- This topic has 10 replies, 5 voices, and was last updated 9 years, 10 months ago by
.
-
Posts
-
Hi everyone,
I am a gout sufferer and have recently discovered this forum. It seems that there is a lot of valuable information around. Here is my story, feel free to advise a gout newbie as me.
?
I am 44 years old male. For the last 4 years or so due to various reasons (sedentary lifestyle, overeating, stress) I have put on a lot of weight, 20 kilos / 44 lbs. I am now considered overweight bordering to the obese. 2 months ago I had my first gout attack. No need to describe how horrible it was. I am sure all of you know how it feels. It lasted 2 weeks and I could barely walk. My doctor immediately diagnosed gout, ordered blood tests and prescribed colchinine. The blood test for uric acid level was quite bad: 7.7 mg/dL. The thing is that the doctor blames my high uric acid and gout attack on my excess weight and also my high purine diet. I admit that I used to eat lots of meat, sea-food and I was also a beer drinker. He wants me on a low purine diet and believes that if my weight goes down, uric acid will also fall. He is very much against prescribing any uric acid lowering drug at the moment. His reasoning is that I should first try dieting and if this fails then we can choose the pharmaceutical route. Another reason he gave me for avoiding drugs is that some of my liver enzymes were elevated. I am now on a 6 month low purine diet. At the end of the 6 months I will have to check my UA levels again. For the past 2 months I have lost 2 kilos which is good but I really dread the prospect of a second gout attack. Sometimes during the night I feel a tingly ache in my big toe and when this happens I get scared to death that this may be an imminent gout attack. What should I do? See another doctor? Start allopurinol which seems to be the drug of choice for gout beating? Stick to my diet plan? Please advise.
?
PS: sorry for my poor English, it is not my mother tongue.
Your doctor is following a well-trodden path, but it is one driven by experience of medicine, not experience of gout.
The biggest problem with gout is that uric acid crystals keep forming unless you get uric acid down to a safe level. Losing weight might be the answer, but 6 months is along time to find that out. During that time, if uric acid crystals continue to form, your problem is worse.
My view is that you have to balance the risks. There is virtually no risk with allopurinol if it is prescribed properly (see recent drmarclevine on My gout story). There is a small, but increasing, risk of osteoarthritis from uric acid crystal deposits in the joints. There is a significant risk of an acute gout flare.
The logical approach is to take allopurinol for 6 months, and reduce weight at the same time. Monthly testing of uric acid levels ensures that you get uric acid below 5mg/dL. You need to start with 100mg allopurinol, and get liver function tests with each uric acid test. After 6 months (though I would suggest 12 months is more realistic), you review the dose, and reduce it if possible. This approach covers all the bases, and gives you the maximum chance of clearing old uric acid crystals out of the joints as quickly as possible. If excess weight was the problem, reducing it will prove that, and you will be able to reduce allopurinol to zero. You should still get tested at least once a year to make sure the problem does not come back.
If I were you, I would try to persuade my doctor of the value of this approach. In my experience, doctors react well to good reasoning, but they often need to be reminded of the need to get uric acid down to 5mg/dL to reduce the risk of joint damage.
There is nothing wrong with your English.
Thanks Keith for the prompt reply.
Hopefully I will be able to convince my doc to prescribe allopurinol and follow my diet along with the drug treatment.
I have a another quick question. While researching gout, the consensus seems to be that symptoms are severe to excruciating pain in the joints -usually one of the big toes- which strikes without warning. Certainly this is how my first gout experience was. But can it be possible to have gout with mild to moderate pain which may be persistent but tolerable lasting for days and then fades away? How about gout that strikes with warning such as a dull ache that lasts for days and then gradually ?transforms into a full-blown attack with unbearable pain??
Both presentations you mention are common; the exact reasons for why you might get one and not the other are more difficult to explain, as they depend on so many individual variables which may make your immune response decide to be satisfied with a bit of whinging or losing the plot completely and throwing all the toys out of the pram.?
It's what makes the decision whether to take prophelactic medication, or not, so hard, if you're trying to keep meds to the minimum: NSAIDs, for example, which can be pretty corrosive on the intestines. Having not had a serious flare since starting Allo, I tend to wait & see a bit longer than I would have done before because I don't tolerate NSAIDs well, but I can't deny having taken one before bedtime on a number of occasions “just in case” when I've felt some twinges.
Markin,
?
Just to add a bit to clarify Keith's post. I'm sure he did not mean it to read that you should stay on 100 mg. allopurinol for 6 months. That is a recipe for disaster.
?
You want to get to at least 300 mg. allopurinol as fast as possible, I recommend IMMEDIATELY after your SECOND gout attack has subsided (don't treat after only one.)
?
Weight LOSS is a very potent gout trigger (cell destruction releases immense amounts of uric acid,) more so even than weight GAIN?so slow and steady weight loss ?WITH the help of allopurinol is best.
