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Jeff,
If I read you right you did yourself an EXTREME disservice by going on and off probenecid. Once started the committtment to these drugs must be for LIFE. Going on and off is the absolutely best way to guarantee painful attacks. That pertains to probenecid, allopurinol, or Uloric.
Just keep on with both drugs until your attacks stop and then judge whether you can go off of ONE of them. You will NEVER be able to get off both (unless you replace Uloric with allopurinol.)
GOUT does NOT go away.
Amazing…I have taken 4 of my 6 Z-pack (bronchitis) and I awoke with a fairly sharp flare. I walked it off and then it whacked me again for about a second. Gone now. So there might be a connection.
(But truth be told, I also had 1.5 Liters of Cabernet yesterday.
)I've never taken ciproflaxin.
You are right.
But the reason they aren't removed until they get grossly big and interfere with a joint is that all surgery carries the risk of infection/allergic reaction to anaestehtics/death.
With gout, perhaps there has been experiences where removal of most of the tophi exposed the remaining urate and caused horrific attacks after being sewn up.
If your stomach is strong:
The upside of surgery is that gout seems to be deposited JUST UNDER the skin. The body seems pretty successful at getting a lot of this cement OUT of the joints. My only tophus, a little one on my little finger, is about 1/8 inch up from the joint (that never caused any pain.)
That attack at the cuboid-fifth metatarsal (little toe side on the upper arch middle of foot) is where I had a doozy of a “minor” attack before the BIG DEFINITIVE one. It had me on crutches for a week because no flexing of the foot was possible without a lot of pain,…this was before any thought of gout.
It went away as mysteriously as it had come on.
So yes, with your history of tophaceous gout I think you can say with near 100% certainty, that it IS gout you are now suffering…another common attack site you might see is your ankle.
Now: I HATE to see anyone administering teeny doses of allopurinol. Those silly 50 and 100 mg. doses only cause more attacks. When this attack ends with colchicine…yes, it is a wonder drug…go onto 300 mg. allopurinol immediately, not 50, not 100. With tophaceous gout any dosage lower than that will merely rearrange urate deposits causing endless bouts of grief in other joints.
You may readily need MORE than 300 mg. but you will certainly not need less.
Translate for me: Are you waiting until this attack stops or are you taking 300 mg. allopurinol right now? If the former, then start the allpurinol today. If the latter just keep taking it and get a couple uric acid tests over the next few weeks. You want to see numbers <5.0. If you are not getting them, go to 400 mg. allopurinol.
And remember, colchicine is both better and safer than prednisone for pain.
Just a couple additional thoughts Jeff.
The Uloric will eventually do it's work but you will need patience and a complete lifetime committal to it. If you are uncertain of the side effects of allopurinol perhaps you might give it another trial if the cost of the Uloric becomes onerous.
Yes, diuretics, especially thiazides, or worse clorthalidone, can readily cause…it caused mine and it is so sad because absent these drugs, GOUT need not have happened. But alas, once you have had an attack you can not become UNgouted by stopping the diuretics. You will always have some crystallization sites for more attacks. Doubly bad because back in the1960's and 1970's almost EVERYBODY who walked into a doctors office was found with hypertension and given “water pills.” Why did they prescribe diuretics for you?
Since uric acid is caused by crystallization of uric acid triggering the immune system inflammation and uric acid is liberated when lean tissue is destroyed or catabolized, the flooding of the body with uric acid is probably IMMENSE about 17 miles into a marathon. THe concomitant dehydration further concentrates this overload and it comes out into your foot joints.
X-rays to reveal gout are very unreliable. They can be trusted only when you can already see rather large tophi and even these only appear as fuzziness. X-rays DO show extreme joint damage in CHRONIC gout but this is later in the game.
Indocin (indomethacin) is a good analgesic. But it causes far too many side effects, the worst being bleeds (gastrointestinal, and apparently EYES) that it should not be used on a day to day basis.
Have an ultrasound done on your kidneys and ureters. A side effect of the potent uricosuric, probenecid, is kidney stones. If positive, you will need an alkalizing agent to melt them away.
Tri season is coming fast and I have already committed and paid for three tris, several bike races, and a few running races. I would rather not lose all of that.
Last night I was so frustrated and angry that I almost drank a beer out of spite. Life was better when I could drink beer and eat cheeseburgers.
I think you might consider the payment for these races a sunk cost and walk away from it. Hammering away at gouty joints is not a good idea because they can hammer back with all the fury of Hell unleashed.
