“Has GoutPal gone mad?” I hear you ask.
“Why is he always telling us that uric acid management is much more important than gout pain management?”
OK, I have not gone mad. First, let me remind you why managing uric acid levels is much more important than managing gout pain, then I will explain why I say “lowering uric acid is useless.”
Gout Pain And Tooth Decay
There is no link between gout and tooth decay, but regular readers will recognize my oft-vaunted (overused?) analogy.
When you visit a dentist to treat toothache, you expect an examination for decay, treatment of that decay, and pain relief to help you endure the treatment and associated soreness and gum inflammation.
Treatment for gout, ignoring complications such as allergies, and other health conditions, should be just as simple. Take allopurinol (or some other uric acid lowering therapy) and support this with pain relief, such as colchicine, until the allopurinol has removed the excess uric acid threat.
But what should be simple, rarely is.
Tooth decay treatment starts with drilling, and you know this is going to hurt. Do you know that, as with any uric acid lowering therapy, including diet, allopurinol treatment for gout can hurt? Many gout patients do not understand this, and so they stop taking the uric acid lowering treatment. The equivalent of leaving the dentist’s chair half way into the drilling process.
All dentists, and most of their patients, understand that all the decay must be drilled out before the cavity can be filled. Almost no gout patients, and very few healthcare practitioners understand that uric acid levels must be maintained below 6mg/dL (preferably below 5) to get rid of existing uric acid crystals. Frequent uric acid tests during uric acid lowering treatment are just as vital as frequent checks to see if all decay is removed.
Tooth decay treatment ends with agreeing an appointment for the next inspection. Nobody assumes that one dentist visit fixes everything. We continue with daily teeth cleaning and return to check all is well. The gout patient who has lowered uric acid long enough for all existing crystals to dissolve must continue with a daily maintenance dose of allopurinol (if necessary) and return for a uric acid test every three to six months. Even when symptom free, it is unwise to go longer than 12 months without testing blood for uric acid.
You can stop being a gout sufferer, but you can never stop being a gout patient.
Once you have had a gout attack, you have changed. You have lost your gout virginity. You can never become a person who has never had gout, but you do not need to return to being a gout sufferer. You just need to manage your uric acid level, and never let it rise above 6mg/dL again. Standard uric acid tests might declare you “normal” at 7 or even 8 mg/dL. See Normal Uric Acid Levels guidelines for more information.
You are not standard. You are not a gout virgin. You must not let uric acid rise above 6mg/dL.
Managing uric acid
So if I feel so strongly about the importance of uric acid, why do I say “Lowering uric acid is useless?”
Because “Lowering” is not enough – you need to manage it.
Lowering uric acid from 9mg/dL to 7mg/dL is pointless. It might slow down the rate at which new uric acid crystals form, but it will do nothing for the existing urate deposits that are eating into your bones.
Lowering uric acid to below 6mg/dL, then letting it rise back up to 7 is worse than pointless. You will get pain from old crystals dissolving, then pain from new ones forming. You will be in a mess.
Lowering uric acid is simply not enough. Here is how to manage it.
Phase 1
Get uric acid down to Phase 1 Target Level (usually 5mg/dL – agree something lower than 6 with your doctor). It does not matter how you do it, just do it. Allopurinol is the obvious choice, but there are medical alternatives.
You may be tempted to rely on dietary / lifestyle changes – this is fine, as long as you definitely lower uric acid, and not just seek to stop the pain. In practice, dietary and lifestyle changes are not quick enough to get uric acid levels down immediately, so it is better to support your lifestyle plan with immediate allopurinol support.
Phase 2
Maintain uric acid below the Phase 1 target level until you achieve six consecutive months without a gout flare. During this phase, you will experience gout flares, but they will become less frequent, and less intense.
These gout flares are due to your immune system reacting to old uric acid crystals as they dissolve. I know it is hard to convince you that such pain should bring you joy, but each time you experience a gout flare when uric acid is permanently below 6mg/dL, you are getting better. Compare this with occasional gout flares from new crystals when your uric acid level is higher – every day moving nearer and nearer becoming crippled.
After 6 months without a gout flare, you can be certain all existing gout crystals have gone, and you are no longer a gout sufferer.
Phase 3
No longer a gout sufferer, but still a gout patient. Uric acid tests every 6 months to stay below 6mg/dL.
