in depth, as once I realized I might be a victim, I adopted an alcohol intake pattern similar to yours. I’ve read some reports about this, and i can best describe it as a sort of pre-cirrhosis condition. My symptoms were stiff legs, with low-level inflammation in knees and feet. Immediately I thought gout, yet this isn’t really the same, as gout tends to only affect one or two joints. A chance discussion with a fellow heavy drinker revealed that he had similar problems, but was definitely not a gout sufferer. A little self observation and restraint confirmed to me that prolonged excess alcohol consumption can definitely make inflammation more likely – at least for me. However, because this is bound to vary from person to person, I believe it has to be viewed in the light of personal history. It’s a factor that might be considered, but can be discounted for many people. Can I suggest it falls into the category: “Be aware of, but don’t worry unnecessarily.”

Of course, if anyone reading this is seriously worried about alcohol affecting there gout, then feel free to start your own personal discussion about it.

If you are worried about it, Ron, a monthly appointment is a good thing. Dedicate a year to the experiment, and alternate months of abstinence with months of normal drinking. Don’t feel obliged to do this. I hope you can see that it is probably a red herring in your case. I’m just trying to consider all possibilities, based on your “I also enjoy my alcohol & beer” reference.

I’m really pleased that your knees are feeling better. Doubly so, because you are pushing yourself to stay mobile rather than wallowing in a pit of self-destructive inactivity. Chin up! Boots On! Walk it off, and celebrate with a pint 🙂

• This reply was modified 6 years, 9 months ago by Keith Taylor.

[Ron Avery]

Once again thank you Keith for such a detailed and informative response. I feel honoured to have a “theory” named after me on GP!

My biggest fear when it was confirmed that I had gout was that I’d have to live a rigid life when it came to food and alcohol while all my friends and family were enjoying themselves at parties, restaurants, get togethers etc. it seems this is not the case. As long as one eats and drinks in moderation and makes healthy choices say 70-80% of the time then binges that occur occasionally whether food, alcohol or both should not be of concern once debulking of UA has taken place and your level is safely below 5.

Knees are feeling even better today(about 70%) so I am going to try and ride the stationary bike for 10-15 minutes (lightly) just to get the blood flowing. I haven’t been able to exercise in a good 3 weeks or so so I’m feeling like a slug. Also, I haven’t had any alcohol in over 2 weeks but friends are coming over tonight so I’ll probably have a couple of cocktails or glasses of wine. I’ll let you know how both affect me if at all.

Cheers !

[Keith Taylor]

I hope you’re enjoying your weekend, Ron.

Thank you for the inspiration for http://www.goutpal.com/7734/make-room-for-gout/

I couldn’t have done it without you. 🙂

[Ron Avery]

Keith, I should be thanking you for providing the wealth of information and support that set me on the right path to conquer this beast.

To anyone reading this who has recently been diagnosed or has been sitting on the fence not sure what to do the best advice I can give you is read, read, read and ask questions. Knowledge is power and the more you have the better you will be able to understand how to beat gout and that you don’t have to live in constant fear. I realize that there may be setbacks with the occasional flare-up as my body cleanses itself of UA crystals but I know there is a flare-up free light at the end of the tunnel as long as I stick with it.

I am on day 4 of 200mg Allo and 2x.6mm Colchicine and so far so good. Right knee is almost 100% and my left knee is at about 70%. I will try to post weekly as to my progress, side effects, flare ups, blood results etc.

If anyone has any questions for me as I begin UA reduction journey feel free to ask. Once again, read all the information that’s on this site and tap into Keith’s wealth of knowledge. He’s done all the leg work for us.

Thanks Keith !!!

[Keith Taylor]

Cheers Ron 🙂

I see it very much as a two-way partnership, or better still, three-way if you include your doctor.

I see my job as being to help gout sufferers, and I can’t do that just by writing pages of stuff on GoutPal.com

My knowledge, gleaned over many years of investigations, and personal experience, only comes to life when I discuss it here. It gains meaning, and I learn to express myself better through interesting discussions.

Trust me Ron, I need you, and people like you, just as much as you need me. Your posts mean a lot, and I’m grateful you intend to post weekly.

Many gout sufferers understand their own gout more when they respond to the questions and experiences of others. I’m currently committing as much time as I can to encourage people to post here as regularly as possible. Thanks, Ron, for doing your bit.

[Ron Avery]

Just a quick update.

I left for Vegas last Thursday and came back last night. While there I can safely say I overdid everything ! I drank excessively (mostly alcohol & wine) and I ate whatever I wanted including many high purine foods such as red meat, crab, mushrooms etc. I was diligent in taking my Allopurinol and Colchicine and I am happy to report that I had a great time with no flareups or twinges at all.

Now that I am back I will return to moderate consumption of alcohol including several days a week of abstinence and will be back to healthy eating with the occasional indulgence.

I am scheduled for blood work on March 17 and will report my UA level when I get it.

Thanks again Keith for the support and encouragement you’ve given me and all others on this site who come for info and help.

[Keith Taylor]

Brilliant, Ron 😀

I’m glad you did Vegas justice, and I’m looking forward to seeing your uric acid test results later this month.

[Ron Avery]

Update.

Got my blood test results yesterday. Liver & kidney functions are normal. UA is at 303 which is down substantially from 503. My Dr. is happy that I’m in the normal range and refuses to increase my Allopurinol dosage to help with the debulking phase. She attended a conference a few months back where they specifically addressed gout and said doctors should prescribe to treat to a point where UA levels are within the normal range which is below 360 here in Canada. Since I am well below “normal” range and I haven’t had any more flare ups she doesn’t want to increase the dosage as it goes against “Canadian Standard Guidelines”. So I’m stuck at 200mg/day and she’s discontinued the 2 x .06/day Colchicine. She said if I do feel an attack starting I should treat immediately with Naproxen 2 x 500mg/day and Tylenol for pain until it goes away.

She’s been my doctor for over 20 years and she’s great so I am hesitant to push the issue and request to see a Rheumatologist.

Should I insist or stay the course knowing it will just take longer to dissolve the older imbedded crystals?

I have an appointment to see her in a month once this prescription of Allopurinol is finished. Not sure if she’ll want another blood test or not. On a good note, still no more flare ups (knock on wood) but I have stopped the Colchicine as of yesterday so we’ll see.

[Author]

Posts