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11:53 pm
October 19, 2009
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fredwilson
Toe Torture (status changes after 50 posts)
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Hi all,
Sorry this is going to be a long message but I want to completely explain my circumstances.
I believe I have had gout for quite a while (years) and never took medicine for it and never got a positive diagnosis from a doctor. I started having “gout” attacks more often and was having them about once every 2 months. Usually I could feel an attack coming on and I could drink lots of water and it would stop the attack. Finally about 4 months ago my doctor was concerned because my uric acid level was 8. He told me to start taking 100mg of allopurinol once a day and if I tolerated it, go up to 100mg twice a day. I didn't have any problems with the allopurinol but was still having problems with the gout attacks. He told me to take 300mg twice a day. I had been taking that amount for the past 3 months when I had a follow up appointment about 4 weeks ago. He changed my allopurinol to 150mg twice a day, ordered a blood test, and wanted me to return for a follow up in 3 weeks. So, I did what he said, had a blood test done 4 days afterwards. The following Monday I woke up to a major gout attack in my ankle and knee. This was 2 weeks ago yesterday and I still can't put any pressure on my leg. I tried colchicine, indocin, water, etc… nothing really helped. I was taking 800mg ibuprofen 4 times a day and that made the pain tolerable. Another follow up appointment to my doctor 4 days ago and he gave me Prednisone, told me to stop taking the allopurinol during the gout attack, and wants me to restart at 200mg twice a day after I've been pain free for 10 days. I asked about my current uric acid reading and it was just over 4. Now from what I've read, since I've been on allopurinol for 3 months, I should NOT stop the drug during a gout attack.
Now, I'm also having some other issues that I believe may be caused by me taking allopurinol. I have noticed that I am getting “man boobs” and a google search says that breast enlargement in men is a very rare side effect of allopurinol. I brought this to my docs attention and he didn't think it was caused by the drug and sent me for an ultrasound and mammogram. I'm waiting for those results.
My questions are below…
1) My blood test showed a uric acid level of 4. This was 4 days after my doctor lowered my daily allopurinol. Would this be an accurate reading based on the lower amount of allopurinol in such a short time?
2) Would lowering my allopurinol cause this current gout attack even though my uric acid was 4?
3) Do I keep taking my allopurinol during this current gout attack?
4) Should I stay on 150mg twice daily or go up to 200mg twice daily (allopurinol)?
5) Has anyone else heard about allopurinol causing breast enlargement in men?
6) I'm a little concerned that my doctor isn't very versed in gout treatment, should I seek the advice of a Rheumatologist?
Thanks in advance for any/all responses!
Fred
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12:55 am
October 20, 2009
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Utubelite
Tophi Terror
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I am not an expert but from what ever I know, your treatment sounds very different. I am really surprised that you were taking 300 mg of Allopurinol twice a day ( that is 600 mg daily) wihtout any Uric Acid blood test for 3 months. Generally, the dose is started at 100 mg and then increased weekly with UA tests till time the level drops to target of below 6 ( or 5, 4 etc. whatever the target is).
The Allopurinol should not be started during a gout attack but if the gout attack happens while one is taking Allopurinol, it should be continued.
And now the doctor wants you to stop Allopurinol and then re-start with a dose of 400 mg daily( again too high). I have not heard such a treatment on this forum before.
I do now know what the experts like Zip or Trev or GP feel; If I were you, I will change the doctor asap.
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4:40 am
October 20, 2009
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trev
Tophi Terror
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Well ,UTube- No expert but certainly a fair share of gout over the years.
In some ways the pulling together of different background experience of 'the many' is an antidote to the well intentioned, but sometimes inadequate, ministrations of the medical world.
It has to be stated again- the legal responsibilty for health advice is with ones medical advisor- but that only goes as far as 'reasonable care' and stops short of 'side effects' responsibilties. These fall somewhere between the courtroom and the unspoken masses who 'do the meds'!
