Diagnosis

[Breandan O’Shaughnessy]

Well, first I’ll lay out the facts I guess:

Went out for a night of beer drinking on a friday for my birthday, a couple days later my ankle hurt. That went away but the next morning (monday) my toe started hurting. Pain was not severe and no visible swelling yet. I figured I must have somehow sprained it in my sleep or something. Monday night things got worse, and I eventually went to get some ibuprofen. I looked up the dose that my dentist had previously given me for severe pain and took that (800 mg).
Pain seemed to be going away but I kept trying to figure out what it was. Google kept suggesting gout, which I initially dismissed since I’m not aware of a family history of it, I’m not overweight, and I’m 34. After reading how common it really is (6% of men in the US) I decided it might be that after all. I made an appt with my doctor and asked him to do a uric acid test. Also, as a confounding factor during this I was trying a low carb diet.
A week later, (foot still feeling better, but visible swollen lump on the side), the doctor called back, said my UA test came out to 10 mg/dL. He said the upper limit is 8.5 (where do they get that from? everywhere else says 6-7) and therefore it is probably gout. He asked if I wanted a prescription, I asked what he would prescribe. He said colchicine, I said no thanks, ibuprofen worked fine and it’s going away now anyway.
That’s when I bought a URIT-10 (anyone try this one?) uric acid tester and started trying to change my diet. I tested it at first every morning, got 8.5, 11.1,12. I then cut meat out of my diet the next few days, drank a lot of water (don’t know how much honestly), and cut out beer. now I was measuring 7-8 mg/dL at the same time in the morning. That’s when the pain came back. I called my doctor back told him it stopped getting better and started getting worse again. He told me he would give me a presription. He gave me 20 tablets of colchicine. The dose reccommended was 2, then 1 an hour later, then 3 a day as needed. I took that for 3 days, but then it started to make me feel sick, and it didn’t seem to be doing anything at all. I kept having to take some aleve to get to sleep.

That brings us to today. I stopped taking the colchicine, started just taking the aleve and my foot is finally feeling better, but still visibly swollen. My meter told my my UA level was 5.4 mg/dL this morning. It’s been 3 weeks since this started. Between the colchicine not working, and the sudden drop back to normal UA levels, I’m starting to wonder if this is gout at all. I also wonder if my meter just doesn’t work. My most optimistic idea is that the pain is just not going away because it flared up again as my UA level dropped and crystals started dissolving. I think I am going to make an appt at a podiatrist for a second opinion. Let me know what y’all think.

[Keith Taylor]

A podiatrist will tease you for years until the gout gets tophaceous and he can charge you for surgery.

Sorry Breanden, that’s been building up for years, and I had to let it out. If any podiatrists want a serious discussion about whether that is true or not, please start a new topic.

Now, despite me qualifying everything I write by saying I’m not a doctor, and I can’t be expected to diagnose gout, I’m prepared to bet one of my limbs that you do have gout. Every word you have written matches the gout experience. Also, a very small number of people can carry a 10mg/dL uric acid load for years without gout symptoms. But, it will ruin their lives later. Best deal with it when you’re young and fit, rather than giving your older self a crippled retirement.

Home uric acid meters are useful as a guide in some circumstances. But, an individual result is not reliable. The meter itself is not an issue, unless it’s faulty. The problem lies with the sample. With a lab test, they use a syringe of blood from a vein. It’s representative of what’s happening throughout your body. Not perfect, but a realistic alternative to taking a pint. With a home test, you use a tiny droplet of capillary blood. 10 tests will give 10 different results on the same day, so you can only rely on averages and trends.

OK, that’s how uric acid tests work, but here’s the rub…

Uric acid test results have got nothing to do with gout attacks!

Long term, you obviously can’t have a gout attack unless uric acid has been high enough to leave crystal deposits. But, it’s the crystals that create the attack. This has nothing to do with the level of uric acid that is dissolved in your blood.

Breanden, I hope I’ve explained why I think you have gout. Now, I have to think about what you do next. There are two issues. One is a long-term plan to get uric acid safe. I’ll leave that for now, as I believe managing gout pain is more immediate.

Colchicine is a great friend to gout sufferers. But it’s a friend that needs to be understood. It’s a poison that stops inflammation spreading. It’s great as a preventative during the early weeks of uric acid lowering treatment. It is not 100% effective, so it often needs the help of anti-inflammatories like your ibuprofen and Aleve(naproxen). It has no effect on pain, so it often needs the help of pain-killers like Tylenol or codeine. A good pharmacist can help with a package of pain control for gout. In the UK, hospital nurses are very good at pain control advice. I’ve not yet had experience of American hospitals, so I’ll leave it to other GoutPal members to have their say. Who knows pain control best? Here’s my view:

The best gout pain control has to be personal, based on what works for you. It’s a 3-pronged attack:
1. Colchicine at the first twinge, plus gout strength anti-inflammatory (gout strength = max dose advised by doctor). Colchicine dose should be one or two according to your tolerance.
2. After 2 hours: Tylenol or other compatible pain blocker at gout strength.
3. After 4 hours: Repeat anti-inflammatory if necessary. If swelling not improved, take second and final colchicine.
Repeat pain-blocker and anti-inflammatory steps as long as necessary up to maximum daily dose.