With Uloric (or allopurinol) you will be able to enjoy a cheeseburger and a couple beers…but maybe not another marathon anytime soon.
K.
Have another uric acid test this month and see if you can get confirmation on that 4.4 reading. If you DO get another one that low, then gout is probably off the table as a diagnosis.
Labs make mistakes, uric acid falls during an attack, cold acidic joints precipitate urate at much lower levels (although cold is rarely a problem in June in the NOrthern Hemisphere, etc. so another test is the wise choice.
If you DO get another attack after another low uric acid reading, then you and your doctor have no choice but to do a joint fluid biopsy to look for crystals, as odo said. If you get a HIGH reading then my advice is either to wait for ANOTHER attack or start now on allopurinol, 300 mg. If you get another low reading and an attack, or yopu find NO crystals, then the pressure is really for a good differntial diagnosis in the absense of gout…that is never easy.
I know, DOUBT is often worse than the disease…except for a full blown attack that is.
I too take that estimate of allopurinol's effectiveness with a grain of salt. If alloprurinol's effectiveness was 20% you'd have a world filled with gout cripples.
It sounds like a ploy to sell Uloric.
Often when allopurinol is used in studies it is used in 200 mg. or 300 mg. doses. When it is shown ineffective, the correct and logical procedure is to increase the dosage to a point where it IS effective…up to 800 mg./day but this is often not done.
It sounds quite reasonable with one exception. I dislikee the idea of 100 mg. allopurinol to start. It just is not enough for most of us and can cause more problems than it alleviates.
Hoow much probenecid? 1000 mg./day?
It definitely LOOKS like gout, Now you must confirm it with a high uric acid reading (or three.)
See if you can get some colchicine from your doctor…if it works well that is MORE evidence of gout.
(Have a foot X-ray just to make sure you haven't broken a bone.)
It sounds like it's possible the body distributes 15 years of urates in ways that keep the joint stable and perhaps removing them and making the deposity crumbly will DEstabilize joints.
But it's hard to talk about the knee because it is complicated beyond complicated.
Nate, have you given much thought to the possibility that your knee is suffereing inflammation from old injuries, like meniscus tears, and less gout?
I have damaged both my knees long long ago…they “healed” themselves, no interventional surgery. Every now and thn my right medial meniscus (one in the middle) breaks free and wanders getting stuck in the joint, causing a lump in the back etc. Depending on where the piece winds up there is more or less pain. But then it goes back into place for months. I doubt my gout has anything to do with the phenomenon.
Allopurinol works…$4 a month.
Uloric works…$150 a month.
U.S. prices.
I recommend Uloric to anyone who has a rare hypersensitivy reaction to allopurinol…and to all the multi-millionaires I know.
A real consideration is that Uloric is a new drug and taking a new drug forever carries certain unknown risks. People have been taking allopurinol for more than a half century so a lifetime of taking it is pretty well documnented as safe. Very few drugs can one take that long without severe repercussions.
GoutGal,
Like Utube, I have trouble interpreting your post but I take it to mean you WERE on allopurinol but STOPPED wjhen this attack began. But then you say this is your first attack. It cannot be so because then you would not have been on allopurinol in the past?????????
Fill us in.
You've undoubtedly read my recommendation for colchicine use in a protracted attack: 2 to start then one an hour until:
cure,
diarrhea, or
16 pills.
Once you start allopurinol you are NOT supposed to stop it for any reason other than acute allergic reaction. Do NOT stop it during a gout attack.
Mark,
You asked:
Will Allopurinal lower my UA levels enough that I can toss back a few cold beers on the weekend?
I answered:
Yes it will!
Will Allopurinal lower my UA levels enough that I can toss back a few cold beers on the weekend?
Yes. it will.
Utubelite said:
You may be right in your theory. I have not taken any Colchicine for 6 months now and though on couple of occasions I got serious twinges but I did not take colchcine or any other pain killer just to see if it was gout pain, it should flare up. And the twinges went away without flaring up. Never got twinges that last more than few minutes, 30 minutes to be max.
The same happens to me every couple weeks, especially after a beer blast. I'll wake up and the first footfall is oh-oh, but I'll walk it off and the foot will feel normal after a few minutes. I also haven't taken any colchicine is at least 6 months. It is always the right bunion joint and that's where I had my big attack nearly 2 decades ago.
My assumption is there is still tophus buried in the joint, which is slightly larger than the left foot bunion joint, and it is being dispersed a few crystals at a time causing a slight attack by white blood cells.
My rule of thumb is to take colchicine only if the attack/twinge persists for a half hour.
