Gout Pal Interactive

Do Not Be Ruled By Food

“What food should I eat with gout?”

“What food should I avoid with gout?”

“Will [food] make my gout worse?”

The gout sufferer’s diet questions are endless, and the gout doctor’s diet advice is monotonous.

No Alcohol. Avoid purines. Lose weight.

Not particularly bad advice, but too general to be helpful, and too restrictive to be accepted.

The real danger here is that gout patients focus on food, and not on what really matters - controlling uric acid.

It’s heartening to see that some doctors are realizing that strict low purine diets are not the right way. “In treating gout, don’t overdo diet restrictions” is a refreshing article from Dr Robert Shmerling. He does not…

recommend strict dietary modifications after an initial attack of gout.

Like me, he points out the research showing weaknesses in strict low purine diets. Significantly he continues:

these studies looked at people who had not had gout before. They did not assess the effect of diet on people who already had gout.

In a nutshell, you need to stop obsessing about specific foods. Eat a healthy varied diet that satisfies you. Enjoy what you eat, but just eat enough to maintain a healthy weight, and exercise as often as you can.

Drastic changes simply do not work, and some can make your gout worse. Small improvements every few days soon make a big difference. Most importantly, you feel better because you’re in control.

To feel even more in control, learn more about gout. When you understand how gout pain is caused, and why uric acid control is so important, you are much better placed to help yourself, and ask the right questions of your doctor.

Your added bonus is that, when you are learning about gout, it helps you to stop worrying about food.

Tags: food, purines, uric acid

I’ve just seen some more out-of-date medical advice on a doctor’s website, and it’s making me seethe.

Everybody trusts these guys to give sound, current health advice, but what do they churn out?

Disproved speculation that at best does no good.

At worst, it condemns you to years of pain and discomfort. Years of low quality of life.

I’m tempted to name the offending site, but that would only single out one miscreant among the many - online and in their consulting rooms.

Instead, I’ll analyze a few quotes, and allow the diligent among you to guess where the site is by virtue of GoutPal’s Worldwide Search Engine.

The Symptoms

Our doctor starts with:

severe pain in the big toe…condition affects the age group 30 to 50 years old

So it could be gout. But what about 48% of gout sufferers who don’t get pain in the big toe?

What about the small number of people under 30 and the massive number of people over 50 who get gout? Will they not even be considered for a gout diagnosis?

The Diagnosis

Fatal Flaw #1.

To be sure therefore if your joint pains are due to this disease [gout], a simple blood test called uric acid can easily be determined in any lab

All that a uric acid blood test will tell you is how much uric acid is in your blood.

If it’s high, it suggests that you are at risk of uric acid crystals forming in your blood which may induce a gout attack in the near future (a bad thing).

If it is not high, and you are having a gout attack, it suggests that you might be suffering from a reaction to new uric acid crystals that have formed recently (a bad thing). Or you might be suffering from a reaction to old uric acid crystals dissolving (a good thing).

If it is normal, it tells you that your uric acid level is normal (a waste-of-time thing, but reassuring to some people who don’t understand gout).

A uric acid blood test, though useful as part of a program to reduce uric acid, will not tell you if you have gout.

Because a uric acid test is inconclusive, our inexperienced doctor will prolong the investigation, and repeat the inconclusive test, until he can conclude, rightly or wrongly, that you have, or do not have gout.

Find the last paragraph incomprehensible? At least it’s not in Latin.

Get a rheumatologist to perform a proper test for gout. That way, if you have gout, you can get treated fast. And if you haven’t, you won’t waste your time and money on gout cures when you have pseudogout, septic arthritis, bursitis, or one of the other conditions commonly misdiagnosed as gout (presumably as a result of an inconclusive uric acid test)

Our doctor should learn that:
A uric acid test can play an important role in managing the correct treatment of gout as part of a urate lowering strategy, but plays little or no part in the diagnosis of gout.

Let us assume that, by chance, we have a correct diagnosis of gout. Surely our doctor can prescribe the right treatment.

