My Story – please Advise!

[Luke Haymond]

I have dealt with annual gout flares with indomethacin 50mg 3x/ day with great success – typically resolved after first dose. Current flare first occurred in ankle – indo handled, but immediately moved to knee. Having never experienced in knee – I did not recognize as gout and delayed treatment for close to a week. Began treatment with indo and treated with ibuprophen for a couple of days before making appointment with GP for indo refill. She prescribed colcrys .6 mg 2x/day along with 50mg indo 3x/day. I have seen no improvement on my third day of treatment today. I have read the forum, but still have these questions:
1. Is it unreasonable to expect results at this point – if so, how long do I continue with this treatment
2. if there is a better route what modifications should be made and when
3. Prednisone, increase Colcrys – something else

I’ll research lowering/monitoring my uric acid levels going forward, but would like to get back to my active lifestyle ASAP – I am an angry sloth!

Please help ASAP

Thanks
Luke

[Luke Haymond]

UPDATE – Keith – I just heard from my GP and they are calling in a prescription for a “steroid pack”. They also reported a uric acid level of 7.2 – mind you this was taken prior to any colcrys.I am completely onboard with taking steps to monitor and reduce my uric acid level going forward – first things first…. does it sound like we’re doing all we can to get me over the current bout? When should I expect results from indo+colcrys+steroid pack?

I guess you know how helpful you are to us gout neophites?!

Best,

Luke

[Keith Taylor]

Colcrys (colchicine) is good to stop inflammation spreading, but it doesn’t do anything for existing inflammation.

Indomethacin or ibuprofen are good at reducing inflammation. Note that they are both Non-Steroidal Anti-Inflammatories (NSAIDs), and should not be taken together. NSAIDs often reduce pain as they reduce inflammation, but there are also pain-blocking analgesics to consider.

For severe attacks, analgesics that complement NSAIDs can be useful. It is important to consult a doctor or pharmacist to make sure the combination is safe.

It can take a week to 10 days for bad gout attacks to subside, and you never know if a second attack might prolong the painful inflammation.

Many doctors swear by prednisone or other steroids. I swear at it, having seen bad side effects in other people. It’s a personal choice.

Other things to consider, are protecting affected joints from the cold, and staying hydrated. Dietary improvements that lower inflammation might help. This is a difficult area to get good facts, as there are an awful lot of people selling snake-oil products that have no affect. They get noticed because inflammation will resolve naturally in a few days, even if you take nothing. Switching saturated to unsaturated fats might help, as might turmeric.

I’m a firm believer in gentle exercise to ease gout pain. I proved to myself over many years, that attacks did not last as long if I pushed myself into walking, or similar stress-free activity. It might be the last thing you feel like doing, but that is why you need the combination of colcrys with gout-strength NSAIDs and sufficient pain-blocking treatment.

[Keith Taylor]

I spotted the update before I posted my last response, but I think it is valid.

For all gout sufferers, we need effective uric acid control that brings it safely to 5mg/dL or below. But, we know that this can take months to reduce the years of old uric acid crystals, so we need effective pain control.

The best pain control knowledge comes from nurses in hospitals. They understand the need to provide appropriate combinations.

Appropriate means “right for you.” As I said above, I won’t touch steroids, yet they make gout bearable for other people. It’s about being flexible until you find what works for you, and having a doctor who will work with you on this.

The principles for gout pain control are:

1. Stop inflammation spreading as soon as possible. That means colchicine at the first sign of gout, or as a daily preventative during first weeks of uric acid lowering.

2. Reduce inflammation. Doctors have hundreds of options. Find the one that has least side effects for you.

3. If pain still unbearable, block it with appropriate analgesics. Again, you need to find the one that has least side-effects from the hundreds of options.

So, Luke, if the indo+colcrys+steroid pack works for you, celebrate it with a walk. Then, when you feel ready, get that uric acid down. Despite some common attitudes, there is no need to wait until your attack concludes before starting allopurinol or Uloric. They will not make your current attack worse, and the sooner you start, the faster you gain complete control.

[Luke Haymond]

Keith – After one day of steroid pack – I am seeing significant improvement – pain down from 8/10 to 5/10. I have been convinced that I need to surpress my UA levels to less than 5mg/dl to purge my system of hibernating crystals.