I would say- it takes time to get results, things are still settling down. Freds' attack isn't out of place as we all know (though I don't take AP)- and side effects usually recede on dose change.
Fred: It does seem like the your Dr. is on the case, even if a bit heavy on the doses- Zip would probably find his approach in your case as 'far too uncommon'. Very proactive, I would say- and trying to tread a difficult path on treatment for you!
The reason why 3 attacks seems the threshold for starting uriscoric drugs is exactly because the side effects are often more trouble than the illness. This is true of many drugs in specific cases.
So what I'm saying is: Bear with it a while- you're on track for a handle on your gout and getting tests to clear worries of side effects. Your UA is good- it will need time to pay off and flares are inevitable to some degree- your case rather bad ones.
Docs will rarely admit to side effects- as they can't be proven without a barrage of tests which are worse than stopping the offending drug.
Further they have no wish to cause harm- and therefore bound to be in denial.
They are caught between the grip of the law/procedure and big Pharma.
Stay strong, stick with medical advice – and in a week, I bet things will look better!
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4:46 am
October 20, 2009
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zip2play
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Fred,
(I would normally have tried using your post and putting my comments in line by line but I'm afraid our primitive little bulletin board might make a mish-mosh so I;ll do what I can.)
Firstly, your doctor is making a pig's breakfast of prescribing allopurinol. Almost nobody goes to a 600 mg,/day dosage without a LOT of care, certainly not in any kind of quick progression of 100, 200, 600 over a matter of a couple weeks. Once allopurinol is started it is NOT to be stopped during an attack and thrashing around to this super-high dosage and then pulling you off is malpractice. A logical treatment is something like 300 mg/day FOREVER with MAYBE an adjustment every year. Frequent dose changes are going to cause more attacks than prevent.
Gynectomastia (man boobs): I am not an expert here but I think the likely cause, if they have come on recently, is the STEROID treatment, presumably prednisone? that you are taking. The drug of choice for an acute gout attack causing inability to walk is COLCHICINE, taken during one day at a dosage of 2 pills and then followed up by one an hour for 11 more hours…15 if necessary or until exctreme diahrrhea or pain relief intervenes. Do this in ONE day and don;t take more than 2 or 4 pills the next day if you are satill in pain. THe diarrhea can be quite vicuious. Diddling with one or two pills a day during an acute attack is useless.
If you take the colchicine the right way, there is no heed for the huge doses of ibuprofen (I'm amazed you still have a stomach! ) Do NOT take aspirin except for a 75 mg/day regimen if you take it for your heart.
1. and 2. There is no need to take a divided dose of allopurinol, its metabolites stay active for several days so taking one dose a day of 300 mg. is precisely equal to taking 2 x 150 mg. Yes, huge doses of allopurinol will bring blood levels down to 4.0 very quickly…alas that sometimes frees up stored uric acid from joints to revisit other sites and cause further grief.
3. Do not stop the allopurinol during a gout attack. The rule is don't START during one, but NEVER wstop.
4. Take 300 mg. allopurinol in a single dose…that's enough.
5. No man-boobs that I;ve heard about from allopurinol. Are you a body builder on any OTHER anabolics?
6. Your doctor IS trying but he sounds out of his league here and is thrashing around with try thi-try that. See aa rheumatologist.
Addendum: Have you had the classic TOE? Are YOU certain of the gout diagnosis (never mind the doctor.) Remember colchicine is somewaht diagnostic. If it doesn;t work in the BIG dose, then let the rheumatologist make a final determination…perhaps with a joint fluid bioply during an attack.
Re-addendum: You might be amazed at how rapidly you can abort the worst attack with colchicine done right.
WHEW!
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6:48 am
October 20, 2009
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fredwilson
Toe Torture (status changes after 50 posts)
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First off, thanks to everyone for the quick responses!! Now some more info and a plan that I'll need comments on.
As I suspected, my doctor seems to be going a bit crazy on the allopurinol. I think I'm going to take the 300mg ONCE a day instead of 150mg twice a day for now until I can go see a rheumatologist.