The Treatment

Fatal Flaw #2

Taking simple steps starting with our diet can go a long way in improving our health

I’m not sure it’s a starting point, but anyway, let’s consider the doctor’s gout diet advice?

NO NO if You Have GOUT or High Uric Acid:

* The NUMBER ONE on my list is ALCOHOL!!!!
* Anchovies
* Gravies
* Herring, Sardines
* Mussels or Tahong
* Internal Organs like liver, kidney
* Dinuguan, Chicharon Bulaklak
* Mackerel
* Patis and Soya Products
* Bacon and scallops

Use in Moderation:

* Crabs, Oysters, Shrimps, and eel
* Poultry and Meat [including] soup and broth
* Oatmeal
* Certain Veggies like asparagus, spinach, mushroom and cauliflower
* Legumes like beans or lentils

Let’s leave the alcohol for another discussion - do doctors always advise less alcohol so there is more for themselves?

The doctor’s recommended gout “diet” is the list of high/moderate purines in food that’s been kicking around since scientists discovered that uric acid comes from a certain type of protein in our bodies called purines. The key here is “in our bodies”, not in our mouths. Uric acid comes from cells in our bodies, not in our food. Whilst it is true that an imbalanced diet, rich in purines, can raise uric acid levels, this is true of many imbalanced diets. Including starvation.

This type of food advice is dangerous nonsense. At best, gout patients will stumble into a healthier diet by considering what they eat. At worst, as frequently happens, gout patients believe gout management is simply a food issue, and so they delay proper treatment.

Our doctor should learn that:
Where gout patients are overweight, but excrete uric acid normally through urine, gradual weight loss can reduce the amount of uric acid produced by the body. Patients who under-excrete uric acid will gain little benefit for gout from dietary changes and must focus first on medication to promote uric acid excretion.

The Consequences

As the above is published on a fairly prominent website, it attracts questions from many gout sufferers and their carers. These questions often give scant information, then are met with generalizations that could mean anything. Example:

[edited for clarity/spelling]
I’m 44 yrs old, 5′ 8″, 188 lbs. I first experienced pain in my left ankle 4 months ago w/c was diagnosed I have hyperuricemia. The pain went without medication. Now my left knee & its surrounding areas ached which sometimes makes walking difficult. What medicines should i take to lessen the uric acid?

My response would be something along the lines of:

I’m not a doctor, and can’t give specific medical advice, but my observations are:

• You are 9lbs away from clinical obesity, and excess weight is a significant factor for hyperuricemia.
• Hyperuricemia simply means higher than normal uric acid levels, though you haven’t said what your levels are, so I cannot confirm that diagnosis.
• High uric acid levels are a common cause of, but do not always result in, gout. You need to have fluid from the affected joint(s) tested to see if you have gout, and to rule out other diseases.
• After you have had the joint fluid test (arthrocentesis), consult your doctor for advice on which uric acid medication, or changes in lifestyle, suit you. He will carry out kidney function and other tests, and review your medical history and other medications. He will discuss this information with you to ensure you get the correct medication to suit your circumstances.

Instead, we get, from a doctor who is presumably qualified to give medical advice:

If the problem is really due to high uric acid and you have an inflammed joint, a specialist like a rheumatologist will do certain tests including getting a sample of your inflammed joint and to look at the fluid if they indeed contain uric acid crystals. Drugs like NSAID e.g ibuprofen, and Colchicine can reduce inflammation; But you may need drugs to reduce the production of uric acid like allopurinol Talk to your doctor about these drugs.

I think “You need a rheumatologist as I’m not really up to explaining the complexities of gout” is a bit poor for an MD.

It is sad that ordinary people feel that they cannot trust their own doctor and seek information on the Internet. Perhaps the doctors busy lives mean they cannot explain conditions and treatments well enough to give patients the confidence to follow their advice.

It’s sadder still, that where doctors do have a platform on the Internet, and thus the resources to fully explain causes and effects of complex conditions like gout, they still fail to measure up.