Thanks for posting this. I am male, 37 years old, and new to the long line of gout suffers. I have had two flare ups in one month. The pain has been intense. This is definitely be a life style change. One I am willing to make! My general practitioner is not as aggressive as I am on fixing this for good. I intend to see a Rheumatologist next week and devise a diet and medical plan to manage my uric acid.
Absolutely. No point in waiting for repeat flares, and definitely no point in increasing the risk of crippling joint erosion from slow build-up of urate crystals.
Get the uric acid lowered now, with allopurinol or other uric acid lowering treatment, then you are protected during your lifestyle changes and may be able to reduce the medications.
I completely agree with nearly everything goutpal says at this site. But let me share something about my gout journey. I have suffered since I have been 21 years old. I am now 47. After years of attacks and drugs to combat the problem, I finally went on allopurinol for life in September 2008. My doctor recomended starting on the the name brand Zyloprim, for gout. Which I did. I also took colchicine during the first 2 months. I had no flare ups and I felt good. Then, in November of 2008, I switched to the generic, allopurinol. I also stopped the colchicine. Big mistake. I experienced a major attack in my knee that lasted for 26 days. Went back on colchicine and I felt very good. Then, on December 23, 2008, I get another major attack in the other knee. I took a 5 day methoprednisolone pack which knocked it out very quickly. From that point, I went nearly 11 months without an attack. I exercised regularly, watched my purine intake and took my allpurinol every day. Then, a month ago, I was walking and running hills near my home. I am in good physical condition I think. That evening, I feel pain above my knee cap. Not excruciating pain, but moderate pain. Over the next few days my knee begins to moderately swell. I can deal with it. I am mobile and it did not interfere with much other than excercise. I think it is a knee injury. I take some NSAIDs, the swelling seems to be subsiding and the pain is tolerable. The knee seems to be fine. Then, I get more swelling and pain. I take a steroid, and all seems well. In week 3 after the “injury”…the swelling returns. I take steroids again. To make a long story short, the swelling becomes intense along with moderate pain. I go to the orthopaedic surgeon to get the knee drained and a cortisone shot. The doctor sent the fluid for testing and he ordered an MRI. He thinks it’s a torn lateral meniscus.
I believe arthroscopic surgery is going to be required. I go to the doctor a few days ago expecting him to arrange a surgery date. He walks into the examination room and says……GOUT!…The results of the knee fluid showed crystals. Now, after 11 months of being gout free, taking 300mg of allopurinol, here it is again. Now, I must get blood work and see my uric acid levels. This was unlike any attack I ever had. I was able to walk and funtion the entire time. I had no significant pain and the swelling, other than for a few days, was moderate. The good news is that I have no damage to my knee joint in the least. Either from injury or from years of dealing with gout in my right knee.
So, what is a man to do. Increase the allopurinol? Move on to Uloric? Or throw myself out a window. You think you are home free but it appears that after being gout free for nearly a year, it can return.
Read the article again, Giovanni.
Everything you say is about colchicine and pain relief. That is not the way to manage gout.
You MUST manage uric acid levels.
Though you have not given your uric acid levels, they are clearly still too high. You have been on allopurinol over a year, so you must have had some tests during that time (unless the prescriber of your allopurinol is a completely incompetent fool). What were your results?
I hate to make judgments without the facts, but I will make an exception here. This sounds like a classic case of allopurinol under-dosing. Not only does this do very little, if anything, to get rid of old urate deposits, but it also prolongs the period and intensity of gout attacks until those deposits are dissolved.
I understand completely GP. Initially I had the expected flare ups but they were more intense I suspect because I disconitinued the colchicine within 6 weeks of initiating allopurinol. I have not had recent blood work so I cannot tell you where my uric acid levels are now. After 2 months it was 7.2. Down from 10.4. After 6 months it was 6.2. If 300mg of allopurinol is underdosing, then I guess I am in trouble. I really do not want to increase it beyond this dosage but I know that the maximum dosage is 800mg per day. The perplexing aspect of this is that I went nearly a year without a problem and this attack did not fit the norm. I had no significant pain, just swelling. My knee was not hot or red and I was able to walk without much discomfort. I personally think I prolonged this attack by treating it as a knee problem. This happened with in hours of running hills. Putting ice on the knee and not immediately going to the doctor was a mistake. Then, I used with a compression wrap which exacerbated the problem and forced me to go to the orthopedic surgeon.
