First time gout flare up - lots of questions

Foot care
1

Hello everyone,

Last Wednesday, I had my first severe and debilitating gout flare up behind my left toe. I had to call in to work for a couple of days, and I saw my GP for a blood test. He started me on indomethacin, but it feels like it didn't help with the pain, or inflammation.  I returned to the doctor today, and he is referring me to a rheumatologist, and switching the medication to prednisone. I haven't been formally diagnosed, but he said that "it sure looks like gout". My uric acid level was 9.4mg/dl on the first day of the flare up, and it dropped to 8.7 two days later. 4 months ago, my UA was 8.3mg/dl.

Hopefully, the rheumatologist will take some time to discuss this with me, but I still can't quite wrap my head around why this is affecting me. I'm relatively young, don't drink, don't smoke, don't have diabetes, and I don't have an extreme diet. I'm not in perfect shape, but I'm not obese. I don't currently exercise regularly, but I walk regularly with my job. I am however guilty of eating food with preservatives, or easy to cook food.

I know that some people just get bad luck, but I question if something else is going on that could have caused the gout. Could gout be caused by a kidney problem? Should I ask the doctor for any additional tests to determine if any other conditions might have caused it?

The doc wants to put me on allopurinol once this attack is over.  I think I recall reading that some people suggest alternative treatment methods before jumping on allopurinol for the first time. Can anyone explain this logic?

Finally, is it normal for the bruising to migrate away from the joint? I'm on day 5, and I noticed a new bruising/red skin on the outside of where the metatarsus is. It almost follows the bone. It's hard to see in normal lighting, and I can see it better when the lights are dim. See the attached pics. The dark line running along the contour of the arch is not a shadow - it is a red bruise.

2

In most people (90%} gout is caused by genes and aging. The classic gout sufferer is a man in 40s or later, but some get it earlier. (10% is caused by overproduction of uric acid but treatment is pretty much the same). At 9+!during an attack - that's a very high level as the attack reduces the level of urate in the blood. Is it caused by kidney problems - yes, probably. It's an imbalance - the kidney both removes uric acid and pulls some back... the system gets out of whack. You can help your kidney by drinking water - lots - and not drinking alcohol - which causes dehydration. If you have a problem with alcohol then you need to address that. Another thing you need to stop is sugar - especially high fructose corn syrup and soda drinks is the way to get lots of sugars without knowing. But many people (inc me) don't drink soda drinks or sugar, don't drink alcohol, and still got it (aged 55). Vegetarians get gout so it's not the diet - but certain foods may trigger an attack in some people.

Allopurinol simply breaks down the uric acid into a form that makes it easy for the kidney to eliminate. My experience and most people is take the allopurinol and life goes to normal except you need to drink a bit more water.

Be aware that allopurinol will cause gout attacks for a few months as excess monosodium urate is slowly flushed from your tissues. There are other things you can take to knock those flares on the head just as the begin e.g. Colchicine.

The problem with gout is not the pain, although that can be debilitating. The gout is a symptom of hyperuricemia i.e. Too high blood urate. Too much monosodium urate in the blood causes inflammation as the white blood cells feel there's an attack going on somewhere but they aren't sure where (this is the Mickey Mouse version btw). Long term this inflammatory response does damage - the most obvious is in blood vessels, leading to very high levels of heart disease in untreated hypericemia. You need to not just stop the flares but treat the underlying disease.

You will hear that you can stop gout flares by excluding purines in the diet, or eating cherries or whatever - but you need to address the high blood urate - and 85% of the purines (the precursor chemical for the uric acid) come from your body daily recycling your own cells not your food.

As for allopurinol - most people take it with no problem. The way to look upon it is the same as a diabetic takes insulin.

Finally there is a small chance that the gout is caused by another underlying illness - but it's a small chance. As doctors are taught - the common stuff is common - and about 4% of men have gout.

There is also a small chance that you'll never have another attack - I'd hope for that perhaps. But if your blood urate remains high then you need to solve that for _*long term* health.

Good luck and I'm sure your rhumatologist will explain it all.

In the meantime drink loads of water. Some people find keeping the toe in ice cold water helps other very hot water other mixing both.

