How do uric acid crystals cause different pain?

[Barry]

I think I am recognising the “signs” of a possible attack but am a bit confused by the science of it all. Yesterday I spent the whole day wondering whether a “burning and broken” feeling in the usual right big toe and front of foot area was telling me an attack was imminent. Do I don’t I take some colchicine? I didn’t as it makes me feel ill so I took a chance. Anyway – it didn’t develop into a painful attack.
My confusion is this: surely it is the crystals that cause the swelling/pain. So surely you either get crystals forming or you don’t – I cannot really understand the concept of a “mild” attack. Once the level has reached crystallisation point then crystals form?
Maybe somebody can enlighten me.
Thanks
Barry

[Keith Taylor]

That’s a great question Barry, so I’ve split it from Tom’s post so it doesn’t get caught up in discussion of allopurinol and blood test results. I’m now going to try and explain the concept of uric acid crystals and different pain levels.

The science is confusing, and a lot of recent research reveals that we are only just beginning to understand the complexities of gout pain.

It’s all to do with our immune system. I understood the basics of this when I saw the white blood cells attacking uric acid crystals at http://www.goutpal.com/1810/uric-acid-crystal-pictures/

That made me realize that gout is an immune system disease. Nothing to do with “needle-like crystals” grinding into your joints. Having realized that, it’s the key to why we might get gout flares during the first few months of lowering uric acid. It also partly explains why some people see tomatoes as bad for gout – they’re probably lowering uric acid and releasing old crystals.

Because I bang on about it so much, many GoutPal visitors now know that dissolving uric acid crystals might cause a gout flare. We accept it because we know the importance of getting uric acid safe. But the actual pain process is very complicated. It relies on signalling processes within our immune system that the brightest brains on the planet are just beginning to understand. I’m struggling to learn all the terms involved in cellular human biology. Macrophages, leukocytes, interleukin are foreign to me, but one day I’ll understand it well enough to explain to a six-year old.

As I understand it, white blood cells attack free uric acid crystals. Once they’ve engulfed them, the coated uric acid crystal is hidden from the immune system, and inflammation stops. The complex stuff is why inflammation happens. Not all white blood cells are alike, and they can change. Some promote inflammation – presumably to signal for more reinforcements. Some inhibit inflammation. The organic chemical reactions that form the signalling processes are beyond my understanding at the moment. However, I do know that other substances, besides uric acid, are involved in the process. Recent research suggests that Free Fatty Acids (FFAs) are probably involved. A study on mice showed that uric acid crystals alone do not produce gout flares.

One way I try to think of it is like fire. We heat our homes as safely as we can, but if fire gets out of it’s cage, we call for help. We might first try to smother the flames. A wet tea towel on burning toast is probably enough to combat the risk, but what about the smoke? That might be a signal to nearby people to lend a hand. But what about our fire alarm, or smoke drifting out to the attention of neighbors? It’s easy to imagine several scenarios from “No Dramas” to “Fire Service wrecking the house” Different signals produce different situations, and that is what’s happening with our immune system tackling the threat of uric acid crystals.

I’m not going to pretend that this shoddy explanation will enlighten you, Barry. But, I’m hoping it will lay the foundation for the sort of discussion I love. We’re pushing boundaries here my friend.

I’d better finish with an @bazzer mention to ensure you know I’ve moved your message here.

[Barry]

Thanks Keith!
You obviously have suffered plenty to be taking all this so seriously! Great and keep it up – glad I found this site!
Regards
Barry

[Barry]

Trying to understand …..
Now – colchicine supposedly inhibits swelling – is it therefore stopping the white blood cells doing their designed job? and if so then this is bad? does colchicine prevent the white blood cells attacking the crystals? or just the resulting imflammation? I am a bit nervous that I am interfering with my white blood cells by taking colchicine?
thanks again!

[Keith Taylor]

That’s a brilliant question about colchicine, Barry. I’m sure I’ll be thinking about that for months.

My understanding so far is that colchicine reduces the ability of white blood cells to split and multiply. That process triggers inflammation, so colchicine effectively stops inflammation getting worse, or at least slows it down. This is obviously not the best way to treat our immune system. Doctors justify this, as with just about all medicine, by balancing the risk. So, the argument for colchicine is that a little bit of immune system poisoning is justified if it stops the immobilising agony of a gout attack. The argument against is that it reduces the number of white blood cells available. Balancing those two things is an individual decision, that might vary depending on your stage of a gout attack and your stage of gout treatment. In the past, colchicine has definitely been oversubscribed. I hope modern doctors are aware of the need for caution when balancing the risks. They should always limit prescriptions to no more than two colchicine a day.

I usually add a caution to avoid colchicine if you are at risk of infection. I believe this as I think you need the best available white blood cell army to fight any bacteria or viruses. Until today, I never thought about colchicine compromising the ability of white blood cells to engulf uric acid crystals.

This is quite complicated to me, because I don’t think that uric acid crystals should be there anyway. If white blood cells merely hide them, is that good or bad? Maybe there are enough cells in most cases to deal with free uric acid crystals, and the intense inflammation might be an over-reaction?? I just don’t know. 😕

I think it’s always right that the patient should choose whether to take prescribed treatments, but the doctor should explain the risks so we can make informed choices. I feel it’s my job to try and see things from the patient’s and the doctor’s points of view. Then try and agree a plan that best balances medical risk and patient aspirations.

I take it seriously because I love problem-solving (nearly 50 years as a Sherlock Holmes fan). I have been affected by gout physically and mentally, but I learned to deal with it. Mentally, I’ve been more affected by the terrible lack of consideration, communication, and care that exists in the world of gout. Some days it’s frustrating, but I always enjoy the challenge. This latest challenge – the curious case of the colchicine and compromised white blood cells – is fascinating.

Maybe I should get out more 😉

[Barry]

Thanks again for your time Keith.
And sorry if I have muddied the waters for you – or maybe NOT sorry as you confess you like solving problems!
I think I will try to avaoid colchicine but will take it if I get a severe attack – just not willy nilly start a course if I suspect an attack is imminent.
It’s all about finding out what works best.
Thanks again
regards
Barry

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