I have been on allopurinol before and never had a problem like this. The drug effectively ended the gout attacks. But, like a lot of folks with gout, I quit the medicine. I was a young man and had a difficult time reconciling the fact that I had to take a pill for life. At this point I have been on the drug for 13 months. Clearly my desire is to end these attacks once and for all. I am reluctant to switch to fubuxostat and I am not so comfortable with increasing the allopurinol. Of course, I will listen to my doctor.
What’s the difference between 400mg per day and 300mg per day?
300mg allopurinol is clearly not getting uric acid below 6mg/dL, therefore not allowing old crystals to dissolve. I.e. it is a waste of time, effort, and money.
400mg is likely to get uric acid below 6mg/dL, then old crystals will dissolve. Once they have all gone, you may be able to relax the dose back to 300mg, as long as you keep testing every 3 to 6 months to make sure you never go much above 6. 6.2 is fine after you have got rid of old crystals – it is simply not low enough whilst you have crystals in your body since as they dissolve, they will soon take you back into the danger zone.
The 300mg dose is leaving you in a dangerous state – just enough allopurinol to start old uric acid crystals dissolving, but not low enough to finish the job. Therefore, they start dissolving, initiate a gout flare, but never allow the crystals to completely dissolve.
Going back to the dental analogy in the original article, it is a bit like getting the cavity filled without proper drilling out of the decay – it might seem like a fix but it is going to keep coming back until you do it properly.
I completely understand the stakes her GP and I certainly appreciate your input. At this point I will get my uric acid level checked and then talk to my doctor. If we have to increase the dosage to 400mg then so be it. What kills me is that I eat very little red meat; I am getting sick to death of chicken; I stay away from shellfish and I exercise regularly. At least I did until this latest flare up. I drink more water than any man alive I think. 80-100 ounces per day. I suppose my only indulgence is red wine which I will not give up. My belief is that wine is an absolute good and that there are more benefits to drinking wine than there are negative health effects.
If you’ve had gout since you were 21, it probably has very little to do with your diet. If you are genetically an under-excreter or over-producer of uric acid, there is little you can do except take the medicine.
In the very best of cases, diet will only influence uric acid by about 2mg/dL, though gradual weight loss (if you need it) can improve things further.
If you are on allopurinol, diet is largely irrelevant (for gout, though you should still eat sensibly for general health). Most uric acid comes from natural cell metabolism – not from what we eat.
GP may I say that you may know more about gout than most doctors. Like you, I have tried to study this ailment for a long time now and just when you think you found the answer, you are proven wrong again. Therefore, the simple truth about gout is that to fight it, one must control uric acid levels. Nothing else matters if our uric acid is out of control. Certainly maintaining a healthy weight, regular exercise and diet are important in general.
My first attack happened when I was 21, yes. Of course, I did not know what it was at the time. It resolved in a day or so and my next attack occured 7 years later. I did not have many attacks in my 20’s. The worst of them came in my 30’s. Before I went on allopurinol last year, I whent 7 years without a major attack. I had some very minor flares but nothing that would convince me go on medication. I must admit that attacks in the 2 months following the initiation of allopurinol were the worst of my life. I honestly did better when I was not taking the medicine. Once those attacks ended, I felt fine until this past month. By the way, I am an overproducer not an underexcreter. I am probably in better physical condition at 47 than I was at 37. I do have hypertension however. No bad, but I started 10mg of norvasc last November. I don’t know if anyone else has experienced this but my blood pressure rises in the throws of a gout attack. Once the attack is gone, the pressure reduces significantly.
There are studies currently being conducted on the issue of whether gout is secondary to high blood pressure or whether symptomatic hyperuricemia causes high blood pressure. There is a doctor in the state of Florida who has proven in rats that hight blood pressure is secondary to symptomatic hyperuricemia. It has yet to proven in humans.
Thanks for all these helpful information! Just to clarify. During Phase 3 when you have gone 6 months without an attack and uric acid is below 6 mg/dl, should allopurinol still be continued or is proper diet sufficient to maintain uric acid level below 6 mg/dl?
In most cases, allopurinol will need to be continued, though dose might be reduced as long as uric acid levels never rise much above 6mg/dL.
It is not a simple question of diet, but a wider issue of identifying what caused higher uric acid levels in the first place. Diet might be a factor, but it is rarely the only one. It is dangerous to generalize here, so I urge anyone who is considering relaxing there allopurinol to discuss their circumstances in the gout forum and with their doctor.
This point is well said “Lowering” of Uric Acid is not enough – you need to manage it. ….