Prolonged Frequent Gout Attacks

[Jay Bertuzzi]

Prolonged Gout Attacks Despite Allopurinol

Hi – I was diagnosed with Gout in mid December 2012.? I have probably had high uric acid for close to 3 years, but very few attacks and I had misdiagnosed them as sports injuries.? After being diagnosed, a blood and urine test was taken and the doctor prescribed me 100mg of Allupurinol daily, and provided me with colchicine and Indocin to take for gout attacks.? My uric acid was 11.4 – unsure of the unit of measure, but I’m in the US.

After 2 weeks, with the medication and some diet changes, my uric acid came to 7.7.? After a subsequent 2 weeks my uric acid came to only 7.4; my medication was increased to 200mg, and my blood tested 2 weeks later.? There was no change in my uric acid and I am currently taking 300mg/day.

I continue to have frequent, but somewhat minor gout attacks.? At least weekly, if not more.? Moreover, I have chronic post-tibual tendinitis – which I actually believe is just gout attacks within the soft tissues of my ankle, since tedinitis would have healed over 2 years given no significant further injury/stress.

I avoid high purine foods, I attempt to excercise when I can – although that tends to prompt gout attacks.? I still drink, but almost exclusively wine (no beer) and really perhaps consume 3 glasses of wine 4 days a week, and 5-6 glasses of wine one other day.? It’s still fairly heavy alcohol consumption by most standards I suppose.? I consume at least 2 liters of water daily, typically 3 liters.

With that background in mind, I’m concerned that this won’t really end anytime soon.? I’m curious of others experiences with allopurinal and their initial period of finding a proper dosage and the frequency and intensity of gout attacks during that.? Also, if there is anything else people found which could hasten this process since it is particularly painful and I was hoping to be past it after what is now 2.5 months.

Furthermore, I am concerned that I’m taking a lot of NSAIDS for quite some time.? I’m basically taking indocin daily at this point to either reduce a moderate gout attack, or parlay a minor one from getting worse.? I take 25mg doses, but really find only 50mg to be effective at reducing attacks.? I receive 10 days of medication at a time, which is 30 25mg capsules.? These last me approximately 15 days or so, since I take them as needed.

[KeithTaylor]

Hi Jay,

Your uric acid test results are almost certainly mg/dL, and the safe level is 5. If you have any trouble convincing a physician, ask them to check the 2012 gout management guidelines from the American College of Rheumatology. In some circumstances, 6 is allowed, but that is usually where there are complicating factors such as kidney disease.

7 is too high to get rid of old crystals. I actually believe it is worse than doing nothing. At 7, you are in danger of constant dissolving and reforming of uric acid crystals. Our immune system attacks uric acid crystals whenever it can “see” them, and this happens as they are forming, and as they are dissolving.

I do not recommend doing nothing, as untreated uric acid crystals will continue to spread throughout your body. In joints, they stop new tissue growing to repair bones and ligaments, eventually causing joints to crumble (osteoarthritis). In soft tissues, they cause permanent damage to skin, kidneys, heart, and eventually spread to all organs.

The fastest way to get rid of old crystals is to take maximum dose of allopurinol for six months, then review. If all is well, gradually relax the dose until uric acid levels reaches 5, or slightly below. Otherwise, continue maximum allopurinol until you are free from gout attacks (without pain meds) for 6 months.

I am currently taking 900 mg per day (UK maximum), but the USA maximum dose is 800 mg. That should be enough to get you gout free in a few weeks, but you should arrange monthly blood tests for uric acid, kidney function, and liver function. Once stable, relax the test frequency, but never less than once per year.

I share your concerns about prolonged use of NSAIDs. I used to take ibuprofen, but Indocin, and all NSAIDs such as naproxen, carry the same warnings. Early on in my treatment, I took one colchicine per day, with a second one if I felt an attack coming on. If necessary, I added ibuprofen. I found this to be the most effective way to stop, or relieve gout pain, but after a couple of months on maximum allopurinol, I never needed any pain relief.

I hope this helps. If not, please ask me for any clarification you need.

[Jay Bertuzzi]

Thanks very much Keith, I’ll propose that step-down approach to medication next week with my doctor after my blood test of results for 3 weeks at 300mg.? I had an attack yesterday, so I suspect no significant decrease in uric acid from the change up from 200mg.? And yes, I am experiencing minor attacks 1-2 times weekly at a level of 7.x and it’s been getting quite old, going on 3 months now.

This forum is a fantastic resource, thank you for doing this.

[Keith Taylor (GoutPal Admin)]

Thank you for your kid words, Jay.

I’m astounded by the number of gout patients I meet who are perplexed by prolonged gout attacks, despite doing everything right.

To be fair, the American College of Rheumatology have recognized this, and hope that their recent guidelines will get the message across to frontline medical staff.

Doctors must treat to target. That has too important considerations:
1. Allopurinol dose, in isolation is unimportant. For too long, doctors have assumed that 300 mg is a “standard” and if it lowers uric acid, they do not think about if it is low enough.
2. Uric acid target is vital. 5 mg/dL is the safe level for anyone who has ever had gout. It is the most important number, though some patients may have to settle for 6 if they have other health problems, including kidney impairment.

Hopefully, the message will get spread far and wide, and we can see an end to prolonged gout attacks despite allopurinol, or other uric acid lowering treatment.

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