Come on doctors. Raise your game.

Take a little extra care to keep up-to-date.

Take a little more time to check latest research.

Take a little more notice of all the needs of your patients.

Please stop killing our health.

Tags: gout diagnosis, gout symptoms, purines, uric acid test

Maybe it’s the gout pain in my wrist that’s making me tetchy.

Or maybe it’s the amount of BS I’m seeing today.

New gout research means hope for new gout therapies?

More like new gout research reaches new heights of BS.

Actually, the research I have seen, is probably of massive interest to those who need to understand how gout pain works. It’s just not relevant to us poor gout sufferers. We need better treatment using the therapies already available rather than wasting time and money on inflicting gout on mice.

Let me explain

Read the rest of this entry »

Tags: gout research, gout treatment

This article has been deleted.

If you feel there is no hope for gout sufferers, or if you feel that there is hope, please discuss in the gout forum.

This one is to allopurinol takers everywhere.

Why do you put up with such shoddy service?

Every week, I get messages from gout sufferers, and their carers, about problems with allopurinol. Most of these show that absolutely no thought has gone into the treatment.

If you bought a car with only two wheels, would you accept it and drive round in a shower of sparks?
If you called a plumber to fix your leak, would you be happy to pay a weeks wages for him to merely turn the water off?
Would you pay an optician who grabbed the nearest pair of specs and said, “Here, these will do,” without testing your eyes?

Why take allopurinol without checking that it is doing it’s job?
Read the rest of this entry »

Tags: allopurinol treatment, _alipurinal, _alipurinol, _allipurinal, _allopurino, _allopurinol, _alopurenol, _alopurinal, _urate lowering therapy, _uric acid

Just like me, it seems, the LA Times gets letters from it’s readers about the danger of gout.
It published three letters about gout yesterday, and the depth of ignorance from sufferers, alternative medicine promoters and qualified medical personnel drives me to despair.

One gout sufferer blames beer. Though alcohol can affect kidney performance in some people, and drinking beer can promote dehydration - a sure cause of gout, to hope that simply stopping drinking beer will stop gout is naive in the extreme. He notes that avoiding dehydration and restricting joints can trigger gout attacks. Both these are true, but avoid the main danger of gout.

Another reader claims respite from gout pain for a year through black cherry concentrate capsules daily, and indomethacin when required. These may well reduce gout pain, but again, they do nothing to avoid the main danger of gout.

The worst story come from a man who has consulted 4 doctors - 2 of these have had gout and ought to know what they are talking about. But they don’t. He has even been given allopurinol, the best current cure for gout, but it has not worked - presumably because he has not been advised properly how and when to take it.

I was moved to write to them, in the hope that at least a few gout sufferers in Los Angeles might find some permanent relief. I have no idea if they will publish my letter - I’m not even US resident, never mind LA.

Just so you don’t miss out dealing with the danger of gout, here are the key points:

Keep uric acid levels below 6mg/dL.

allopurinol is best, but if you cannot tolerate it ask about other uricosuric treatments, or new uric acid lowering therapies, like febuxostat or uricase derivatives

Get treated!

Many gout patients do not get uric acid lowering treatment. Those that do are not monitored to ensure the dose is correct - a complete waste of time and money.

Expect pain

Reducing uric acid often causes temporary gout pain until all existing crystals are dissolved. Your doctor should prescribe appropriate pain relief, like colchicine, ibuprofen or other NSAIDs

Consider alternatives

You might lower uric acid through dieting, if your got is not too severe. It is vital to monitor uric acid levels frequently. Do not rely on pain to tell you if you are getting better. The pain caused by new uric acid crystals is the same as pain caused by old uric acid crystals dissolving.

Consult a rheumatologist

I’ve mentioned The American College of Rheumatology listing of rheumatologists on many occasions. Use it.

Do not waste your money on anything unless you understand these basic facts about gout. There are many things that will help you, but only lowering uric acid below 6mg/dL will avoid the long term danger of gout from uric acid crystals.