1) I have read a fair amount of information on Uloric vs. Allopurinal, but can’t quite understand your apparent preference for Allopurinal beyond price (which is enough of a reason, I would just like to be armed with any additional rationale prior to having the conversation with my GP). Any additional selling points?

2) Assuming I begin the reduce UA effort – i should expect a flare response, right? Are there some of us that have not had negative fallout?

3) If fallout is all but guaranteed – all the more reason to start while the steroids seem to be addressing my pain, right?

4) Finally – you seem to be big on activity. When I am not gout stricken I am in the gym three days a week – Crossfit (burpees box jumps, pushups, running stairs etc) and tennis on the weekends. Is it your position that I can resume my activity as soon as I can tolerate the discomfort?

Thanks for all your guidance

Luke

[Keith Taylor]

Luke, my main aim is to help you improve your relationship with your doctor so that you both work together for the prime aim of maintaining your general health the best it can be, and getting you a personal gout treatment plan that is carefully matched to your circumstances.

Many visitors don’t have that relationship. I can offer some general advice on the best way to manage gout. Please do not mistake this for professional medical advice. You must discuss your concerns with your doctor. If you do not know what to ask, I can help. If you do not understand your doctor’s responses, I can help.

I would far rather you asked these questions of your doctor, then report back here with responses, comments, and questions. That makes sure you are getting useful advice from your doctor that respects latest gout management professional guidelines, and respects your health history.

Having said that, my responses to your 4 specific questions are:

1) Allopurinol has almost half a century of safe uric acid management – Uloric is still being field-tested. A doctor’s response to the Uloric vs allopurinol question often tells you more about the quality of that doctor than anything else. Above all, the answers depend entirely on the patient. The general rule is to prefer allopurinol first, and consider Uloric if there is a history of allopurinol intolerance. Uloric might also be considered first for patients of Han Chinese, Thai, or Korean descent. Both allopurinol and Uloric might have side-effects. Uloric’s tend to be liver-related. Whichever uric acid lowering treatment is prescribed, it is only correct if backed by appropriate blood tests. Test frequency is patient-dependent, but must be at least once per year. Blood tests must include kidney function and liver function, as well as uric acid. Reliable old faithful, or hot new thing in town? It depends on the patient.

2) Reducing uric acid is likely to trigger occasional flares, but not certain to. Uric acid lowering treatment without provision for some form of pain treatment is a sign of a bad doctor. Patient preference should determine if pain control is daily preventative or as required.

3) No, that is not right. Nor, is it wrong. Just inappropriate logic. You should start uric acid lowering treatment asap because that is the right thing to do to minimize further joint damage. The fact that you are already taking pain control might be a bonus, but not a good basis for determining a medical procedure.

4) I recommend activity commensurate with a healthy lifestyle. To me, that involves walking in preference to driving, with public transport somewhere between. It involves partaking activity that promotes physical and mental well-being. Social sports, or helping in community projects are useful ways to incorporate gentle exercise into your daily routine. In my experience, that helps gout recovery. Some studies also indicate that regular exercise is associated with lower uric acid, so good for long-term. Tennis sounds great. Gyms are not my style at all, but I respect the right of anyone who enjoys a gym workout. I’m far from an expert on gym matters. The goal for a gout patient is to maintain strength and mobility whilst avoiding excess muscle-mass. My son-in-law is a highly-regarded personal trainer, so I should find the time to talk to him about the best gym routines for gout sufferers. The key points about exercise are:
a) Exercise that encourages blood flow to joints is good.
b) Exercise that helps maintain BMI below 23 is good.
c) Exercise that builds muscle mass (a rich source of uric acid) is bad.
d) Exercise that stresses tendons, cartilage, and bone joints is bad, as these are weakened by the presence of uric acid crystals.
As with gout treatment plans, exercise plans must be tailored to the individual. A good personal trainer should understand the 4 important points about exercise for gout patients, and develop a suitable plan. You need to be aware of the risks of joint damage, and not assume that pain whilst exercising is part of the process. It could be a sign that gout-weakened joints are suffering. Discuss this with your doctor, as it might be wise to get x-rays, ultrasound, or other scans of your joints.

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