Don Burns'
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Everything you wanted to know about Gout

Everything you ever wanted to know about Gout

I am was one of the worst gout sufferers I know. I have suffered from this malady for almost 20 years and have learned a great deal on the subject. I write here about my experience in hopes that someone might benefit from what I have learned and can avoid some of the ignorance that is out there with regards to this disease.

I am not a doctor. So, most of what I write about here is based on a nearly 20 year database of personal experience, and a lot of trial-and-error. Actually, it is my experience that the knowledge of hyperuricemia (the actually name of this disease), is somewhat limited, even amongst doctors for a couple of reasons. First, the malady is not that prevalent. Second, most gout sufferers respond well to modern medicine intended to treat gout, so there is not a need to understand cases where this is an exception. I seem to have been an exception to this and, therefore, have learned much through the school of hard knocks.

For a good medical article on hyperurcemia, click here.

I have seen a quiver of doctors and four rheumatologists, three of whom have given up on me and sent me to other doctors, or just asked me not to come back (seriously). My case is a difficult one and a threat to doctors who aren't up to a challenge.

My current rheumatologist greeted me with the statement, "I love to heal this disease!". He has been attentive, understanding and supportive and for the first time, I am currently on a treatment that looks like I will be able to join the group of normal respondees to medication. I am hopeful.

What is gout?

Gout is the result of crystalization of uric acid in the blood stream. Uric acid is a by-product created when the body breaks down naturally occurring substances called purines. Gout occurs when the uric acid index in a blood test climbs over 7.5. Below this number uric acid dissolves, but above it it will tend to accumulate in a joint, anywhere on the body, crystalize and can cause pain ranging from an annoying discomfort to debilitating anguish. (Picture crushed glass splinters inside any joint on your body).

The most common place for gout to occur is in the big toe. I assume this is probably because it is a good place for uric acid to gravitate to. But, in more advanced cases, gout can occur in any joint of the body.

I have also had gout occur in ligaments; ankles, the achiles tendon, the ligament just below the knee-cap. These are the most painful and debilitating, and seem to be the least responsive to anti-inflamatory medication.

When gout pain occurs, it can often last for days as excruciating pain, keeping one bed-ridden and unable to move. The joint, or area affected swells and becomes very hot.

Relief from a gout attack can be had by taking one of several different types of anti-inflamatory medications (see below), getting the fluid extracted by a doctor, or a cortisone shot. While getting the fluid extracted seems like the most extreme way, it provides the best instant relief when the procedure is done correctly.

What causes gout?

Doctors classify patients into two categories: Over-producers and under-excreters. The over-producer is a person whose body produces uric acid at higher rates than normal. An under-excreter is a person who is not good at filtering out the uric acid that is either produced by the body or consumed in the diet.

I am an over-producer. Many well-meaning folks will offer advice about diet to me. "I had an uncle once who....", etc. The truth of the matter is that my gout has never been affected by my diet. I am overweight, yes, which may have something to do with my overproduction of uric acid, but my experiements with diet have been disasterous.

One rheumatologist put me on a strict diet of low purines. Purines are those things that introduce uric acid to the body through consumption. Some foods, high in purines, may not suprise you, like meat, but then there is a list of others that probaly will. For example beans, oatmeal, spinach.... Its not about whether the food is healthy or not, its about whether it contains purines.

The result of this diet was a rash of gout attacks like I had never experienced up until that point. In retrospect, I have formulated a theory on why this was. As an over-producer, the body may have reacted to the drop in uric acid I was getting from normal consumption of foods with purines, and may have increased the production of uric-acid, resulting in painful attacks.

Alchohol is the only source of consumption that seemed to have a direct affect on gout attacks. A glass of wine was almost always a guarantee of attacks the very next day. I still have not formed a theory on this one, but I suspect that it has something to do with chemical reactions within the body and/or the ability to filter through the kidneys.

I cannot speak for under-excreters as this is not my experience, but theory has it that these folks are probably more apt to be affected by diet. And, in fact, these are probably the majority of "occassional" gout sufferer, who do not have a malady that deteriorates over time, but just experience the occassional discomfort when they've consumed a good steak and beans dinner.

The Medications

One of the biggest obstacles to getting reasonable treatment for gout was the ignorance (mostly on my part, but partly on the Doctors' part) of gout medication and how it works. I would often read articles on the different medications and run across statements that read, "It is not know why colchicine works to relieve gout, but ....".

I dropped chemistry in high-school and never returned to it. I also have no medical training. But what I provide here is my experience with the different medicines and some conjecture as to why they worked like they did.

All doctors seem to believe in colchicine. Colchicine is commonly given to patients during a gout attack, with the intention of relieving the attack. My experience, however, was that I got absolutely no benefit from colchicine whatsoever during an attack.

