Im a 45 year old Male with gout, my father (past away last year, 72) had one of the worst cases that any of the doctors had ever seen (toes, feet, ankles, knees, fingers, wrists, hands,?elbows -many at the same time). About 8 years ago a got the gout in my knee (some of the worst pain?I have ever felt), they prescribed indocine and the flare was gone in about?2 days. After that?I didnt have any problems for about 3 years, then?I started to get flares in my feet and ankels, I would take indocine when I first started to feel pain and this worked well.?Since?I didnt have a GP (used walk in clinic), all they ever did was treat the symptoms with Indocine?and not the cause. So all?I did was take the indocine every time?I had a flare- and it did work well for me. I have just recently started seeing my fathers doctor (UA level 9.75), and he has perscribed 300mg Allapurinol once a day, I have been on the allapurninol for about 2 weeks, a few days ago I got a pretty good flair in my left wrist/thumb area (never had it here before), and this morning I started feeling that familiar pain in my left knee (have only had it once in the knee- not fun)- This is not at all good because?it can put me out of action and unable to work.
I have a few questions:
-I know that when starting Allapurinol there is a chance of flares, Do?I stop taking the Allapurinol and wait to restart after?I am better? (I ask because this is what a ‘specialist’ told my father to do)
-From what I understand when the Allapurinol lowers the UA level, and causes the built up crystals to melt, and this causes the UA levels to rise back up and partially cause the problem?I am having now, If this is the case?is there any way to estimate how?long?it will?take for this roller coaster to level out?
-I have seen a post on here describing Coltracine and a NSAID? My impression is that Coltracine works because it lowers your white cell count making it harder for the white cells to attack all of the crystals, is this what NSAID’s do also?
-When?I have a bad attack?I take?Coltracine,2X .6mg twice a day until the?diareaha starts, then?I stop the Coltracine and switch to Indocine (2X 50mg?twice a day- yes it is a large dose, but seems to be the only way to stop a flare semi-quickly). Can?I take both at the same time?
Thank you for any replies,
Neil
Hi Neil,
First-off, you are not seeing a good doctor, and the ‘specialist’ your father saw was a useless fool.
1. Never, in all it’s history has anyone ever advised stopping allopurinol during a gout flare. It is absolutely the worst thing you can do. Experts used to recommend (and some still do) not starting allopurinol during an acute gout attack. However, a study last year proved that it is perfectly OK to start allopurinol even if you are having an attack. This is good, because the sooner you get uric acid under control, the better. You will need pain relief, and I’ll come to that on q3 & 4
2. Your explanation is partially right, and melting uric acid crystals will push up concentration in the blood. This is why some experts recommend adding probenecid to encourage uric acid excretion. That is usually only necessary if tests show that you are not excreting enough. You need to make sure that you are drinking enough fluid to pee around 2-2.5 liters per day. The amount you drink to do that will vary according to the weather and your exercise. Even better that water, is skim milk, as this promotes uric acid excretion.
The main reason for gout flares is related to the white blood cells you mention. When the crystals formed, white blood cells engulfed them, hiding them. As they start to dissolve, the coating falls away, exposing them to the immune system again. This is why it is so important to get uric acid as low as you can.
The absolute maximum for your uric acid is 5 mg/dL. However, that is what you should aim for once the flares stop. For the first few months, I believe that you should max out on allopurinol, and I persuaded my doctor that this was the best way forward. Doing that makes the rise in uric acid levels that you mentioned insignificant. It minimizes the effect of dissolving crystals that I mentioned. It reduces the amount of time to get gout under control, and it smooths out your “roller coaster”
To give an estimate of how long it will take requires a lot more information about your uric level history. It is basically a question of how much uric acid has built up round your body, and how low you get your uric acid.
