Tendinitis and gout

[kryptonium]

Hi all,
I had my first gout attack 5 years ago with a classic podegra attack (at the time I thought I was bitten by a spider), it was followed the next few years by 1/year events in other joints of the feet. In the last year have had about 5 or 6 attacks, but only 2 in joints. I had one in the ankle and jumped to ED where a tissue fluid sample showed UA crystals.
Several attacks have been above or below the patella, and at the moment my wrist is affected and quite swollen but it seems to be the extensor fascia/tendons rather than the joint. The doctor agreed with this. I am normal weight, 37 and even with little meat in my diet (and never red meat or shell fish) I have not been able to control it so started allupurinol this week at 50 mg (targeting 200 in a few weeks), since my wrist is still swollen.
My questions are:

Is it ok to start allupurinol at this low dose even though the wrist is not completely recovered? It is swollen and hurts to move, but no pain unless I move it quite a bit. I just want to get started as soon as possible and doc was ok with 50, but I am not sure he has that much experience with gout.

Do other people have these tendinitis/busitis presentations? From my googling they seem rare – any thoughts/knowledge on this?

Last year I had tendinitis on the infrapatellar ligament. Sometimes I can still feel a slight pain from this area. Is there any hope allupurinol can help with this?

Thanks in advance and good luck to other sufferers out there!

[Keith Taylor]

Do not target 200mg allopurinol. Target a good uric acid level, and accept whatever dose that needs. Some will say 6mg/dL is a good target – it is certainly your maximum. I prefer 5mg/dL, and this is becoming the new standard.

Those targets are good when you have got rid of all old uric acid deposits. They will dissolve quicker if you get levels lower, which is why I am targeting 2 to 3 for a year – I want the tophaceous lump on my arm gone. My point is, at the risk of repeating, set the target, and that will define the dose.

Doctors frequently advise not starting allopurinol during a gout attack, but the evidence to support this is weak. If you are taking colchicine, which I recommend when you start allopurinol or febuxostat, it will be OK – especially with only 50mg allopurinol, which is almost certain to start some scathing comments from other contributors, because it is too low to have much effect. It will, however prove that you can safely tolerate allopurinol, which is good.

There are two forms of gout googling. One is the standard use of google, where you type gout terms into the search engine at google.com. The better one is where you type gout terms into the search box at the top of this page, and all GoutPal pages. The first choice is polluted by self-serving misinformation promoters. The second choice is pure gouty goodness that will lead you to many an interesting page on tendinitis, bursitis, and other conditions that are related to gout. It is complicated, but needs individual case-by-case study. Uric acid deposits from gout can cause destruction of cartilage, tendon and bone. Tophi can block bursa. They can all co-exist from different causes. Best to get the uric deposits cleared ASAP, then if sore joints continue, the medics can look for co-existing conditions and treat them.

This is similar to my view on allopurinol. I have a knee injury, but I also have gout. I am maxing the allopurinol in a desperate attempt to dissolve all the old deposits as quick as I can. That takes gout out of the equation, so if I still have a knee problem, I know it is damage that may need surgery to fix.

[kryptonium]

Thanks for the informative reply and this excellent forum.
What I meant was we target 200 mg and then assess with blood tests. I just read the national guidelines here and that also seems to be what they suggest. Thanks for the site specific google tip too, very useful.

[BelieveInScience]

kryptonium,
I share your “unusual places” syndrome. I have never had an attack in my toe. I have had them in my feet (multiple locations including soft tissue), ankles, Achilles tendon, wrists, and knees. Many of my attacks are mild, however, my attacks from hell have taken place in my knees and lasted for 6-8 weeks before I knew what to do about them. For many years I thought I was going nuts, or some sort of hypochondriac.

I started Allopurinol about two months ago. I did 2 weeks at 100, 2 weeks at 200, and have been on 300 for one month now and am down to ~4.0 mg/dl. 10 days ago I had my worst attack in a long time, and it was in my foot. It went around my arch and sort of through my ankle. I was able to kill it in 24 hours with large cholchicine doses, but holy sh*t was it bad.

I am flare free at the moment, and about 2 months into Allopurinol. I don’t know if I am done being attacked, or if I have more to come. But, and this is a big but (hee hee) I used to get really upset about flares when I had no idea what was going on. Now, I know it is part of a path out, and the flares lack the mental beating they used to provide me with. Big difference.

My thought for you is to get your dosing up and your SUA down as soon as you can and get it over with. Have cholchicine on hand.

Good luck,
BIS

[Keith Taylor]

kryptonium said

…
What I meant was we target 200 mg and then assess with blood tests. I just read the national guidelines here and that also seems to be what they suggest. …

Where in the national guidelines does it suggest that? It is seriously wrong, and if that is what they are saying, I must write and correct them. The target is the uric acid level. The dose is a transient stage during titration to reach that target.

Sorry to bang on about this, but it is the most serious aspect of uric acid lowering treatment, and the most significant point of failure.

[kryptonium]

Thanks for the support BIS and best wishes you will be attack free from now on! Yes it is funny how at least knowing the cause of something does ease anxiety a bit.

I was a little quick with “national guidelines” Keith. What I had googled (in AU) was this one http://bjchealth.com.au/how-to-use-allopurinol-in-patients-with-gout/
I think this is aligned with your views. So when I say target, I mean the “preliminary target” before the first blood test. The next target is then decided by the SUA of the test.

[Keith Taylor]

Amazing link. It is written in a very similar style to mine, yet has serious errors. I think I’ll rewrite it properly.

Never confuse targets (purpose/rewards/objectives in my vocabulary) with strategies. You are certain to lose your way.

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