I found value in colchicine, however, after much experimentation, and one doctor, who prescribing it to me this way: "take one pill every hour until you get diarrhea". I've concluded that colchicine does not relieve an attack, but, instead, keeps uric acid from crystalizing. It is best used as a medication to avoid gout attacks when one is not having an attack. The reason it works, for many, during an attack is because the body may have already begun the process of dissolving the gout crystals from the affected joint, and the colchine keeps further inflamation from occuring. This, however, seems to be effective only for those who are not in a more advanced stage of hyperuricemia.

Colchine does nothing for curing the cause of gout, however, which is elevated uric acid in the blood. It will affect your stomach when taken too much and is quite easy to get diarrhea.

Update May 29, 2007

Please accept my opinions as coming from a lay-person with no medical training, only years of trial-and-error experience. Dr. Daniel Bravo de Laguna sends me this email, especially regarding colchicine:

Hello Mr. Don Burns,

I read your webpage by accident, in fact it was through a patient and he gave me the url. First and foremost, I feel your pain, gout is truly a terribly painful disease that sadly although understood is poorly known by most physicians and society in general. The reason I am writing is to inform you that the mechanism of colchicine is rather well understood, clearly not everything but a great deal. One of the main anti-inflammatory mechanism of colchicine is via inhibition of granulocyte (better known as white blood cell, specifically neutrophils) migration into the inflamed area. FYI, WBC is a very broad term, there are granulocytes and non-granulocytes. The granulocytes are termed as such because of the fact that they contain granules which are basically proteins and the like. This subset of WBC are responsible for the immediate response by our system while the non-granulocytes would be the lymphyocytes and they are typically responsible for the memory response. Thus granulocytes phagocytose different substances, in other words they gobble it up. By the way one of the problems with these uric crystals is first they literally look like rapiers and cause physical damage, as well as these granulocytes cannot break them down causing an increased inflammatory response among other things. In any case back to colchicine. The drug inhibits mitosis (cell division) thus affecting cells with high turnover (GI tract, marrow). Symptoms of a fatal overdose are similar to those of severe radiation poisoning. This is why you typically get the diarrea, typically seen within 2mg. The way it inhibits mitosis is by blocking something called tubulin. These tubes basically are used in many ways including mitosis by seperating the DNA during division as well as diapedesis. This is a nice word for cell migration. These white blood cells travel through our blood until they encounter a trouble spot in which they then pass through in the tissue, diapedesis. I hope this helps you in your quest for knowledge as well as others. Good luck with your gout the so called Disease of Kings.

Endomethacin is a powerful anti-inflamatory. It is, in fact, the only medication that I've been able to use effectively during a gout attack. In some cases relief could come within a day or two. In other cases, however, especially if a tendon or ligament is affected, the inflamation can last for two weeks.

I never took Endomethacin during the day as it really can knock a person out. I do take strong dosages (100-150 mg) at night and allow it to do its work while I sleep.

Endomethacin does nothing to prevent crystalization, but does a good job at breaking up crystalization that has already occurred. It is also no good at curing the root of the problem: elevated uric acid levels in the bloodstream.

Doctors all tell me that Endometahin is a very strong drug. From the effect it has on my coherent thought process, I believe them, but I don't know why or what the negative effects of taking too much of it is. No doctor seemed to have a problem with the dosages I was taking.

Prednisone is the big guns of anti-inflamatories. It is not actually the last resort drug, there are more powerful ones, but it is a step over the steroid line. It is a steroid and should not be taken more than it is possible to get away with. Prednisone is given when Endomethacin and/or colchine just aren't doing the trick.

There is often some ignorance on how this drug should be given, but I've found pretty good consistency amonst doctors, that it is started at high dosages (80 mg/day all at once), then reduced with time. If a doctor has you "chasing" pain, by increasing dosages when lower dosages are not doing the trick, one might become suspect.

Update December 18, 2005
As of this date, I've spent nearly 10 months on Prednisone, to get my system accustomed to taking allopurinol. Looking back, I'd recommend highly against taking this path. If you must take prednisone, be sure you can restrict it to a couple of weeks in length of usage.

Prolonged use of Prednisone shuts down the adrenal glands. This is where we get our adrenalin from. For me, at least, this caused me undue psychological stress. In the early stages, the feeling was that of great euphoria, increased productivity and a seemingly unending source of mental energy. As time went on, however, my mood became very dark and life seemed extremely stressful. As I began to cut back on prednisone use, in an attempt to wean myself from it, I found times of near psychosis and internal rage. I've searched the web for corroboration of this experience and found some useful links here.

This is, evidently, not that common of an occurance as my doctor did not seem to believe that my feelings could be coming from the prednisone. In any case, I would recommend avoidance of this drug if at all possible.

As of Dec 15, 2005, I am no longer taking prednisone and I hope I will never be faced with the decision of taking it again.