?
Low-purine diet is very 1940's (and 1740's)?before they had anything better. It just doesn't work. Don't waste your time and energy. If you are going to limit ANYTHING make it beer and ale.
?
Yes, the ankles and metatarsal joints of the foot are very prone to gout attacks. The pain can be brutal but NOTHING compared to a cripppling PODAGRA (bunion joint being chewed on by SATAN himself.)
Personal experience tells me these ancillary foot?attacks last 3 days or so?but may still require a crutch. They are NOT a walk in the park. For some reason the podagra attacks can go on and on and on?like the Energizer bunny.
?
Yeah, get a new doctor. This one seems to have NO experience with gout.
Markin said:
[…]can it be possible to have gout with mild to moderate pain which may be persistent but tolerable lasting for days and then fades away? How about gout that strikes with warning such as a dull ache that lasts for days and then gradually ?transforms into a full-blown attack with unbearable pain??
Gout pain is an immune sytem response to uric acid crystals, but there is more to it than that.
When a white blood cell sees a uric acid crystal, it tries to engulf and kill it, like it would any foreign invader such as a virus cell or bacteria. If there are only one or two crystals, you will not notice it. With more, you get painful inflammation as your white blood cells go into battle and send signals for reinforcements. I have no idea what the threshold is but I'm certain that it varies from person to person, and also depends on your general state of health. At the top end of the scale you get an acute attack, but in between there are a range of reactions of different severity that include redness, itching, numbness, and tingling, as well as pain.
It is interesting (at least for me) to note that uric acid is suspected as being a carrier for the signals that call for immune system reinforcements, which might explain the exquisite torture that more than one lady gout victim has described as worse than childbirth.
Personally, I suspect I had several minor gout attacks prior to the biggie that hospitalized me, but I will never be sure of that. What I am sure of is the fact that modern imaging techniques (search for DECT at the search box above) have shown that crystals start to buildup in joints before there are any gout symptoms.
Just for completeness, it's worth pointing out that the white blood cell coating around the uric acid crystal is not permanent. When uric acid levels in the blood fall, the coating is often shed revealing partially dissolved crystals. Again, it is a numbers game as far as severity and symptoms are concerned, but it is common to have some problems when uric acid levels fall. That is why you cannot judge any treatment, including diet changes, on pain or absence of it – you must know your uric acid number.
Quick update. Just finished talking on the phone with my doc. I was not very happy. He is adamant that gout is a disease that people bring upon themselves at least for 80% of people who develop gout. He admits that they are a few unlucky ones that do everything right, eat and live well and still get gout but they are the minority of the cases. The bottom line is he wont prescribe allopurinol?because a) I've only had one attack so far and b) because my 7.7 level of UA is diet-manageable according to him. Oh well. I am going to start looking for a specialist, probably a rheumatologist. Thanks again for the valuable information everyone has provided.
Just to play devil's advocate here, although I agree with everyone that you should change your Dr, it has to be said that he is following best practice guidelines. Here is a link to a recent Lancet review
http://dl.dropbox.com/u/12859658/Gout.%20The%20Lancet.%20Jan%202010.pdf
However, he may also consider that obesity poses a greater risk to your health and feel that the threat of gout provides a strong incentive to lose weight, which is notoriously difficult for many people to achieve and maintain, as it involves so many adjustments to lifestyle rather than popping a daily pill.
Pretty tough love though, and one would question whether a Dr has the right to make such a subjective judgement about an individual which poses the risk of real pain & suffering. The main issue I have with his decision is whether dietery restrictions can lower uric acid by 2-3mg/dL. In most cases, I think not; in your case, who knows?
Any doctor who blames a patient for his disease is of no use to the patient.
Flush the jerk ASAP.
?
Perhaps tell him that 20% of doctors are genetically incompetent but the other 80% have to work at it. (I'll bet he won't see the irony.)
zip2play said:
Perhaps tell him that 20% of doctors are genetically incompetent but the other 80% have to work at it. (I'll bet he won't see the irony.)
I would solicit a second opinion from a rheumatologist.? Though many gout risk factors are lifestyle-oriented (e.g., being overweight, too much alcohol, etc) that does not necessarily mean that lifestyle measures are the best ways of controlling the disease. That seems to be the logic flaw in your doc's argument.?
I asked my doc similar questions.? He told me that the majority of uric acid in your body is a result of normal cell metabolism so a perfect gout diet will, by definition, only have a minor impact on your uric acid level.
My GP wanted me to have a second atttack before commencing Allopurinol because there are some people who have one attack and never a second.? That seems like a reasonable approach in that Allopurinol is a powerful drug that you wouldn't want to take needlessly.? But be sure to arm yourself with anti-inflammatory meds like Colchicine and Indomethacin so if a second attack does come you're prepared.?
- You must be logged in to reply to this topic.