In my case, I had at least 16 years build-up, and I got my uric acid level down to around 2 mg/dL. Serious flares stopped after two months. They reduced in frequency and intensity over the next 3-4 months. After 6 months they had stopped completely, and 18 months later I have not had one, though I still have one visible tophi on my elbow. It is not painful, and appears to be shrinking very slowly.
Other people have reported continuing flares for longer – they simply did not get low enough.
3. Yes, colchicine lowers white cell count, as it inhibits natural cell division, so new white cell production is lower. It does not ease existing inflammation, and it does not block pain signals, I supported it with NSAIDs (specifically ibuprofen) because they do reduce inflammation through a completely different process, but they do not block pain. General pain-killers, e.g. Tylenol/paracetamol (acetaminophen) will block pain, and there are lots of other choices. Therefor, a 3 line strategy for stopping inflammation spreading, reducing inflammation, and blocking pain means you should never have mobility issues with gout. If your doctor does not understand this, you could try talking to a pharmacist who might advise what you need.
Anyone reading this who is not taking uric acid lowering medicine should note that this is not a long term solution. It is dangerous to take colchicine or NSAIDs for more than 6 months. If you have been doing so, get a medical checkup immediately.
4. Please stop playing about with your own pain relief combinations. Colchicine knocks out your immune system, and is a frequent suicide option. Maximum is 2 X 0.6mg per day. Indocin overdose may rip your guts to shreds, if it doesn’t give you a heart attack first. Maximum is 50mg 3 times per day. The answer, as I mentioned above, is to back those with a painkiller that is compatible with NSAIDs. Pharmacists are usually a good source of info, as they focus on meds every day. If you are still in pain after the three way pain treatment, then best get to ER because it is probably something other than gout.
I hope that helps, Neil. I have an appointment now, so I’ll get back with some reference information to backup what I’ve said. You can use that to train your doctor. However, you need to book a uric acid test today, and be sure to include liver function and kidney function tests,
That’s an amazing reply Keith.
I hope it educates Neil as much as it has me.
I too was of the impression that I should stop allopurinol once an attack starts, despite me not being able to reason out why that would be in my own mind.
Just goes to show that the average GP know little about Gout.
And the 3 line strategy for dealing with an attack is also an eye opener. My mind-set has been to simply write off a day or two where I lose all mobility that doesn’t involve me crawling on my hands and knees around my house.
Thank you Keith for all of the great information!
Looks like I need to back off on the indocine/coltracine, this is a good example of what risks people are willing to take to stop/prevent pain, but dying isn’t the way I wanted to accomplish this haha.
On a positive note- I think I caught the flare in my left knee in time, it hasn’t started to swell and the stiffness is almost gone (time will tell) – my wrist is still puffy and stiff but the pain is almost gone (woohoo!)
As for the Allopurinol dosage, It makes complete sense that a larger dose should be taken during the first part of the treatment, but I am going to get the Liver/Kidney tests done before I increase above the 300mg a day – I could increase now, as I have an ample supply, but I will play it safe on this.
I am verry happy that I found this forum, it may be a life saver (Literally!)
Many thanks – Neil
Thanks Keith. Just read your post above & let me tell you it is the most informative thing I’ve ever read on my condition since I first became a sufferer 10 yrs ago.
I’m in a similar situation to Neil. I am 50 and started having gout attacks when I was 40. Very infrequent at first – but recently I am getting them almost every month. After my last attack I finally agreed to go on the allopurinol – starting on 100mg per day but with a view to increasing slowly up to 300mg per day.
However when I increased my dose from 100mg to 200mg it triggered an attack (which I am still having) although it seems to be easing off a bit now. I immediately reduced my allopurinol does back down to 100mg whilst I try to get rid of the attack symptoms with the usual NSAIDs diclofenac & naproxen. But from what you are saying I need to get up to 300mg (or more) as soon as possible? Even during a gout attack? I am determined to get rid of my gout once and for all and finally be free of it (like yourself) so any advice you can give me would be greatly appreciated.
Best Regards
Ivor