No More Gout Attacks

Rheumatology can be a challenging field. Often, we don't have a specific lab test to count on to make a diagnosis. Listening to the person in front of us and doing a good physical exam is so important. And then, when we do make a diagnosis, science is not quite there yet for us to know the exact right treatment for the person right in front of you. For rheumatoid arthritis, we know methotrexate is the gold standard, but we also know it won't work for everyone. We just can't predict it yet. So, it's trying to figure out the best path forward for every person we see.

That can't be said for gout 99 times out of 100. While not always, gout can be diagnosed clearly by identifying uric acid crystals in the joint, either by a joint tap (taking fluid out of the joint and analyzing it) or more recently, through a sophisticated type of CT scan that can identify uric acid crystals.

Once diagnosed, having future gout attacks really is preventable. You would almost think we would have made gout nearly extinct by now. Except, we haven't. We haven't done a good enough job learning the rulebook on gout, but if we all followed it, we'd probably cut gout attacks down by 90%.

So, what are the rules to prevent gout attacks:

1) Not so much rule, but a principle to follow. Gout is caused by high uric acid. So, the goal of treatment is to lower blood uric acid and keep it low. Depending on what units you're using, that means getting uric acid below your target of 6 mg/dL or 360 umol/L. If you can't reach that target, you will likely continue to have attacks.

2) If that's the principle, then the first rule is that the dose of the most common treatment to prevent gout - allopurinol - is not a single dose. The dose is entirely based on reaching the target uric acid. If your dose of allopurinol has your uric acid above your target, then it's not going to work. It's like not taking it at all. You and your health care provider need to continue to slowly increase allopurinol dosing until the uric acid has reached the target.

3) Once the target is reached, continue allopurinol. Don't stop for anything (other than side effects). If you get a gout attack, continue allopurinol. When the attack stops, continue allopurinol. Don't lower the dose or increase it. Just keep it going. In the first 6-12 months of the right allopurinol dose, you still may get attacks. That's normal and your body still adjusting. Keep things going and you will get there! If you follow these first two rules, you will likely do great!

4) Have colchicine on stand by. Colchicine does not lower your uric acid levels but it can help with gout attacks. Often, it's a good idea to take colchicine regularly when starting allopurinol to prevent attacks during the adjustment period. Once allopurinol is sorted out, have a colchicine tab on standby. If you think - just think - you may be having a gout attack, take the colchicine right away as it may abort the attack.

5) Drink less beer. Alcohol is a big risk factor for gout and higher uric acid levels. All alcohol increases uric acid but beer is particularly not good for you. Some folks can treat gout entirely by cutting beer from their diet.

Gout treatment can be much more complicated than this, but for most people, this does the trick. Speak to your health care provider to ensure you are on the right path and gout can be gone from your life for good.

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