“Has GoutPal gone mad?” I hear you ask.
“Why is he always telling us that uric acid management is much more important than gout pain management?”
OK, I have not gone mad. First, let me remind you why managing uric acid levels is much more important than managing gout pain, then I will explain why I say “lowering uric acid is useless.”
Gout Pain And Tooth Decay
There is no link between gout and tooth decay, but regular readers will recognize my oft-vaunted (overused?) analogy.
When you visit a dentist to treat toothache, you expect an examination for decay, treatment of that decay, and pain relief to help you endure the treatment and associated soreness and gum inflammation.
Treatment for gout, ignoring complications such as allergies, and other health conditions, should be just as simple. Take allopurinol (or some other uric acid lowering therapy) and support this with pain relief, such as colchicine, until the allopurinol has removed the excess uric acid threat.
But what should be simple, rarely is.
Tooth decay treatment starts with drilling, and you know this is going to hurt. Do you know that, as with any uric acid lowering therapy, including diet, allopurinol treatment for gout can hurt? Many gout patients do not understand this, and so they stop taking the uric acid lowering treatment. The equivalent of leaving the dentist’s chair half way into the drilling process.
All dentists, and most of their patients, understand that all the decay must be drilled out before the cavity can be filled. Almost no gout patients, and very few healthcare practitioners understand that uric acid levels must be maintained below 6mg/dL (preferably below 5) to get rid of existing uric acid crystals. Frequent uric acid tests during uric acid lowering treatment are just as vital as frequent checks to see if all decay is removed.
Tooth decay treatment ends with agreeing an appointment for the next inspection. Nobody assumes that one dentist visit fixes everything. We continue with daily teeth cleaning and return to check all is well. The gout patient who has lowered uric acid long enough for all existing crystals to dissolve must continue with a daily maintenance dose of allopurinol (if necessary) and return for a uric acid test every three to six months. Even when symptom free, it is unwise to go longer than 12 months without testing blood for uric acid.
You can stop being a gout sufferer, but you can never stop being a gout patient.
Once you have had a gout attack, you have changed. You have lost your gout virginity. You can never become a person who has never had gout, but you do not need to return to being a gout sufferer. You just need to manage your uric acid level, and never let it rise above 6mg/dL again. Standard uric acid tests might declare you “normal” at 7 or even 8 mg/dL. See Normal Uric Acid Levels guidelines for more information.
You are not standard. You are not a gout virgin. You must not let uric acid rise above 6mg/dL.
Managing uric acid
So if I feel so strongly about the importance of uric acid, why do I say “Lowering uric acid is useless?”
Because “Lowering” is not enough – you need to manage it.
Lowering uric acid from 9mg/dL to 7mg/dL is pointless. It might slow down the rate at which new uric acid crystals form, but it will do nothing for the existing urate deposits that are eating into your bones.
Lowering uric acid to below 6mg/dL, then letting it rise back up to 7 is worse than pointless. You will get pain from old crystals dissolving, then pain from new ones forming. You will be in a mess.
Lowering uric acid is simply not enough. Here is how to manage it.
Get uric acid down to Phase 1 Target Level (usually 5mg/dL – agree something lower than 6 with your doctor). It does not matter how you do it, just do it. Allopurinol is the obvious choice, but there are medical alternatives.
You may be tempted to rely on dietary / lifestyle changes – this is fine, as long as you definitely lower uric acid, and not just seek to stop the pain. In practice, dietary and lifestyle changes are not quick enough to get uric acid levels down immediately, so it is better to support your lifestyle plan with immediate allopurinol support.
Maintain uric acid below the Phase 1 target level until you achieve six consecutive months without a gout flare. During this phase, you will experience gout flares, but they will become less frequent, and less intense.
These gout flares are due to your immune system reacting to old uric acid crystals as they dissolve. I know it is hard to convince you that such pain should bring you joy, but each time you experience a gout flare when uric acid is permanently below 6mg/dL, you are getting better. Compare this with occasional gout flares from new crystals when your uric acid level is higher – every day moving nearer and nearer becoming crippled.
After 6 months without a gout flare, you can be certain all existing gout crystals have gone, and you are no longer a gout sufferer.
No longer a gout sufferer, but still a gout patient. Uric acid tests every 6 months to stay below 6mg/dL.