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Hello.
I am in desperate need of some other opinions. I will preface this with an apology for being so long but I think it’s necessary to fully understand my condition.
I am 45 male. I have suffered from gout since I was 33. Up until this year I averaged maybe 1 flare up a year. In all but one instant it went away in a few weeks and I just treated it with ibuprofen. Not really sure why I even have gout. I am not over weight, I work out religiously and watch what I eat. I did drink moderately. 12 to 14 drinks a week probably on average. All my gout flare ups until now have been in either my left or right big toe. For the past 5 years it has only been in my right toe.
This past January I moved from Atlanta to Boston and within a few weeks had a severe gout flare up in my right big toe. This flare up lasted for months. I tried everything on my own from drinking large amount of water and drinking cherry juice. Finally in the first week of April my skin ruptured on my big toe and tophi came pouring out. I knew at that point, lifetime medication was in my future. I went to the doctor and he prescribed colchicine and allopurinol. He wanted me to take the colchicine for 2 weeks before starting the allopurinol. Once started I was to take 50mg the first week, 100mg the second week, 200mg the third and fourth week and finally 300mg from then on. At that time my uric acid levels were 7.2.
Here is my current situation. After about 4 days on the colchicine, my big toe shrank to normal size and looked better than it had in years. I was able to walk normally for a couple of days. But then I started noticing pain in the outside of my foot in the area between the fifth metatarsal and the cuboid bone. At first I thought I had just strained some muscles or tendons from walking normal for the first time in 4 months. (I will add here that I had stopped drinking so much water once my toe shrank back down) After a month it was not better so I went back to the doctor. I had x-rays and an mri and neither showed anything other than inflammation in that area. At this point I had started the allopurinol and had just finished the first week of 50mg a day. My uric acid level was at 7.5. It had actually gone up.
My doctor was still convinced that it was gout and he put me on a 6 day run of prednisone. It had very little effect. My doctor wants to wait another few weeks and re-test my uric acid levels before doing anything else. Up until now there was no pain except when I walked and it was only minor discomfort that forced me to walk with a slight limp.
However, last night one of my children left a small toy bead on the tile floor. I stepped directly on it with my heel. My foot reflexed from the pain to get off the bead forcing me to use the muscles and tendons in the affected area. The pain was severe. The mental image I had as I was going down to the floor was the muscles and tendons being ripped apart. For the next hour I was not able to put much pressure on it at all without severe pain. This morning when I woke up it was better but it is still quite painful to walk which I do with a severe limp.
My question is, do you think this is gout? If not, what else could it be and who should I go see. I would appreciate any insight anyone can give me. I have been limping for almost 6 months now and I am becoming very discouraged at this point.
It is almost certainly gout. Almost every word of your description supports that.
There are some common misconceptions that cloud the issues.
- Diet often affects gout, but it is rarely a cause. The food & drink issues surrounding gout are always overplayed. It can be a factor, but hereditary issues with regard to kidney function and purine metabolism are the main causes of gout, together with medications for other conditions including high blood pressure and cancer..
- Uric acid levels often fall during an acute gout flare as uric acid moves from the blood into the joints and other tissues.
- Colchicine and prednisone are both painkillers. They should releive pain symptoms, but do nothing to get rid of the uric acid which is the root of gout pain. Colchicine is usually the best for gout.
- Untreated high uric acid leads to an increasing number of joints being affected. You do not always notice this build up, as pain does not always result immediately from slow build-up. The pain comes when the immune system sees uric acid crystals. Trauma can easily trigger this reaction, though it can also occur simply because a concentration threshold has passed. Your immine system often coats crystals without too much immediate reaction, but when a certain (unknown) amount of uncoated uric acid crystals are floating around, the immune system calls in reinforcements, and these signals are what cause the inflammation and pain.
The allopurinol approach suggested was the right one to take, and gets more and more urgent every day. However, keep getting tested even when on 300mg dose, as this is not always the final step. Dose can be up to a maximum of 900mg. The dose should be determined by your uric acid level, which needs to be lower than 6mg/dL. For the first few months of treatment, a level much below that (say 3 to 4 mg/dL) will ensure you dissolve existing urate crystals faster.
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.
Thank you both for you responses. I am now taking 300mg a day and have been for 4 days now. I am due for another uric acid test next week. I still have pain in my foot and can not walk normal. It has been with me now for about 6 weeks I think (not counting the prior 4 months with the big toe). Any ideas on how much longer before I can hope to walk without a limp. I am so used to being extremely phyiscally active and this sedentary life style is driving me insane.
I had been suffering with gout for over 15 years when I had my first attack in that part of my foot, and I had my wife drive me to the emergency room because I thought for sure that I'd broken my foot. It never occurred to me at the time that it was gout, even though I'd been dealing with it in other joints for years. The longest I've had the effects of an attack last was one I had in my elbow that took almost a year to return to normal. I hope this doesn't happen for you!!
Usually the first couplee attacks last only a few days…mine went away by themselves in 4 days. But then my fourth or fifth attack, the doozy, lasted a full 9 days before I could stand it no moe and did a husge dose of colchicine aborting the atttack.
So after 4 days that attack should stop soon.
Confused?: I see 2 posts by twstephens but the number of Posts under his name says “posts 1”????
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