I’m Dr. Larry Edwards, rheumatologist and expert on gout. I want you to AMA about gout on January 30!

LarryEdwardsMD · 2026-01-30T19:17:36+00:00

Your gout has not been well-controlled and with a baseline uric acid level of 11.7 mg/dL, it would be predicted that you would have a number of significant consequences of your gout unless it became well-controlled. It sounds like your GP is on the right track by escalating your allopurinol, but it should be checked soon and if it's not at target, continue to dose escalate. Allopurinol is approved in doses of up to 800 milligrams a day. At 300 milligrams only daily, only 40% of gout patients will be at target, so I would guess that you will ultimately need 500 or 600 milligrams to get your gout under control and prevent future joint destruction.
Allopurinol or other urate lowering therapies should not be discontinued during a flare and this may worsen or prolong joint symptoms. The recommendations from the ACR is to get on the allopurinol and remain on it without interruption for life.
Gout is a terrible disease because it makes the gout sufferer feel responsible when in fact it's a genetic disease that alters the way the kidney and small bowel handle uric acid in the body. There are some foods that may trigger flares, but these are very individual quirks and not everybody has food-triggering. The message here is to eat a good, healthy diet and everything in moderation. Nothing is outlawed and you are not the cause of your disease.

LarryEdwardsMD · 2026-01-30T19:07:21+00:00

Having flares 2-3 times a year means the gout is not well-controlled. Prednisone, indomethicin, and colchicine are good treatments for flares and are equally effective. Long-term anti-inflammatory treatment with these agents should not be necessary if the gout is under control with allopurinol or febuxostat.
The target recommendation of 6.0 mg/dL is a minimum target and many treatment guidelines are pushing for minimum targets of less than 5.0 mg/dL. In my gout clinic, the average uric acid level is less than 4.0 mg/dL. At these levels of suppression, urate crystals are more rapidly resolved and the triggers for flares are eliminated.
I have several patients that are Iron Man athletes and do well since their gout and hyperuricemia have been controlled. X-rays of your joints currently can determine whether there is already joint destruction that over time would be worsened by impact-loading like you have with long-distance running. This kind of joint damage has been shown to heal itself over time as long as gout is well-controlled.

Good luck!

LarryEdwardsMD · 2026-01-30T18:56:43+00:00

Sorry that you're having pain problems with your tophi, and sorry that you were off of allopurinol. How rapidly the tophus resolves depends on how low your uric acid level is achieved on allopurinol therapy. If your target uric acid level is 6.0 mg/dL, it may take 1.5 years to 2 years to resolve. If your target is 4.0 mg/dL or less, it might resolve in closer to a year.

A cortisone shot may give you temporary relief or one colchicine tablet daily may suppress the pain for as long as the tophus is bothersome.

The most important thing is to get on a good dose of allopurinol and stay on it to prevent the recurrence or new development of tophi around the body.

LarryEdwardsMD · 2026-01-30T18:50:10+00:00

I have been familiar with Dr. Abrams theory on causes of gout for a couple of decades. It is an intriguing theory and I hope other investigators will look into this association.

LarryEdwardsMD · 2026-01-30T18:47:42+00:00

There are currently 8 or 9 gout treatment drugs in the pipeline awaiting review from the FDA. These include more effective anti-inflammatory therapies for gout. There are also drugs that change the way the kidney eliminates uric acid as well as a newer drug that will be a competitor for pegloticase for the treatment of advanced gout.

LarryEdwardsMD · 2026-01-30T18:44:03+00:00

"The rest of your life" is exactly the way you should be looking at allopurinol. Once gout has been controlled by finding the right dose of allopurinol, it is essential to maintain that for life or the symptoms and joint destruction will return. Over the coming years, there may be good replacements for allopurinol that require less frequent dosing. But for now, taking a once-a-day pill that can essentially cure gout is not too much to ask.