If you do not treat uric acid crystals they will increase, often slowly, over many years, and with no real pain symptoms. Then the true danger of gout reveals itself - crippling joint damage and skin-bursting tophi.

---

These are some of the most important points about gout. As part of my better gout treatment campaign, which I launched in my last newsletter, I am developing key points about gout into a gout patients charter. Please help me focus on the issues that are important to you by completing my gout survey.

Can you cure your own gout?
You might have to.
If you do not take responsibility, and demand the right long term treatment, you will never cure your gout.
If you do not take action, the chances are nobody else will.

I get many messages from disillusioned gout patients who don’t feel that their gout treatment is working. I’ve just seen an article that suggests that you might have to cure your own gout.

In Patients Learn Chronic Disease Self-Management Online on MedScape, the authors note that:

managing a chronic disease has become a normal part of life. The healthcare system, however, … was designed to focus on acute illness and injury, not long-term conditions.

This is why most gout sufferers get pain relief treatment, but many go without the long-term uric acid lowering treatments that are crucial to curing gout. But it is vital that you get this treatment to avoid crippling joint damage and skin bursting tophi.

The authors conclude:

There is no doubt that patients will need to become good chronic disease self-managers. The healthcare system and individual professionals providing healthcare should increase the focus on ways to offer patients with chronic disease convenient, economical, and high-quality programs to help them attain the best possible therapeutic and quality-of-life goals. For the growing proportion of the population, this vision is becoming a reality through use of the Internet.

Compared with individual visits and group-based programs, the Internet is far less expensive and has the potential to reach many more people. … Online disease self-management can be an effective delivery method for teaching patients the skills and self-confidence they need to take charge of their chronic disease care.

I don’t know what online services your healthcare provider offers, but my online advice to help you cure your own gout starts with:

1. See the listing of rheumatologists, go and see one, and make a plan to get your uric acid levels down to 5mg/dL. Then monitor uric acid every few weeks
2. Drink about a gallon of fluids daily. Spread throughout the day, so you are drinking more or less constantly. All fluids count, but water is best.
3. Consider baking soda (I’m also researching potassium citrate for gout) unless you have high blood pressure. This, and the increased fluid intake, helps avoid kidney stones.
4. Lose weight slowly - uric acid can increase from binge eating and starvation.
5. Exercise regularly, but gently - uric acid can increase from prolonged exertion.
6. Don’t become obsessed with particular foods. Gout sufferers need a healthy balanced diet that includes a wide variety of different food types. Keep meat and fish to about 20% of your diet - balanced with plenty of fruit and vegetables.
7. Painful swelling will occur occasionally until you get rid of all the uric acid crystals in your body. You and your doctor should discuss different pain relief options. You might need to try different medications until you find something that suits you.

Take responsibility, seek a little expert help, and you can cure your own gout.

I’ve recently been discussing the itchy side effects of allopurinol with a reader. I wonder if it is caused by insufficient fluids or something else. Whatever the reason, it is vital that you get good advice.

I first emailed this gout sufferer about the advice given when allopurinol was first prescribed, as it caused a nasty rash. Since then they have had to return to allopurinol because there was no suitable alternative. It is difficult for me to comment properly on this advice as I have no direct involvement, but I find that hard to believe no other suitable uricosuric is available.

Now the allopurinol side effects seem to be limited to itching. Again, I don’t know if this is due to reduced dosage, or some other reason.

You might ask why I chose to comment on something that I am so far removed from with so little verifiable information. Allopurinol is so important to gout management, yet so often mismanaged, that I’m glad of any opportunity to try and emphasize the correct procedure.

• Before taking allopurinol, it is important to have kidney function tests. Any kidney deficiency can render allopurinol unsuitable.
• You should be advised that allopurinol treatment can cause gout flares at first and discuss your choice of preventative anti-inflammatory treatment, or pain killers as you need them.
• You should be advised to drink plenty of fluids when you take allopurinol, though as a gout patient you should be doing this anyway.
• You should be advised about allopurinol side effects, distinguishing from those that are harmless, and those that should prompt immediate consultation with your doctor.
• You should be asked to return every few weeks for uric acid tests and dosage review.

