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Hello fellow Gouters:
Background: After three months of thinking (wishing?) my big toe(s) painful inflamation was due to my running, my primary physician has diagnosed my condition as Gout. During my first acute attack in February, '09, I woke up with my left big toe in so much pain, I couldn't walk on it. Refused to go to a doctor. Two weeks later I was running again. Three months later — early May, 09 — my other big toe came down with the same malady and this time, after induring two weeks of pain, I went to my primary physican who, after inspecting my swollen red toe, suspected Gout, measured my uric acid level (7.2) and prescribed colchicine. After taking 8 tablets of colchicine over 12 hours, my only reward was crawling to the bathroom for the next six hours with diarrhea. Lovely combination. Was switched to indomethacin which eased the pain within six hours of taking. Three weeks after the pain went away, my uric acid blood test came back 8.8 mg/dL. My doc recommends, if the pain comes back, to take indomethacin again.
Question: Since you all talk about allopurinol for life, would you all please weigh in on when to start allopurinol vs. simply waiting for the next acute Gout attack and just treating the symptoms. Since allopurinol has side effects, there must be a tipping point between “hope it doesn't come back” and becoming an “Allopurinol Lifer.” Do you think I shoud immediately join the allopurinol club?
Thanks for your thoughts and for this forum.
This is my first post also. My first attack occured in my wrist, which was excruciating and sent me to the ER after a sleepless night. All the staff believed I had been bitten by some kind of spider or scorpian at first, but changed the diagnoses to “celluitus” after I did not recall any encounters with any of those pests recently. The pain was unbearable, and could feel each heart beat felt like a hammer falling on my wrist. The ER sent me home on anti-biotics and pain killers. (I did mention to them that I had been drilling steel all day with a hand drill, but the doctor did not snap to this).
The pain went away after a few days and all was well for a few months. Then I had an attack on my big toe, and finally went to a foot doctor when the pain got unbearable, and the swelling was bad.
He then told me about gout, and the wrist attack made more sense. He sent me home with colchicine, which was very effective. Several attacks though the next few years, each lasting longer, but none quite as intense as the first two. I learned to get the colchicine started quick, and found that less than the prescribed dose was effective for me, without the side effects. I also used a decreasing dose of Prednisone (30-25-20-15-10-5) to kick the attacks quickly. I tried reducing or avoiding the high purine foods, but that did not seen to help. I found out about cherry juice, and it helped some. I still drink it daily because I like it, and 100% black cherry juice is availiable around here at a reasonable price. The gout finally seemed to settle in my right foot, flareing and subsiding every few weeks, keeping the foot swollen, and building a knot on the side of the hinge joint of my big toe.
My new HMO internist saw it and prescribed 300 mg /day allopurinol, but did not inform me about the tendency for the medicine to cause attacks. I was about to give up, and then I ran across gout pal. This is absolutely the best source of gout information I have found on the Internet.
The Goutpal/administrator drove home the point that it is most important to drive the uric acid level down quickly. Most of the web sites just focus on diet, and giving up pleasures, which may help a bit, but seem drag out your treatment and prolong suffering needlessly.
I kept taking the allopurinol even when it hurt, and after 2 1/2 months, the pain/swelling/redness is disappearing. Even the toe bump is shrinking. Listen to the wise man. The GoutPal is the Best.
Ah, lovely new gout forum people making some very interesting points. I particularly enjoyed the wisdom and insight of philr…
who said:
I was about to give up, and then I ran across gout pal. This is absolutely the best source of gout information I have found on the Internet.
The Goutpal/administrator drove home the point that it is most important to drive the uric acid level down quickly. Most of the web sites just focus on diet, and giving up pleasures, which may help a bit, but seem drag out your treatment and prolong suffering needlessly.
I kept taking the allopurinol even when it hurt, and after 2 1/2 months, the pain/swelling/redness is disappearing. Even the toe bump is shrinking. Listen to the wise man. The GoutPal is the Best.
[My bold] 😉
On the “allopurinol lifer” question, I believe we need to take a step backwards and consider the real issue. Excess uric acid.
It is a sad state of affairs that the (almost) universal advice from the medical profession, including the world’s leading rheumatology institutions, is to treat pain first, then consider uric acid lowering if gout attacks continue.
Would dentists get away with the same attitude to toothache? Would you continue to use a plumber who simply turned up with mop and bucket (perhaps a portable pump as his version of a steroid shot for worst cases)?
Clearly not, so it is up to us, as healthcare consumers, to insist that our doctors take our uric acid level seriously.
That does not necessarily mean automatic lifetime daily medication. But it does mean a schedule for monitoring. And it does mean a plan for maintaining uric acid below 6mg/dL.