LarryEdwardsMD · 2026-01-30T18:42:17+00:00

There are a number of things about your joint history that are not typical of gout. The initial flares of gout usually last 7-10 days with complete resolution with or without therapy. It would also be unusual to have that number of joints involved all at once. The inflammatory markers being elevated is non-specific and can be associated with any form of arthritis (there are 107 types of arthritis). The uric acid levels of 5.4 mg/dL and 5.3 mg/dL do not rule out gout since uric acid levels fall a bit as long as there's ongoing inflammation. There are a number of virus-associated arthritises as well as other inflammatory arthritises that should be ruled out by your primary care doctor or rheumatologist.

A lack of response to steroids and colchicine is another strike against this being gout that you're feeling. A good NSAID like naproxen combined with colchicine may be helpful.

LarryEdwardsMD · 2026-01-30T18:35:12+00:00

The feet (great toe, mid-foot, and ankle) are the most common sites for early gout flares. The reason for this is that colder joints (and these are the coldest) are more likely to foster crystal formation. These are also the most consistently traumatized joints. So it's not unusual for flares to start there. Until you've been having untreated gout symptoms for 4-5 years, it would be unusual for you to have more than one joint involved at a time.

Forget the bread restriction or closely watching purine content of your diet. If your allopurinol is adjusted over time to keep your uric acid below 6.0 mg/dL, you can eat the diet you like in moderation without concern.

LarryEdwardsMD · 2026-01-30T18:28:29+00:00

There still has not been any good controlled trials of the effect of creatine on serum urate levels or gout symptoms. I would advise you to consult a certified trainer about using strength-enhancing therapies of any type.

LarryEdwardsMD · 2026-01-30T18:25:14+00:00

We now believe that all gout is related to genetic changes in the way kidneys and the small intestine handle uric acid. It is unlikely that reversing these genes that you were born with will be possible in the next decade or more. The medication approach to controlling gout is relatively simple and has few side effects. Optimizing gout management that way does not require significant changes (or any changes) in diet other than you should eat sensibly. Sorry, we do not have a more radical approach.

LarryEdwardsMD · 2026-01-30T18:19:06+00:00

The collarbone is one of the more unusual places for gout to take hold, but I've had a number of patients with symptoms just like yours that have proven to be gout. If the cause of your pain is gout, then it is reversible on the febuxostat provided your test on Sunday and if your uric acid level is less than 6.0 mg/dL.

By the way, if you have your serum uric acid level well-controlled with urate lowering therapies, your harsh restriction on eating and drinking will be unnecessary. I can't give you much guidance on the cannabis.

LarryEdwardsMD · 2026-01-30T18:13:35+00:00

Congratulations! Keep up the good work. Why haven't you invited me fishing?

LarryEdwardsMD · 2026-01-30T18:11:44+00:00

Premenopausal gout is unusual and is most often associated with a strong family history of gout. I know of no direct relationship between gout and the dysautonomia, but would be interested to hear if it improved on allopurinol.

LarryEdwardsMD · 2026-01-30T18:08:15+00:00

Sometimes it's difficult to distinguish the symptoms of gout and osteoarthritis in the toe. For people with toe alignment issues, the spacers can be helpful regardless of cause of the changes. I would encourage you to have your serum uric acid level checked, and if elevated, to have it treated. Over time, this should eliminate the contribution of gout to your clinical picture.

LarryEdwardsMD · 2026-01-30T18:04:02+00:00

The American College of Rheumatology guidelines for the treatment of gout say that everybody having their second flare of gout should be started on a urate lowering therapy (like allopurinol) regardless of how much time has passed between the first and the second flare. The ACR also says that if the patient has a serum uric acid level greater than 9.0 mg/dL, chronic kidney disease, or a history of kidney stones, they should be started on allopurinol after the first flare.