Mark,
Suggest to your doctor allopurinol + probenecid until your attacks subside. Explain to him that while allopurinol causes our bodies to MAKE LESS urate, probenecid will allow a lot of extra urate that might have been liberated by that surgery to be excreted quickly.
Make it sound like it was HIS idea…they like that, the little dears.
Here's the basics in a nutshell.
IF you are certain it is gout, then you should get on allopurinal ASAP. Getting control of gout before it has a chance to lay down deposits is the best way to treat it so it never bothers you again.
But if you are NOT certain, then hold off until you are, even if it means a couple painful bouts and the laying down of a few deposits.
Let us know your numbers cheez. I am happy the attack has subsided.
Does anyone think my toe and ankle could have been gout attacks after surgery?
ABSOLUTELY, Mark.
You went to a BUNION DOCTOR, who would see a bunion as the cause of pain for a man just run over by a BUS.
He was wrong, you had no “bunion” but rather a gouty tophus.
Digging out the monosodium urate is all well and good EVENTUALLY but it has repercussions. Your foot doctor cut into walled off deposits (that's how the body deals with excess urate in gouties) freeing up a LOT of urate that needs to find someplace else to hide, like ankles, inteps, fingers and knees.
Alas, while it is floating around it is likely to casue no end of attacks.
I think for you, a wise maneuver would be to take allopurinol to stop more formation AND probenecid to increase the amount dumped by the kidneys. The probenecid wouold likely be temporary until all attacks stopped but the allopurinol would be forever, the normal routine treatment for gout.
How high is your serum uric acid? That number is the most important one in gout and its treatment.
Lickcheeze,
I would be reluctant to go on a lifetime of allopurinol without COMPLETE assurance that I need lt. That assurance could come from a joint aspiration revealing the presence of crystals, an attack so blindingly painful in your bunion joint that it was unmistakable or several lesser attacks in the course of a year…all with corresponding high levels of serum uric acid.
What was your blood serum uric acid reading?
Has your acute attack subsided yet?
Colchicine is pretty gout specific but not completely so.
So if colchicine works well it is STRONG evidence to put into the GOUT column along with serum uric acid, appearance of the joint, which joint, etc.
From what I have read, colchicine works by alkalyzing the synovial fluid of the joint. This alkalyzation slows the inflammatory process (which is acidic) but also mediates the change of uric acid to mono-sodium-urate which the body can compartmentalize as a “neutral” tophus. It seems the immune system can more readily ignore MSU tha it can uric acid.
(This is a lot of my own theorizing…I cannot point to an article in Lancet.
)So you are buying the old patented ZYLOPRIM. (Can I ask WHY?)
I buy generic allopurinol and get it at any major big store pharmacy in the U.S. for $40 a year without using my insurance. ($10 for a 90 day supply of 300 mg.)
Does a Canadian pharmacy beat Wallmart or Target pricing at $10 for a 3 month supply of probenecid?
By a mile. More than 50% less. Besides, all US pharmas, including Walmart, charge >$125 plus tax for 200 pills. I got 400 for $129, including S/H.
Well blow me down. All this while I was proceeding under the misapprehension that probenecid was one of those cheapy formulary drugs that everyone was discounting, like allopurinol (at $3 a month) but it's NOT. Best I could find was Costco at $40.72/100 (for the 500 mg. dose.)
What is the name of your Canadian pharmacy and do they require an Rx. (You can PM me if you choose.)
I find 2 colchicine is a laxative the next day…like a dose of Ex-Lax, Senna leaves, or Castoria…some risk of surprise squirts.
Four colchicine is strong laxative the same day with several urgent bathroom visits.
Therapeutic dose to stop an acute atttack (like 12-16 pills) is a 6 hour period where I might as well STAY in the bathroom, hopping between toilet and shower. Finale is drinking a tall glass of water and having it immediately spray out…I doubt that Niagara falls that fast.
Actually, I find the 2 pills the most risky…one dare not FART for 24 hours.
Water is particulary troubling.
Here's the common scenario…hans you can back me up since we both did our bout with Atkins to our regret.
Water is recommended to do this that or the other…yes it is necessary for ALL bodily functions. So then the “Water is good” mantra becomes “MORE water is good” and then somebody will run with the “AS MUCH AS YOU CAN GET DOWN” ball. This will be repeated ad infinitum on the web and you will have people unhappy if they haven't gotten down their 3 gallons of water in a day. This is NOT hyperbole, but rather common on the Atkins boards. So the feeling becomes that no matter HOW MUCH water you have consumed, it isn't enough. Then the purists will weigh in with “You cannot count coffee. tea, soda, soup, juices, etc,” even though they are all 99% water.