As with all plans, reality will offer choices and results will suggest alternatives. Try diet. Try cherries. Try meditation and prayer if you like, as long as you measure the results by your uric acid levels. Just set yourself a 12 month limit for any and all the different approaches that might work, and if you have not met success, opt for a proven medication that will work.
Once you have had a gout attack, you have lost your gout virginity. You can never return to the no-gout-risk group. You must manage your uric acid levels and accept that every day of your life spent with a uric acid level above 6.5mg/dL is another day’s contribution to bone-crumbling uric acid crystal deposits. This is still happening on the good days when you feel no gout pain. Day-by-day, slowly but surely, you are creating irreversible serious joint problems.
The worst part of that process, is that by the time the avoidable joint problems cripple you, you are older and less able to cope. And you will be on daily lifetime max-strength painkillers as well as allopurinol.
So, I repeat, give yourself 12 months to try alternatives if you are averse to daily uric acid lowering medication for life. Just ensure that you are having monthly uric acid tests to get to know your number, and ensure it is decreasing (it can swing up and down so you are really looking for an average downward trend).
And if you do go for allopurinol, never start on a 300mg dose. Start on 100mg (maybe as low as 50mg if you have other medical conditions). Increase this until two of your consecutive uric acid tests show results below 6mg/dL. You might have to go much higher than the “standard” 300mg dose, but if you do not achieve levels lower than 6.5mg/dL, you are wasting your time.
trev said:
Post edited 1:55 pm ? July 21, 2009 by trev
Wrong post deleted
You just failed your forum moderator interview 🙂
I see that if I’m gonna be complimented and quoted, I best start flattering too. Here goes: GoutPal, you are bester than best!
…kidding aside (this gout is serious business) appreciate philr and GoutPal’s feedback. GoutPal is correct in picking up that I’m in denial. Reminding this 58 year old man that he’s lost his gout virginity is a good point indeed. No – I don’t want future irreversible crippling joint damage, yet I am secretly hoping for this gout thing to be temporary – like the flu – and once past, to go on my way in life happily without any of you. No insult intended. So here comes a genuine compliment for GoutPal: Thank you for being gentle with me and giving me permission to play around with alternatives (recipe for black bean broth looks edible) before accepting that I’m a lifer.
I’ll keep my blood uric acid levels tested to form a baseline.
bout of gout
Doctors have a rule of thumb that I once read but forgot but they will NEVER prescribe allopurinol after just the first attack, or even the second becasue they are loathe, correctly so, to commit someone to a lifetime of a drug if there is a chance the injury was a sprain, a crush, a whack, a repetitive motion injury, a microcrack in a bone etc. They have some rule of thumb like 2 or three attacks in a year.
Probably the only DEFINITIVE call can be made with the big purple bunion joint that is excruciating painful to touch and a high uric acid level…and a fast response to colchicine.
But yes, once your gout virginity is lost there's no way to glue the hymen back on your toe. It's becasue uric acid easily supersaturates and causes no problems BUT supersaturation cannot occur in the vicinity of an already formed crystal…and once you've had that first attack, you have crystals that you will probably NEVER be entirely rid of.
Yep, learning to use colchicine is a fine art and once learned, a VALUABLE tool. Just 2 teeny tablets at exactly the right time can save a LOT of time on the throne of perdition after having to take 12 of them.
Appropos of nothing, I started right out with a 300 mg. dose of allopurinol with not a single problem…no attacks and good uric acid numbers, even with thiazides.
I know most people will get away with a 300mg starting dose, but it certainly isn’t the best approach. Allopurinol dosing has been shown in a few studies to be spectacularly mismanaged, so it’s one of those issues that I tend to bang on about far too often.
I can understand doctors not prescribing allopurinol on the first attack, but I cannot forgive them for not starting a uric acid monitoring schedule. Any f-f-pharmacist can manage pain. Uric acid management needs a little more finesse and professionalism.
Just a quibble keiyh but USUALLY allopurinol dosing is mismanaged on the LOW side. THe problem is the doctors who see problems with 400 to 800 mg dosing.
I think 300 mg to start is quite reasonable…probably most doctors agree with me…now THAT'S a rarity!
I think 100 mg dosing is a waste of people's time.
There are a small percentage of people who react badly to allopurinol.
Starting at 100mg should identify these and allow alternative or de-sensitizing. For the majority, a quick jump to 300 and beyond would be the next step.
I am actually more worried about the doctor showing an understanding of uric acid, and the need to monitor regularly and keep it under 6mg/dL, than the exact dosage pattern.
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