Two Attacks After All This

[Keith Taylor (GoutPal Admin)]

I am a recently retired 61 year old physician with a family and personal history of classic gout.  My first attack was on my 50th birthday and until a year ago was always at the base of my right great toe.  After some heroic repetitive step climbing I have started having attacks in the distal ball of my foot.  Here is my sad tale of woe:

I had not had an attack for at least 6 months or more when my internist decided to check my uric acid level–it was 11 (upper limit 8 in this lab).  He felt that even though I was asymptomatic, that it was important to get this level down.  So he started me on allopurinol.  Well I was one of those for whom this precipitated an acute attack.  And not just that, but rather a revolving on and off attack that would recur each time I stopped NSAIDs.  After three months of this, I reluctantly started on colchicine, which suppressed the attacks completely.  After 6 or so months of colchicine, and with my uric acid level down to 5.3, the colchicine was discontinued.  Six months later, another test showed uric acid again at a wonderful 5.3 level.  My doctor called me and told me, “Congratulations!  You will never have another gout attack in your life time.”  This was the kiss of death as 4 hours later another attack started.  The only possible precipitating factor that I could grasp at was that I had recently stomped on an insect in my basement–so there was minor trauma to the joint.  My internist said that this was still pretty unusual and may in fact be pseudo-gout.  He treated me successfully with naproxen and within 2-4 days things were fine.  But one month later, without history of trauma, the attack recurred.  It responded just fine to naproxen again, but I felt that I had gone through a year of agony with the allopurinol (still on 300 mg throughout this) and find myself still in an unpredictable situation.  The only odd thing I had done differently before this last attack was that after a friend gave me 2 dozen freshly laid eggs, I hard-boiled them and while my wife was out of town for 5 days, I ate a LOT of them.  I must have had a dozen at least in that time.

Now I find little about chicken eggs being a problem with gout, as they are supposedly low in purines–but my uric acid has been low, so I don't think I'm dealing with that issue here.  I believe that I've done enough damage to these two joints that they are likely prone to arthritic flare-ups on their own and that maybe this IS in fact pseudo-gout.  I do take Vitamin D (2000 IU a day) and I have 4 Tums tablets a day.  My serum calcium was 9.4 at last measurement.

If you have any ideas, vis-a-vis what I'm dealing with, causes, treatment, prevention etc.  I would be most appreciative.

Thanks in advance for your help,

Mjrisk

[Keith Taylor (GoutPal Admin)]

From your descriotion, it is clear that you have gout. The 2 big questions are:

1. Is the gout under control?
2. Do you have a co-existing condition?

The first, as there is doubt, requires frequent uric acid tests, and confirmation that uric acid is staying below 6mg/dL. I think every 6 months is not enough until you are without attacks for six months. Maybe every month or two, then gradually relax if the level stays low. If it creeps above 6, you may need to increase the dosage and temporarily increase test frequency until you get back to a stable state.

Remember, even though your hyperuricemia has been described as asymptomatic, the reality is often that you have experienced a long slow build-up of uric acid crystals. It sounds like these are now making there presence felt, and may take some time to dissolve completely.

Other conditions are not uncommon with gout. The only way to be sure is to examine fluid from the joint, usually by a rheumatologist. This might reveal pseudo-gout or perhaps an infection, or perhaps something else. It will also confirm if there are still uric acid crystals in the joint.

[zip2play]

mjrisk,

Here's what I think might be going on. You imply but do not state how long you went with gout attacks (and a presumed uric acid over 10.)

 If this went on for YEARS, you laid down a LOT of urate.

 It responded just fine to naproxen again, but I felt that I had gone through a year of agony with the allopurinol (still on 300 mg throughout this) and find myself still in an unpredictable situation.

Why “a year of agony with allopurinol?” It implies you spent 10 years with untreated hyperuricemia and only last year began allopurinol? THe agony part was the recurrent attacks, right”

If the colchicine-allopurinol worked well and you started having atacks again after stopping colchicine, the indication is that you have lots more urate to disperse.

Here's what I woulod recommend…take 400 mg. allopurinol (to get your uric acid into the 4's and take low dose colchicine with it for a reasonably long time.

In a nutshell, untreated got at uric acid of 11 for a full decade has probably become almost chronic gout. Do you have any permanent, prominent tophi? For that you need a pretty long time and probably a lower uric acid than most.

Another consideration for EXTREMELY low uric acid levels to flush maximum urate is to add probenecid to your allopurinol …that might cut down on the need for colchicine because probenecid has the propensity to quickly dispose of any uric acid freed from dissolviong tophi before it can find another joint to torture.

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