Allopurinol is the over-producer's friend. It is designed to lower uric acid production in the body. Normal dosages for chronic, over-producer patients, is 300 mg/day, and is to be taken for the rest of one's life.

Well, you might ask, why haven't I been taking allopurinol for these past 20 years and avoiding the weeks and months of gout attacks I have suffered? THe answer is a bit complex, but has mostly to do with ignorance on both my part and the doctor's I've been seeing part.

Normally, when a doctor puts a patient on allopurinol, the body will react and produce some gout attacks. This is normal. My theory is that this is a similar effect as when I reduced the uric acid consumption with my low purine diet. The body just feels like it needs to make more uric acid, until it can adjust.

Consequently, doctors will put patients on both allopurinol and colchine at the same time. This seems to work for most people, as the colchicine keeps the crystalization from happening and the body begins to adjust to the allopurinol. Not so in my case.

My body seems to have a large intollerance to allopurinol. So much so that when I begin to take it, I get violent gout attacks, for which the dosage of 0.05 mg/day of colchine prescribed by the doctor had absolutely no effect. My past doctors did not seem to understand this, and in fact, must have written my stories of incredible pain off to exageration. For me this was very discouraging as I would finally have to stop taking allopurinol, just to be able to continue going to work and living my life.

I had one doctor get me on allopurinol successfully. However, it took three months of taking 0.06 mg of colchicine twice a day, until I could report 30 days with no gout before she would begin me on any allopurinol. When she did start me, she started me on 100 mg/day, rather than 300 mg/day. After one month on allopurinol and no gout attacks, I was very encouraged. However, a blood test showed my liver function (ALT) doubled. She immediately took me off of allopurinol as she felt this was dangerous. Interestingly, my current doctor saw the same result when he started me on allopurinol, but informed me that ALT did not get dangerous until it reached 10X the normal. Time lost to ignorance....

At this writing (May 12, 2005), I am on prednisone. I have been on it after a rash of the worst attacks of my life three months ago, followed by over two months of moderate attacks. As of today, I have been attack free for two weeks. I have also been increasing my allopurinol and am happy to say that I am at full dosage (300 mg/day), with no attacks threatening. After two months, my ALT has also returned to almost normal. This is all very encouraging.

Probenecid is the under-excreter's friend. It is designed to help get rid of excess uric acid because a patient's kidneys are not up to the challenge of filtering it out properly. While my previous doctor attempted to treat me with probenicid as an alternative to not being able to take allopurinol, it really did not do me much good as my body has no problem getting rid of the uric acid.

There is one detrimental side effect to probenicid in that it can cause kidney stones.

I spent little time on probenicid and learned very little about it.


Gout is a chemical problem, and it is treated with chemistry.

Endomethacin, colchine and Prednisone are anti-inflamatories for when gout attacks are occuring. Endomethacin is more effective than colchine, and colchicne seems to be a better "preventative" medicine of gout attacks. Prednisone is for when Endomethacin does not work.

Allopurinol is the over-producer's friend and Probenicid is the under-excreters' friend, and these treat the cause of the problem rather than the symptom.

Diet may help under-excreters, but will do little for over-producers.

Alcohol is bad for gout.


Update December 18, 2005
Friday, December 16, 2005 my blood test returned with a Uric Acid level of 4.6!!! This is the lowest I have ever seen it in my entire life. All other tests put the UA levels at 6.5 or higher, in later years hovering between 9 and 11, at times between attacks. My current doctor has successfully gotten me on allopurinol, which I will likely remain on the rest of my life.

I am now begining to experience a kind of remission. It has been weeks since my last attack and some of the built up tophae is begining to disolve away. I am thankful to God and to my doctor for what seems to be the end of a 20 year struggle with this crippling malady.

Update January 31, 2006
A visitor to this web page sends me an email making me aware of a new drug: febuxostat. Read an article here:

My doctor expects to use febuxostat for patients who are allergic to allopurinol. Because of the difficulty I had adjusting to allopurinol, I suspected I would be allergic, but it was not the case. Allergy to allopurinol displays itself with rashes and itching, etc.

According to my doctor, Febuxostat may not be any better than allopurinol for treating chronic hyperuricemia, but is good news for those who are allergic to Allopurinol.

Update May 29, 2007

One can see that I've not done much with this page for nearly a year and a half. I'm happy to report that the reason for this is that there has been little to report in "no news is good news" fashion. In the past year and a half I've had three mild gout attacks, which lasted less then three days and were very easily managed with endocin. It has been more than six months since my last attack. Any evidence of Tophi has nearly all dissapeared.

One of the side effects of gout was that I was nearly incapable of having a regular exercise program. That is, regular exersize would inevitably result in a minor injury, which would become inflamed and lay me up for weeks at times, breaking continuity. Since the gout has been under control, I've enjoyed a level of activity that I had nearly forgotten. The first year after my gout was controlled, I lost 40 lbs.