Serum Uric Acid Levels

[mathman]

Hi – I've been having gout issues for about 6 weeks now.  I had a SUA test during an attack and it was 4.6 mg/dl.  After the attack improved a bit (but was still ongoing), I had it retested and it was 5.9 mg/dl.  My doctor said that this is definitely gout because of its clinical presentation.  He is hesitant to put me on allopurinol, though.  Couple questions:

1.  Can stiffness and mild pain persist after a gout attack?  If so, for how long?  My foot is still a little swollen and hot, and the joint is painful to bend.  But I walk fine …

2.  Has anybody here ever had repeated attacks of gout but has a low SUA level repeatedly?  My doctor says it's possible, but not common.

Thanks!

MM

[Keith Taylor (GoutPal Admin)]

If you are still experiencing pain, your attack is not completely over.

Gout is very sneaky. When it starts you will convince yourself that it could be from a possible injury, maybe stubbing your toe. Dont be fooled. Start some kind of therapy immediatly. If it sets in, your in for some painful days.

Dont stop your preferred thereapy until you are back to 100%. It can sneak right back.

[Keith Taylor (GoutPal Admin)]

mathman said:

Hi – I've been having gout issues for about 6 weeks now.  I had a SUA test during an attack and it was 4.6 mg/dl.  After the attack improved a bit (but was still ongoing), I had it retested and it was 5.9 mg/dl.  My doctor said that this is definitely gout because of its clinical presentation.  He is hesitant to put me on allopurinol, though.  Couple questions:

1.  Can stiffness and mild pain persist after a gout attack?  If so, for how long?  My foot is still a little swollen and hot, and the joint is painful to bend.  But I walk fine …

Ever noticed how some people get a wound and it seems to heal in days, whereas other people take longer? Inflammation from a gout attack is the same. Gentle exercise to keep the blood flowing seems to work best for me.

Also, you cannot discount a second, perhaps milder, attack. As your uric acid level has dropped (common when uric acid leaves the blood to form crystals), it might be that some uric acid crystals are dissolving again and triggering more inflammation.

I know that doctors are hesitant to use allopurinol on first attack, but you still need to get blood tested regularly to monitor uric acid levels.

2.  Has anybody here ever had repeated attacks of gout but has a low SUA level repeatedly?  My doctor says it's possible, but not common.

Thanks!

MM

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It's only possible if there have been periods with blood uric acid levels above 6.8 – the crystals have to come from somewhere.

[zip2play]

I can posit only two situations of a gout attack with low serum uric acid. Severe cold hands or feet, where uric acid becomes extremely insoluble and an inflammatory process that results in an extremely acidic joint (all inflammation is acidic.) And in an acid medium, normally soluble uric acid becomes insoluble at relatively low levels.

So yes, it can happen but it's not common.

A decade ago I read a great article called GOUT WITHOUT HYPERURICEMA, it read like a mystery. I believe it was in JAMA or NEJM. I cannot find a free link to it…but basically a whole hospital was buffaloed by a homeless man who kept coming in with low uric acid but clear gout that responded very well over and over to colchine. After months of this someone soiehow measured the temperatur of his feet when he came in and they were 40 degrees colder than his mouth. The cold feet precipitated uric acid.

[Keith Taylor (GoutPal Admin)]

Very interesting – yes, Gout without Hyperuricemia by Daniel McCarthy in JAMA.

And very surprising: –

At 30°C, however, the solubility of uric acid is only 268 µmol/L (4.5mg/dL).

[zip2play]

Okay,

Come clean…who do you know?

I keep running up against a wall with JAMA!

But thank you for finding it…I'll re-read every word. I read it the FIRST time in the paper version in my doctor's office. I asked if I could take it home and he said sure, nobody ELSE will read JAMA.

I'm impressed with myself for remembering as much as I did…it was 15 years ago so I guess I'm holding Alzheimer's at bay!

EVERYBODY, please read GP's link!