By extension then, the “water is all” thinking will be extended to all disease processes…and then the distilled water people will weigh in.
Yes dehydration is bad…but then so is drowning. In 200,000 years, modern mankind has developed an exquisite sense of thirst. Evolution has gotten man to the premiere spot in nature…not for nothing.
Goutpal – Its strange but I create my best art when I am in Pain ( can we say gout !
Just look at the life of Van Gogh!
Thanks too to zip2play for observations on the urate pool – any definitive references?
Reference for the 50-200 times normal for tophus formation:
http://www.gwu.edu/~med08/worksheets/GOUT.doc
(from George Washington University but today access is forbidden…but I pulled this out:)
Chronic gout – who to treat?
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- Patients with kidney stones (they don’t want to go through that again)
- Patients with tophus (total body pool = 50-200x normal to get a tophus – need long-term therapy)
- Patients with many attacks per year (3-4), or particularly severe attacks (need long-term therapy)
- Patient with hyperuricemia and urine urea of 1,000 (very high) – treat even if they have few attacks/stones/tophi
- Give allopurinol if overproduction of urate is the problem
- Give benemid (probenecid) if underexcreting urate (increases excretion by one-third; old drug with few adverse effects)
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DON’T treat asymptomatic hyperuricemia!
- even in the hospital, only 10% of these patients have gout
- allopurinol has risks, too (like Steven-Johnson Syndrome) – don’t use unnecessarily
Here's a link for the normal male urate pool of 1200 mg.
uptodate.com/patients/content/topic.do?topicKey=~dMMMfuqn3jS4p0
That figure was EASY…it's all over the web.
I remember reading in an ancient PRINCIPLES OF INTERNAL MEDICINE that the average person with gout has 40 grams of urate in his body. But like I said this was an OLD text, as I recall the 1950's, so maybe with more people on the meds now, that figure might be on the high side.
But I think that by the time we see a gouty change in any joint that we have LOTS of urate tucked away. I cinsider myself lucky that I recognized gout early and began treatment before I saw any tophi. Perhaps that explains why I never had any attacks after starting allopurinol.
I pulled up a couple numbers from some obscure studies:
Normal total body urate for a male is 1200 mg. urate.
To get a tophus that number is increased 50 – 200 fold.
So that's 50- 240 GRAMS of urate. So we are talking about OUNCES here.
When we realize we can pass only about 750 mg per day, it is not hard to see how long it can take to play catch up. Even if allopurinol were to stop production COMPLETELY which is impossible, at 750mg./day excretion, to get rid of 75 GRAMS would take what, 100 days?
That's why for tophaceous gout,, the best results are achieved by coupling the allopurinol with a uricosuric to vastly increase that 750 mg. figure.
Sorry nate…I had hoped that 600 mg. allopurinol would have you out of the woods by now.
Liver is easily tested with a simple blood test: about 5 components are tested.
Blood sugar is readily tested with a simple blood glucose measurement but an A1c test is better becausse it measure the glucose that has been tied in to the red blood cells' hemoglobin…and this reflects the blood glucose for the previous couple months…an excellent test that can be taken from the same blood draw. If it's good you do not have diabetes.
Kidney should be tested both by the same simple blood draw and also a urine test which can show cell casts, or blood…both can be indicative of kidney damage.
Make sure to ask for the A1c or you might not get it routinely.
Have your thyroid values measured too…same blood test.
And of course URIC ACID. Don't want to forget that bugger.
And since your a guy…prostate specific antigen. And HIV if you;ve never had it done. And Lyme antibodies if they've never been done.
And HepA, HepB, and HepC… amazing how many things can bedevil us.
Might as well go for H.pylorii antibodies if you've ever had stomach problems.
So except for the urinalysis, all can be learned through a single needle jab.
sputnik,
There's no reason to assume that becasue you were on 200 mg. sulfinpyrazone (a uricosuric) that the same dosage should apply to allopurinol (a xanthine-oxidase inhibitor.) The commonest dosage of allopurinol is 300 mg. but there's no reason one cannot take more, up to 800 mg., to control SUA to desirable levels…like <5.0 (for a safety margin.)
I recommend you upgrade from 200 to 300 mg. and see what readings you get.
Remember, that Uloric costs 30 times what allopurinol costs, so if one CAN take allopurionol, one certainly SHOULD.
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the PAIN