Some people prefer a 3 hour cycle instead of 2 hours. Choose what suits your daily routines best.
I’m recommending max colchicine dose of 2 per day. Studies suggest that it isn’t effective after that. It has to be individual, so if 3 improves your control of swelling, then take 3 if that’s what your doctor prescribes. Understand that gout pain is essentially an immune system reaction to the presence of uric acid crystals. Colchicine works by poisoning your immune system. Good for agony control, but not so good for general health. It’s a personal risk/reward assessment. I’m with you, Breanden, on “I asked what he would prescribe. He said colchicine, I said no thanks, ibuprofen worked fine…”

It boils down to this:
You’ve had uric acid crystals building up for years, and now they are causing trouble. It is not going to go away until your uric acid is consistently below 6. 5 is a better long term target. Crystals will dissolve faster at lower uric acid levels. Gout attacks will occur at random until most uric acid crystals are dissolved.

Those are the facts that apply to all gout sufferers.
How you control it depends on your personal preferences.
I’m here to help.

[Breandan O’Shaughnessy]

So, on the colchicine, since the inflammation had already been there for about 2 weeks before it was even prescribed, it seems that perhaps there was no point in taking it at all. The doctor probably would have done better prescribing a more potent anti-inflammatory? I can keep the colchicine around in case of another flare up and take it right away next time.

I’m not exactly hopeful about the podiatrist, but I’m hoping he can at least get me an X-Ray and put my mind at ease that there is nothing else visible going on, and maybe prescribe something more useful, though I’m not sure what that would be. The pain is pretty manageable now, but I’ve been taking naproxen twice daily for a week now (which makes me nervous) and the swelling is still there. It looks like a round lump or goose egg on the side of my foot at the base of the big toe. It ranges from reddened to purplish depending on how big it is at the moment. When people talk about gout flares clearing up in a few days do they mean just the pain, or also the visible swelling? Do I try to convince them to shoot some cortisone into the joint? Doesn’t sound fun but I’m pretty sure that would clear it up almost instantly. I don’t know what NSAIDs are given on a prescription basis now. People on the internet talk about indomethacin but I was under the impression that isn’t used much anymore, perhaps just a higher dose of naproxen would knock it out. I have no other health issues so nothing should be outright contraindicated.
My last 4 days of morning measurements showed 6.3,6.2,5.6 and 6.2 mg/dL. So I think long term of below 6 should be possible with no medication. The foot pain has been keeping me from exercising and the one time I tried to take vitamin C was when the pain got much worse the next day, so I’m not going to try again until this clears up completely. This will require a rather annoying change in my diet (meat and beer were really cornerstones for me).

[Breandan O’Shaughnessy]

Another thing, and I guess I kinda touched on it between the lines before, colchicine terrifies me. It is extremely poisonous, and I was a little perturbed that my doctor sent the prescription so nonchalantly with no serious counseling. When I read about the toxicity, the uncertainty of lethal dose, and the fact that essentially 100% of patients treated with it show signs of poisoning from it I was more than a little nervous to try it. Needless to say when on top of that I didn’t notice an immediate improvement I was more than a little disappointed. I’m not arguing it shouldn’t be used, far from it. I just think doctors are uninformed and stuck in the dark ages (in the case of colchicine quite literally). They need to take something like that more seriously. Outside of chemotherapy I don’t think there is much that is that toxic that is routinely used.

[Keith Taylor]

I agree with every word you write about colchicine, Breanden. In medicine, there’s almost a trade-off between risks of treatment and benefits to patients. Most meds are toxic to some extent – it’s all about balancing the risks. Frontline doctors get blunted by the amount of advice that gets ignored, so they stop giving it. That’s unfortunate for people like you and I who would listen.

As well as all the personal factors that make gout an individual disease, we have different levels of gout understanding with doctors. My default setting is to try and bring doctor and patient together so that gout patients get an effective treatment plan. I can gauge that plan against expert recommendations. Your doctor can gauge it against medical safety and personal history.

In the end, all that matters is that your immediate and longterm needs are met. Only you know what they are. Or, only you can find your aims and objectives, if you’re unsure now.

If colchicine isn’t right for you, their are lots of alternatives. First, you have to set the framework. Are you looking for pain relief as a short term measure to support you during the early months of uric acid lowering. Or are you looking for pain relief as a long term alternative to uric acid lowering. The choice might seem obvious, but it has to be made clearly, and with commitment.

NSAIDs are often best for most people, but not everyone can tolerate them, and all come with a warning against long term use. They include diclofenac, indomethacin, ibuprofen, and naproxen. Some appear to work better than others for different people. It’s essential that your doctor advises the maximum safe dose. You do not have to take maximum every day. But, on the days you can’t move, you have to take enough to get mobile. Staying in bed just makes the pain last longer. The best pain relief usually involves more than one drug.

I have an inkling that steroids would be safer than NSAIDs longterm. Personally, I hate them, but my best advice is to discuss with your doctor. The main reason I don’t like steroids for gout is that they knock out your natural inflammation fighters. But, if those fighters are not performing, you might have nothing to lose.

It’s good to get second opinion. But, if you get treatment advice from a podiatrist, be sure to discuss it here. I’m sure there are some good ones, but I never heard of one yet that understands uric acid.
X-ray, or other scan, is ideal to rule out (or rule in) any physical impairment. There’s been some fantastic advances in ultrasound and MRI for gout recently. I don’t know how much of that has reached local facilities yet, but physical examination is always good.

Gather the facts.
Consider the options.
Do the plan.

It’s the only way for personal gout management.

As for uric acid control, your test results are encouraging. I’d love to see how they compare to a lab test result. If a heavy meat diet is leaving you in the 6-7 range, then just getting a little more healthy might be all you need. We’ve grown up in post-war years, when the measure of success is overcoming austerity, and consuming the hell out of everything. These days, I see a new study every week about the appalling consequences of too much meat consumption. As well as gout, there’s a whole host of diseases that improve when you see meat as a treat. Most people won’t believe the amount of meat I used to eat in a week. Now, I can’t believe how little I eat every month. It just get’s easier each day, especially if you change slowly.

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