[mathman]

OK, I have an update.  I got my labs back today.  Now, my foot felt 80% or so better when I had this lab test two days ago, and I have a SUA of 6.4.  So here's the summary:

1st test during horrible attack: 4.6

2nd test during attack (about two weeks later): 5.9

3rd test two days ago (during a very brief period of relief): 6.4

Unfortunately, I'm back in horrific pain again.  That's what this will do – it subsides for a little while and then comes right back.  My doctor is hesitant to put me on allopurinol.  But with a SUA of 6.4, plus all my symptoms, is this enough to say gout for sure and that I need to be on a uric acid lowering drug?

What do you folks think?

MM

[zip2play]

MM,

I think your doctor's hesitation against allopurinol will soon vanish. Some rules of thumb are to await the third attack in a year but probably each doctor views it differently. SInce you are at your third attack in a matter of weeks, early allopurinol intervention might be just around the corner. Remember each attack deposits more uric acid that has consequences for a long time. So the fewer attacks before intervention, the better.

If there is still doubt, ask your doctor for an Rx for colchicine and “do the routine” starting today; the method is all over this forum. If it quickly aborts this attack, then go on allopurinol.

Here's something you might try if you can: Since every basic routine blood test includes uric acid, dig out some old blood test results before you started with these bouts (I have all my results back to 1973.)  If you are not quite so diligent go to your doctor's nurse/secretery and have her xerox some results from a year ago, 2 years ago or 5 years ago. Those numbers might be higher than the ones you are seeing now that you are immersed in these repeated attacks. I call this the Agatha Christie approach.

[mathman]

Unfortunately, I don't usually have routine blood tests.  I'm 32, and didn't really do any of this until about a year ago, so I don't have a history of results.

Also, the doctor will not prescribe colchicine because he said there's no proof that they're any better than NSAIDs in the long term.  He also said that colchicine is dangerous because of the quantity of deaths and hospitalizations from overdose.  So I'm stuck with naproxen 3 times a day.

Doctor AND a rheumatologist I've been to say that this is one attack that keeps flaring up – but I've had it for almost 2 months.

This is frustrating.

Thanks,

MM

[Keith Taylor (GoutPal Admin)]

Have you had fluid from the joint tested to confirm this is gout? If not, then treatment is going to be very difficult as you may be treating the wrong condition (and all our advice will probably change)

I'd be very wary of anyone claiming a better long term safety record for NSAIDs (which carry FDA warnings against long term use) against colchicine, a well proven gout pain relief, which has had some bad press because people cannot (or will not) read labels.

I share your frustration, but I'm sure we can move things along. Let's start with a confirmed gout diagnosis.

[zip2play]

Tell your doctor that you don't want colchicine “LONG TERM” just 2 days worth. Ask him if the treatmment he's using to stop your attack will need to be taken “long term”…does he anticipate the attack lasting a year or two?

Basically you are telling him, depending on your country, to GET STUFFED, or to GO F%$ HIMSELF.

If you wish to be gentle with him just say “YOU'RE FIRED” in your best Donald Trump accent.

Your gout is being improperly treated.

Doctor AND a rheumatologist I've been to say that this is one attack that keeps flaring up –

 That's the best line of all…they are telling you that THEIR method, NSAIDS works…and then saying you have one attack that is not reponding to treatment. Did these doctors get their Medical Degrees in HIOGH SCHOOL

 

[mathman]

To answer the questions posed above:

1.  No, I haven't had the joint aspirated.  It's my third toe joint that's the primary culprit, and both doctors have said that those joints are too small to aspirate.  They said it would be painful and that they would not be able to get any fluid out of it due to its small size.  So they say that I have all the clinical presentations of gout, and that through my bloodwork, they've eliminated septic arthritis, cellulitis, rheumatoid, and reactive arthritis.  They say that it has to be gout, even though my highest SUA reading has been 6.5 during this whole time.  Also, it seems to me moving from joint to joint in my toes.  There are days when I have very nearly no pain, and there are days when its excruciating.

2.  Doctor says that colchicine is dangerous.  I think I'll be okay with it, because I'm 6'4″ and weigh 270 lbs.  I don't think that 1 .6 mg pills of colchicine will kill me, but I don't know.  He says that the “doing regime” that colchicine has is dangerous and could land me in the hospital.  I don't know … honestly, he's kind o fscared me into not wanting it because of the danger of overdose.  I'm really conflicted on it.