The gynecomastia didn't show until I started taking the allopurinol. That's what led me to research if it's a side effect of the drug. The prednisone was only started 4 days ago and is only being taken for a week. I'm not a weight builder, in fact, I weighed 375lbs about 2 months ago and have started working to get my weight down. I'm now down to 350….hmmm, could weight loss be a cause of my gout flare up?
I have used colchicine before and it always kicked the gout out in a matter of hours if I took it early enough. I find that I can usually get to just over 4mg in 6 hours before the diarrhea kicks in. I have also read that taking a small, daily dose of colchicine during the initial start of allopurinol helps keep the gout attacks away while the body cleanses itself.
In regards to this current gout attack I'm having, it's now just about gone. I don't have the constant pain but I can't put full weight on my leg and my knee is still swollen, I can't bend it much more than 45 degrees. From my past experiences, I'll be ok in a few days. That being said, I tried the heavy dose of colchicine on the SECOND day of my current attack and it didn't do a thing.
Yes, I have had the classic “toe” on both feet. I've also had attacks in both feet, knees, and in my right elbow this past Memorial day. Speaking of my elbow… I've had problems in the past couple of years being able to straighten it out. Never thought much of it but since being on the allopurinol this seems to have resolved somewhat. Could this be from the cleansing of the joints due to the allopurinol?
So, how does this plan sound?
1) Continue 300mg allopurinol ONCE a day.
2) Go see a rheumatologist.
Hmmmm…. I guess that's it. LOL
Thanks again!
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7:46 am
October 20, 2009
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trev
Tophi Terror
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Fred- You don't give your location or age, which would help a bit on this.
What stands out is your weight and recent losing of it.
Losing more than 2lbs a week ,as you are, is not usually recommended- though it is commendable in effort terms.
The loss of weight is going to add to the effects of AP- so you will be accelerating your UA residue clearance some. Hopefully you are now finding a reasonable balance.
Reducing your weight , over an extended period will help your joint pain, if caused by overwear.
There's no reason why you can't have multiple causes- gout is just more attention grabbing, as we know!
You probably have arthritis in your family, too!
I think your 'plan' is sound- *add something about long term weight loss goals-and stick to it. [2lbs/week max!]
This will reduce stress on joints and lower need for SUA reducers to stay any higher than you want.
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9:00 am
October 20, 2009
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fredwilson
Toe Torture (status changes after 50 posts)
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Trev,
I'm in the U.S. and I'm 41.
As for the weight loss…. Yes, I totally agree with you in regards to how much/often. I originally lost quite a bit when I started and I believe it was due to mostly water weight. I am trying to stay on the 2-3lbs per week schedule but I have only been doing this by doing the Weight Watchers program. My plan was/is to start exercising when I physically can (gout attack gone). I'll have to really keep an eye on my weight and eating so I don't start to lose too much too fast.
I just have to keep telling myself that I didn't get to this point in months!
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2:52 pm
October 20, 2009
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zip2play
Member
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Fred,
Losing the 25 pounds rapidly could have , let me get the word right, “emptied” some of the fat out of your pecs leaving saggy skin that is giving the IMPRESSION of breast tissue. Real gynectomastia can be boobs on a skinny man and then be very easy to diagnose as probably hormonal. For someone 350-375 I think it might be just illusion…just a little sag.
Yes losing weight fast liberates a lot of nucleic acids whose only route out of the body is conversion to uric acid. Continue the weightloss but know that you now have allopurinol blocking some of this conversion. I hope with further loss your man boobs but into hard pecs at 200-250 pounds with some serious bodybuilding…never too late to start.
So if youve had both TOES, then you definitely have gout but whether your current knee bout is due to gout or something else is hard to tell…knees are funny. With non response to colchicine maybe not gout. Elbow might be more likely.
But your steady treatment with 300 mg allopurinol and a visit to your rheumatologist is precisely correct. Test your uric acid again and if you see another 4 you are sliding into home free.
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