If you are not getting this advice, check the listing of rheumatologists and consult one as soon as you can.

Don’t forget to discuss your experience of side effects of allopurinol on your gout forum.

Yesterday, I wrote about the guidelines for longterm gouty arthritis cures. I’ve added topics to your gout forum, so you can share your experiences.

The discussion topics for the longterm gout management guidelines (in reverse order) are:

OLD TOPICS NOW DELETED. PLEASE START NEW DISCUSSIONS IN THE GOUT FORUM

Management of recurrent, intercritical and chronic gout

We are all looking for better gouty arthritis cures, but what we need today is better guidelines for using the cures we already have.
British rheumatologists have completed some guidelines for the management of gout, and it is likely that these will influence gout care procedures throughout the world.

I have already reported on the management of the acute phase of gout, which deals mainly with short-term pain relief. This article summarizes the guidance relating to more advanced phases, where the need to cure gout depends on lowering uric acid. The phases that these guidelines refer to are:

Recurrent Gout

Where acute gout attacks occur more than once.

Intercritical Gout

The time between gout attacks. This is, in my opinion, the most overlooked phase. Just because the pain has gone, most people ignore gout during this phase. Big mistake. If uric acid levels are high, you can still get crystals being deposited in the joint and under the skin (tophi). These do not always hurt, but they can build up to the point of serious, painful, chronic gout.

Chronic Gout

This phase is characterized by tophi and severe pain from damaged joints.

The same evidence driven grading applies to these guidelines. The grades are:

1. At least one randomized controlled trial
2. At least one non-experimental descriptive study (eg comparative,
   correlation or case study), quasi-experimental study, or non-randomized controlled study
3. Expert committee reports, opinions and/or experience of respected authorities

Longterm Gout Management Guidelines

The longterm gout management guidelines are:

1. Keep uric acid in the blood below, 300 µmol/l i.e. approx 5mg/dL(C).
   
   
2. You should take uric acid lowering drugs after your first acute gout attack if you have a second attack within one year, and there are no complications(B).
   
   
3. You should also take uric acid lowering drugs if you are a gout patient with:
   • tophi (C)
   • kidney problems (B)
   • uric acid stones (B)
   • the need to continue taking diuretics (B)
     
     
4. If you are not already taking uric acid lowering drugs, wait 1 to 2 weeks after inflammation has gone (C).
   
   
5. If you have uncomplicated gout, you should start uric acid lowering treatment with 50-100 mg allopurinol per day. You should have uric acid blood tests every few weeks, and increase the allopurinol dose by 50-100 mg, until the target (SUA below 300 µmol/l) is reached, but only increase to the maximum dose of 900 mg (B).
   
   
6. If you fall into any of these groups, your doctor may prescribe uricosuric drugs (B):
   1. Kidney function tests show you under-excrete uric acid
   2. Allopurinol doesn’t lower uric acid enough
   3. You cannot tolerate allopurinol

   The preferred drugs are sulphinpyrazone (200-800 mg/day) if you have normal kidney function or benzbromarone (50-200 mg/day) if you have mild/moderate kidney insufficiency (B).
   

7. When you start allopurinol or uricosuric drugs, you should also be prescribed colchicine 0.5 mg twice daily for up to 6 months (A). If you cannot tolerate colchicine, your doctor may prescribe NSAID or Coxib if these are suitable for you, but the duration of NSAID or Coxib should be limited to 6 weeks (C).
   
   
8. If you take aspirin in low doses (75-150 mg/day) to help prevent heart disease, you may continue (B). However, avoid pain-killing doses of aspirin (600-2400 mg/day) as it interferes with uric acid excretion (B).

Tags: gouty arthritis cures, _allopurinol, _aspirin, _benzbromarone, _colchicine, _diuretics, _gout cures, _heart disease, _longterm gout management, _nsaids