Looking for some advice, thanks.

[Mike Rumble]

Hello all,

I’m a 35 year old man living with gout for the past 3 years. The diagnosis was made 2 years ago and I’ve seen an increase in attacks this year, particularly in the past 3 months. My attacks have always been in the right great toe.

Late 2012 – attack (probably second attack, this was pre-diagnosis)
Oct 2013 – attack during evening away from home, typical nocturnal onset – went to local ED & given Indomethacin – Uric Acid 478
June 2014 – attack, treated successfully with Indomethacin
July 2015 Uric Acid 473 (weeks after resolution of symptoms)
April 2015 – attack, treated successfully with Indomethacin
September 2015 – attack, treated successfully with Indomethacin
–Returned to primary care physician for refill of Indomethacin, prescribed Colchicine
Oct 2015 – mild attack, taken Colchicine ~ 10 days of aching pain after acute attack
November 16 – today – ongoing mild attack, Colchicine taken at outset, multiple NSAIDs taken on days of greater pain, now progressing into right ankle.

I’ve changed my diet and become a vegetarian, reduced alcohol intake (although I was never a big drinker). I don’t drink sugary drinks that often (I take my coffee black). I don’t tend to drink enough water and have a BMI of 32 with 44″ waist. I have a high stress job with periods of inactivity. I’d like to make lifestyle changes but this is more difficult when my foot hurts. I have a family history of what I’m told is debilitating gout on my mother’s side (her brother and, presumably her late father).

My concern is the increasing duration of the attacks and now the progression into the ankle. At what point is Allopurinol indicated… am I headed to that anyway and should just jump on it now to reduce long term effects? I worry the high dose NSAIDs will cause stomach problems/ulcer. Am I just cursed with bad genes, or is there hope to get back to a point where my body can break down the uric acid again?

I’m going to spend some time browsing this site, as I figure someone else has had the same questions but I figure I’ll get my thoughts out now.

[Keith Taylor]

Hi Mike, and thanks for taking the trouble to post your gout history. You’ve given me sufficient facts to paint a clear picture, and one that is familiar to many GoutPal members.

At what point is allopurinol indicated?
The professional recommendations indicate that uric acid lowering treatment is not necessary if you have less than 2 attacks per year, and no visible tophi. Tophi are often quite difficult to detect when small. As with all recommendations, this is a general guide that must be considered in the light of specific patient details. So, the recommendations certainly include you as a candidate for uric acid lowering, and allopurinol is the usual first choice.

With a family history of gout, I would be tempted to say, allopurinol should have been started one or two years ago. As you can see, gout has got progressively worse, and that was predictable.

There are sometimes reasons why allopurinol might be delayed. All these reasons relate to eliminating things that might be causing high uric acid, including:
1. Certain drugs for other health problems
2. Environmental factors such as exposure to toxins
3. Bad diet

Mike, I don’t think the first 2 factors apply to you, but the third one clearly does.

Now, some people believe that delaying allopurinol while you try to correct your diet is a good thing. I used to think that way, but I know I was wrong. When you think this through, it makes no sense to delay treatment.

Let’s say that diet can eventually cure your gout. Even at it’s best rate of performance, it will take years of extreme food and lifestyle adjustments to get from 473 down to 300. I doubt this is actually possible, but let us say that it is. Let us also be generous, and say that you can achieve this in 5 years. That would mean that uric acid crystals are still building up for at least 4 of those years. That’s 4 years of agony that you do not need. Because I’m an idiot, I delayed even longer, but my joints are suffering because of that.

It makes absolute sense to start allopurinol now. If it is managed properly, that will get rid of old crystals, and allow your joints to start repairing themselves again. That allows you to feel good about exercise, and gives you a better chance of improving your lifestyle. Once you are in control, you can reduce allopurinol to maintain uric acid at 300. As you improve your diet, you will be able to reduce your allopurinol dose.

We do not know, at this time, if you can ever reduce allopurinol to zero. But now is not the time to worry about that. I hope I’ve proved that you must use allopurinol to dump the damaging crystals now. That gives you your best chance of minimum allopurinol in future. It also minimizes your exposure to NSAIDs.

Mike, you’re not cursed with genes that give you gout. You’re blessed with genes that give you the intelligence to control it. Let’s start fixing your gout.

I’m here to help, every step of the way.

[Author]

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