It is all about your Uric Acid Number.
If you have any interest in gout whatsoever, then you need to know the exact level of uric acid in your blood.
When you ask the bank manager for your account balance, does “OK, Nothing to worry about?” make you happy? Do you accept “Normal” and rush out on a spending spree?
Of course not. You need the number. And here is why.
Results may vary from lab to lab, but the assessment routines have a common flaw. They use averages to determine low, normal and high values. And those averages contain gouty people. So if you have a uric acid level of 8mg/dL (see Uric Acid Levels for details of other common measurement scales), you may be statistically normal, but you are highly at risk for gout.
Also, the test is a snapshot, usually taken when you have not eaten for 14 hours. If that reads 8, what is your daily average? 9 or 10, perhaps? What is your peak level? 11 or 12 perhaps? You will probably never know exactly, but you should certainly know that any test result above 6mg/dL is a risk for gout, and 8 is almost a certainty.
So never, never, never accept a low/normal/high assessment of uric acid in your blood (sUA – Serum Uric Acid). Get your uric acid number.
And once you have it, what do you do with it?
Simple. Lower it.
Newly Diagnosed Gout
Now there is a common trait amongst newly diagnosed gout patients to seek to lower uric acid through diet and lifestyle changes. There is nothing inherently wrong with this, and you might get your uric acid number back into the safe range. The problem is might. You might reduce uric acid, and you might not. You might change your lifestyle and avoid gout forever. But you might merely slow down the growth of uric acid crystals.
Slow it down, and you just prolong the period when uric acid crystals build up in your body, weakening tendons. Slow it down, and you merely postpone the agony of crippling bone erosion from gout until you are older and less able to cope.
The sensible option is to see allopurinol (or other uric acid lowering treatments like febuxostat or probenecid) as a support tool. Go for an immediate drop in uric acid, below 6mg/dL, to help you cope with the rigors of your new lifestyle changes. Rapid weight loss can increase your uric acid level – no problem with the aid of allopurinol. The exertion of new exercise routines can increase uric acid – no problem with your febuxostat friend.
It’s the safe sensible way to go, but you will need to persuade your doctors that uric acid lowering treatments are suitable for short term consideration. They may stick to the view that uric acid lowering treatments are a last resort, and then for life. The new approach is better. The logic is clear.
If lifestyle changes can work, then you are better protected, and more likely to succeed if you introduce the temporary support of uric acid lowering treatments. If they can work, you have the crutch of uric acid lowering therapy for just as long as you need it, and you can avoid long term treatment (but annual uric acid monitoring remains compulsory).
If your lifestyle changes can’t work, then you have not wasted months or years of your time. You have not prolonged the problem and postponed the agony – you will be that much quicker to the path for long-term gout management.
Long Term Gout Sufferer
So what are the uric acid numbers for long term gout sufferers?
The numbers vary through 3 phases:
- Target Phase
- Urate Lowering Phase
- Maintenance Phase
Uric Acid Target Phase
Depending on how long you have had gout, you will have a varying amount of uric acid in your blood, and more uric acid lodged as crystals in your joints and other tissues. This is often referred to as the urate pool, or urate stores. Getting your blood uric acid to 6mg/dL will stop new crystals forming, and may start to dissolve old urate deposits.
If you have had gout for a long time, the uric acid crystal deposits, especially if tophi have formed, will be high. There is good evidence to suggest that the lower you can get uric acid, the swifter you will dissolve those uric acid crystals. The latest addition to this evidence concludes:
[patients with low uric acid] indicate that maintaining sUA near or below 2 mg/dl would probably be safe. Targeting low sUA could improve the elimination of tissue urate stores
In the light of your medical history, and other relevant factors, you need to discuss this with your doctor and agree a Target sUA. With your target uric acid number in clear view, you can adjust dosage and retest each week until you have achieved target for two consecutive weeks.
Urate Lowering Phase
During Phase 1 and 2, you will probably experience gout flares as old crystals are temporarily exposed to your immune system. Pain relief will cover these, and they will become less frequent and less intense. Uric acid testing can be relaxed to monthly, and maybe three monthly. The phase ends when you have gone 6 months without a gout flare, during which time your uric acid test results must never be more than Target sUA. One gout flare OR one test result above target, and you start counting the 6 months again.
Uric Acid Maintenance Phase
Tests every 3 to 6 months. Relax medication dose if desired, but NEVER allow uric acid over 6mg/dL.