Oh yes - the discolouration you describe sounds normal in gout.

3

Sorry to jump on this thread. I was told by a rheumatologist that some people can have a high Urate throughout there lives but never have a gout attack. Does this mean that they are in the same catagory for heart desease than someone who's had an attack?

If so it's almost like a blessing in disguise if that's the case

4

The rheumatologist was correct. As a whole men tend to have higher blood urate than women, and it tends to be excessively high in men (women are protected till menopause)...until recently there is no clear academic research indicating if hyperuricemia alone is bad and should be treated.

Today however we can say that getting gout is a favour - if you heed the warning. I'll send a link to this on the next reply: =Compared to individuals without gout, we found that individuals with gout died earlier and experienced a 42% higher risk of death. Similarly, individuals with gout experienced a higher risk of dying from cardiovascular disease with a 58% higher risk of cardiovascular death.

We did find that individuals with gout had a greater abundance of many known cardiovascular conditions and risk factors compared to those without gout as others have demonstrated previously. Nevertheless, even when we took these factors into account, individuals with gout and elevated uric acid had higher death rates....Indeed, the unadjusted analysis confirmed that subjects with gout had a 4-fold risk of death and over a 5-fold risk of cardiovascular death. These findings just cannot be ignored.

The prevention of gout and its debilitating consequences is based on reducing serum uric acid concentrations below 300 µmol/L. Treatment is indicated when recurrent gout attacks (>2/year) or tophi are presented by the patients.=

Conclusion gout sufferer with untreated high blood urate is at a substantially higher risk of mortality than those without. A good part of that risk is cardiac, but there's also an increase risk in certain tumours and kidney issues. Gout is the first shot across the bows of mortality, it's a warning to look after yourself. Drink less alcohol, reduce weight, exercise more...and maybe - enjoy every day!

Alternatively you can take a few cherries and pineapple extract every day as advocated by many.

5

Here's the link I promised, but it will be vetted by the patient.info system to check it's not advertising I think:

http://www.news-medical.net/amp/news/20130726/Gout-uric-acid-levels-and-risk-of-death-an-interview-with-Professor-Austin-Stack-Graduate-Entry-Medical-School-University-of-Limerick.aspx

6

The first thing I picked up on was the blood test. Blood should not be taken for about 6 weeks after an attack. The average person on here probably knows twice what most GP's know, so don't presume everything the doctor tells you is correct. There are many myths about gout, and many reports contradict each other. You will find some posters on here disagree with each other on several points, and this is quite often based on their own experiences. I had 4 attacks in 3 months a year ago. I am now on 1 allupirinol a day, drink what I want and eat what I want (I am a vegi though). Some days my foot aches a bit, but I haven't had an attack since my body got settled with the drugs. I am afraid you will have to suck it and see. You may be lucky like me, or you may be one of those poor soles where nothing really works.

Good luck

7

And I must say that my experience is pretty much like yours. I take my 300 mg of allopurinol, I take the occasional colchecine and I get on with life. I try to drink more water than normal, and am especially careful when in the tropics. I eat meat and fish and anything that comes my way. I completely ignore if something is high purine or not - the allopurinol is breaking all purines down to something to what my kidneys can easily handle. I havent had anything more than a twinge in a long time. 

It is my belief that everyone could sort their gout as long as they can tolerate the allopurinol (and the overwhelming majority can) - it just take a bit of discipline to keep taking it in the first months when it triggers the attacks.

8

Yes, when I started on Allupirinol it triggered  a very bad attack, but I stuck with it and all was OK. I have to stay away from the Colchesine though, as all my internal organs desolve and come out of my bottom

9

Gotta laugh at that response. Glad you're on the road to recovery 

10

So Rusty. What you're saying is that people with untreated gout or people that don't follow the treatment are people that fall into that category of high mortality. Whereas the people that change their lifestyle and take treatment to reduce Uric Acid levels to an acceptable level are no longer suffering from gout and as such reduce that mortality risk?

 

11

The recommendation by NICE is that gout (two or more attacks in any 12 months, or tophi or other symptoms), should be treated aggressively, and the blood urate should be pushed down towards what is normal in a 20 year old (3ish) rather than the top of the normal as in most 40+ year old men.