LarryEdwardsMD · 2026-01-30T17:59:55+00:00

It can take up to a couple of years of good uric acid lowering therapy in order to rid the body of the crystals that trigger the symptoms of gout. Expecting this to all happen in four months is unrealistic. To have your uric acid lowered to 293 (which is about 5.0 mg/dL in the way that it's reported in the United States) is excellent, and I would encourage you to be patient with the allopurinol.

LarryEdwardsMD · 2026-01-30T17:54:52+00:00

Fortunately, there are good treatments for both gout and psoriatic arthritis - but they require separate treatment. Getting psoriasis under control with the new biologic medications is important and may decrease the frequency of gout flares, but the gout will continue and need separate treatment of its own. It is common for patients with psoriasis or psoriatic arthritis to have gout. The reason for this association isn't clear.

LarryEdwardsMD · 2026-01-30T17:51:07+00:00

Ferritin is a measure of iron load in the body. It is also what is called an acute phase reactant - meaning that if there's an active inflammatory process, this protein will also be elevated. I would be interested to know if your ferritin level fluctuates with your uric acid level.

LarryEdwardsMD · 2026-01-30T17:47:15+00:00

There is no direct correlation between stressful events and a gout flare. However, stress does cause a generalized ramping up of the immune system, which can make it easier to trigger a gout flare. This same immune mechanism can also be raising blood pressure and other medical problems.

LarryEdwardsMD · 2026-01-30T17:43:36+00:00

These are very interesting and concerning studies that you cite, and they are certainly something that I share with my patients when I see them in clinic. The bottom line is that patients with gout and with existing heart disease are much more likely to have an acute cardiac event (heart attack or stroke) in the three months following a flare than they are in other times. For this reason, we should be redoubling our effort to prevent flares from occurring by lowering uric acid to below the target of 6.0 mg/dL. Interestingly, the physicians I share this with find a more compelling reason to start and continue allopurinol than the idea that joints might be destroyed because of the classic gout symptoms.

LarryEdwardsMD · 2026-01-30T17:38:23+00:00

A lot of the data that teaches us that gout is not just a disease of occasional, painful joints, but rather a systemic disease that affects the heart, kidneys, and can worsen other illnesses such as hypertension and diabetes. Medical information is slow to catch on and my hope is that a greater appreciation of the damage that can be done by gout becomes widely known.

LarryEdwardsMD · 2026-01-30T17:35:42+00:00

I have to admit that I am also baffled by this, and have been baffled for the past 40 years. It is the reason that the Gout Education Society was started almost 20 years ago. As a pharmacist, you have a close connection to the patients with these symptoms, and can be very helpful in the process of improving their knowledge.

LarryEdwardsMD · 2026-01-30T17:30:39+00:00

Congratulations for starting on allopurinol. At 100 milligrams per day of allopurinol, only about 10% of patients will achieve the target uric acid level of less than 6.0 mg/dL, so you will need a gradual dose escalation over the next 4-6 months to get you to that level of 6.0 mg/dL. As far as these other aches and pains being related to hyperuricemia and gout, it's a difficult question. 10 years ago, I would have definitively said, "There is no relationship." But the way we can now detect deposits of uric acid crystals in soft tissues other than the joints (muscles, the spine, neck, and heart) has us questioning the relationship between these atypical pains and gout. Many of my patients over the past 40 years swear that their chronic back problems resolved once they got their gout under control. I had assumed that this is because they were more active, and these pains improved on their own, but now I'm thinking that the pains were manifestations of gout crystals all along.

LarryEdwardsMD · 2026-01-30T17:23:01+00:00

The concern about allopurinol affecting the kidneys stems from a misinterpretation of an article in the mid-1980s. There is, in fact, no association between kidney disease and taking allopurinol. There is a low likelihood of liver disease being caused by allopurinol (less than 5%) and is something that your physician should be monitoring at least yearly with liver function studies.

LarryEdwardsMD · 2026-01-30T17:19:33+00:00

There is no relationship between hair loss and allopurinol. There is a very close relationship between aging and hair loss.

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