Thanks agains\ folks, you've been a real lifesaver.  I don't have anybody else in my life to talk to about this, and you folks have been really understanding.

MM

[zip2play]

Colchicine is the oldest drug. The only argument is whether it has been extensively used for 6,000 years or just 2,000 years. Diclofenac is 40 years old.

My best guess is that colchicine has been prescribed perhaps 1000 times as often as diclofenac.

Find a doctor who knows something about gout…your doesn't.

Colchicine can give you the worst case of the runs ever…diclofenac could cause a fatal stomach bleed and over time will almost certainly cause long term gastritis. And the biggest difference: cochicine will probably work but the diclofenac you are taking is NOT. I wonder why your doctors are tellingyou to take a drug while admitting that the drug isn't working. In my book that sounds like the definition of psychosis?

But, it's your call, MM.

[mathman]

One other question about colchicine … will it still work even though I have been in a state of flare up for a LONG time?  I mean, I've heard it works best when an attack just starts.  Will it still work in these circumstances?

Also, how long will the diarrhea from colchicine last?  What I'm getting at is that I have work this week.  Would it be best to wait until Friday?

Anecdotally, I have found that eat a full pound of strawberries helps significantly.  But if I don't do it every day, the pain comes back.  I've experimented on and off with them … I find this very odd.  It's not a 100% cure, but it helps.

Thanks again,

MM

[zip2play]

mathman,

You are right: colchicine works best, fastest, and at the lowest dose the earlier it is started. After a long attack you need the full whammy!

My worst flare in the big toe was allowed to go without treatment, except for some low dose indocin which I had on hand which proved totally ineffective, for a full 9 days virtually bedridden before colchicine treatment was begun. THus, unaware of the 16 pill sensible upper limit, I took 22 before the diarrhea began and the pain stopped in 45 minutes afterwards.

 The diahrrhea is so severe at this kind of dosing that after a few hours there is nothing left in you. Drink lots of water to avoid dehydration and when coffee colored water is all that comes splashing through, that's pretty much the end of it.

Remember though, stop at 16 pills. Stop at the onset of diahrrhea or the cessation of pain.

Figure 24 hours after the diahrrhea before safely wearing a white suit…stay close to home.

Next attack you feel starting, take 2 colchicine immediately…if it works, fine, If not, take 2 more. THat should do it. At 2 or 4 pills, you'll feel only the slightest laxative effect the next morning…like after eating a cupful of prunes. 😀

[mathman]

Well, I have an update, and it looks like it might be my final one.   I got a work-in appointment with the chief of rheumatology at a local hospital today.  He told me after a thorough examination of my foot, considering that I have pain in about 6 joints, that it's NOT gout.  He's thinking reactive arthritis or ankylosing spondylitis, since I have back problems.  He says that the multiple joint involvement like mine and the fact that my SUA is only 6.5 is strongly indicative that it is NOT gout.  Unfortunately now, my treatment cycle is going to be much harder.  He's trying Celebrex for three weeks, but thinks it's likely going to require methotrexate or a drug that controls rheumatoid arthritis.

Thank you for all your help and encouragement – this is the nicest online community I've been involved with – very kind and helpful.

Take care,

MM

[zip2play]

Get a second opinion! A competent doctor does not make a diagnosis of rheumatoid arthritis or ankylosing spondylitis (a progressive degenerative disease of the spine and ONLY the spine) by default.

 Doctor says that colchicine is dangerous.

Methotrexate:

http://en.wikipedia.org/wiki/M…..thotrexate

I am glad if you don't have gout and multiple attack sites makes gout unlikely, but make sure they give a proper diagnosis BEFORE they start prescribing useless NSAIDS (Celebrex) or potentially deadly (methotrexate) drugs for “maybe this, maybe that” guesswork.

ANy competent rheumatologist should be able to differentially diagnose rheumatoid arthritis from ankylosing spondylitis. Someone who cannot is not competent.

Gout is rather remarkable in that it will not be nay-said. A million doctors can say NO but eventually the answer comes screaming through with THE TOE FROM HELL. Gout ALWAYS has the final word. Everyone with untreated gout will eventually get PODAGRA.

So perhaps the best way to diagnose gout is to wait for that first UNDENIABLE attack. It's how I found out for sure.

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