Diet changes can reduce the blood urate by up to 1.5, but that won't bring it down to 3.5 - in many it will however stop the gout flares, but not the insidious inflation of the arteries.

The problem is that any urate lowering therapy (e.g. Allopurinol), is that (somewhat counterintuitive you), cause gout flares, which usually stop after a few months of treatment. The reason for the flares is that the there are stored pockets of urate in the tissue which slowly leak into the joints, causing flares before they are flushed out. This cleaning out process will eventually stop at which point the level of allopurinol can be reduced (to probably 100 mg). The standard flushing dose for most is 300 mg (still <50% of max dose). During the flushing it's a good idea to have some colchicine at hand - my experience is if I take one at the first twinge of gout, the attack never happens).

To return to your question- treated hyperuricemia reduces risk of heart attacks. It is however impossible to know if the treatment alone did it. As only 30% stick to the treatment long term, those that do may be the most health conscious - maybe they are the ones who buy a bike, and lose weight and get a bit fitter.

Oh - one side effect that everyone forgets is that it reduces LDH (bad cholesterol), so maybe that helps too. Reducing inflammation in the body is good and that probably helps.

All this stuff is a numbers game - we just have to go with what the science shows is best for most.

I personally- after a few slight issues in the first couple of months (initial tiredness cured after a few weeks, then stomach issue cured by hiding the tablet inside a bit of banana), after a couple of months it's a total non issue. I take 300mg allopurinol with breakfast and forget about gout. My blood urate is now low, down from 9, 10 or on one occasion 12.

Sorry this has dragged on.

12

an education and understanding go a long way to prevention and self-care I would say. With it being quite wide spread with no symptoms and such an increase in %mortality im surprised GPs don't check at the old 40yo service. 

 

13

Thanks for all of the responses! A quick update - 

I gave in, and asked the rheumatologist to send me to a podiatrist since he didn't seem too confident in doing an injection. The podiatrist did an amazing job getting me better. It was extremely painful, but it instantly reversed the gout flare up. He was a skilled doctor, and had confidence that he could attempt to pull fluid, and inject steroid in the joint. He also seemed to know more about gout than the Rheumatologist. He said that in a true gout attack, the inflammation gets worse when the limb is lower than your heart. (I was starting to worry that it was septic arthritis)

All in all, the gout flare up lasted a month before the injection turned it around. 2 months later, and the joint is still very swollen, and gets red/black and blue when I'm standing. It isn't inflamed, but it feels hard from the trophi. Hopefully this will go away on it's own as I continue to take allopurinol. 

I've been taking allopurinol for almost a month now, and haven't noticed any major changes. Still a vegetarian with the occasional exception for salmon. No high fructose corn syrup whatsoever, and I've completely given up on alcohol even though I rarely drank it in the first place.  I was originally 225, and now I'm down to 210, and exercising. Hope to knock this one out for good.

14

Hi, Ross. Glad to see you're on the mend and have taken positive steps to changing your lifestyle to help. My last attack in April has almost gone. after a day of standing on my feet, my affected foot feels a little more tired and swollen than the other but im hoping this will get better with time. Out of interests what age group do you fit in? (trying not to be specific here)

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I am 32

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I actually had a conversation with one (well several, but one was very frank) - I asked them why is there not a bigger thing made about gout ? And went as far as to suggest that if this were a disease mainly killing women then there would be a national campaign etc. His reply was that - that may be the case but to suggest there is any sexism involved would be a career damaging move. When I suggested that he had a moral obligation - he said that he does all he can within his professional organisation but as for going to the press - "I have a family to support." He also said that to suggest that GOs were not doing their jobs properly is criticism of other doctors and considered to be unprofessional. 

17

Im curious as to why the doc stuck you on Allopurinol after one attack. its usually if you have two.

18

This is true - I thought the same. My guess (for what its worth) is: 

a) very high reading of blood urate even though taken during an attack (when it will have reduced from the real reading);

b) the attack was so awful.

19

I suppose national campaigns for testicular and prostate cancer can't be classed as sexist then

20

is it two in a two year period?