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Don Burns' |
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Bio Resume HangGliding Recipes El Inca Llora (a song about Peru) Gout |
Everything you ever wanted to know about Gout
I
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Upates
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