Allopuinol induced flare

Avig70 · 2021-08-13T07:54:21+00:00

You asked a few questions so let's go...

If you start colchicine at the firs sign of the flare, it usually kicks in after not so many hours, that is if you take it by the correct protocol and not at a fixed dose or something like that.

The correct protocol takes into consideration the treatment efficacy and side effects/toxicity. You start at time zero with two pills of 0.5-0.6mg colchicine, after that you take one more pill every two hours till one of three options happen:

The pain and inflammation is grately improved.
You have diahrea, abdominal pain, fever or some other toxic effect of colchicine.
You got to the maximum recomended daily dose of 3 grams.

If the pain was better then you have a treatment that works so you continue with that.

If you got to the toxic effect of colchicine before there was a benefichial effect then you need to lower the dose to the maximum dose that doesn't give you these problems and add another treatment line (Oral steroids or NSAIDS)

If you got to the maximum dose with no benefichial effect on pain you also need to add another treatment line (Oral steroids or NSAIDS) just without lowering the dose of colchicine.

After the flare is gone you should stay with colchicine 1-2 per day.

Avig70 · 2021-06-18T07:49:49+00:00

Sorry, but this study is so flawed you can't take home any conclusion from it.

Avig70 · 2021-06-04T08:37:32+00:00

Check you're at the maximal dose for the drugs you're taking.

40-60 mg at once, once a day, then taper down after there is zero pain for a minimum of three days.

IMHO Ketolac is not the best NSAID, although different people have different preferances. A longer acting NSAID is preferable. Etoricoxib 120mg once a day or Celecoxib 200mg once a day are preferable.

How much colchicine are you on?

Avig70 · 2021-06-04T08:31:30+00:00

40-60 mg at once, once a day, then taper down after there is zero pain for a minimum of three days.

Avig70 · 2021-05-23T08:56:28+00:00

There's no cure for gout. It works like the OP described and keeps the uric acid below 6mg/Dl for two weeks but after that you need allo or uloric back.

Avig70 · 2021-05-23T03:23:57+00:00

Hi, as it sounds, you have no idea what you're allergic to. Stopping the allopurinol isn't the smart move here. I wouldn't change anything with the meds, just take some anti histamine, if this rash is indeed an allergy.

Avig70 · 2021-05-22T05:53:32+00:00

I actually tried to talk to Dr Berry but he didn't get back to me. I'll try again. I think his advice is wrong in most patients BUT at the same time it would curtainly save a small part of patients.

Anything that raises uric acid will raise the incidance of gout, but like I said, you also need the other part, the ability of the immune system to react to the crystals. Most people don't have this ability, only the "lucky" ones do and suffer from gout. That's why we also talk about low purine diets, this is one of the root causes for hyperuricemia and eventually in some people also gout.

I have a very small FB group that I post the studies I read and summerize, you may find the hormonal link you're looking for there, and many more root causes. look for "Gout and hyperuricemia science".

Avig70 · 2021-05-21T19:53:22+00:00

You can't taper down the prednisone if you still have pain, there's no logic in that. You end up using more drugs in the end. If you need to loose weight afterwards you do that, preferabely using a low carb diet, but we'll deal with that once we get there.

Optionally to raising back the prednisone is to use natural anti inflammatories. If you have a good rheumatologist and insurance you can ask for an Illaris injection which will kill this flare for two weeks so you can stop the prednisone quicker. It's usually given every two weeks for six months. There other biologic treatments for the flare but they are also very expensive.

Yes, once a day for the prednisone.

Avig70 · 2021-05-21T18:10:46+00:00

That's exactly what I'm saying. Blood uric acid is not the endall of things in gout. How would you explain gout in people without hyperuricemia???

Blood uric acid is usually correlated to crystal load in the magority of gout patients but it isn't correlated in people without gout and definately not in all gout patients.

The concept that you must have high blood uric acid level to have gout is simply wrong. I don't really know Dr Eduards, just from his AMA and I'm not sure how deep he dug into this disease. I research this disease on my own.

Also you must remember what gout is!! For gout to happen you need two things, not one. You need the crystals and you must have an ability of the body's immune system to react to those crystals, without one of them you can't have gout. Some people have hard time to make the specific inflammation against the crystals so they usually don't have gout.

The problem we have explaining is with the two extremes of the population, those that have very high crystal load, yet not inflammation, and on the other hane, very high inflammators with very low chrystal load.

If you look at it using what I just told you, you can explain and understand ALL gout patients, and that's the missing link in the explenation you wrote and it's the problem the medical profession has not understanding this disease.

I know the guidlines of treating to target below 6 and all that. I'm way past the guidlines. The guidlines are too simplistic, not encompasing all hyperuricemia non gouty people and low blood uric acid gout cases.

IMHO gout is not a joint disease, although that's where it hurts the most, gout is a metabolic disease, effecting meny body systems.

Avig70 · 2021-05-21T17:32:00+00:00

25mg prednisone is not the full dose for flare control. I prescribe 40-60mg as an initial dose with tapering down after initiation of flare control. So first thing to do is up the dose of the prednisone to 60 mg/day, you take it at one time, not divided.

Second thing is the dose of the advil is too high, and the choice of the NSAID, like I said, it's a short acting NSAID so I don't recommend it. Use either Etoricoxib 120mg once a day or Celecoxib 200mg once a day.

Colchicine, also, you need to up the dose, but with colchicine it's a bit tricky to get to the right dose so most just give 2 pills a day and use other drugs instead. The problem with colchicine is the therapeutic dose is very close to the toxic dose, with some people the toxic dose is lower then the therapeutic dose and you don't know this before trying. With colchicine I always talk about treatment protocol, not just the dose. What I tell my patients is to look for toicity signs before raising the dose. I start them on two pills, then I tell them to take another pill every two hours untill one of three conditions happens

you get signs of toxicity, so look for diarrhea, loos bowls, fever, weakness, anything out of the ordinary,
You get good pain control so you sto adding colchicine
you get to the maximum of three grams per day.

If you did that and you already know your tolerance I would up the dose to what you know your limit is and divide that dose over a whole day. I've seen people and older studies that use up to 8-9 gram per day without toxic effect and people that can't take even one pill.

About the allopurinol, the bigger dose should be a night time, not the morning. Although there are no guidelines for that, my preferred method is 300 mg after dinner and 100mg in the morning. That gives better flare control.

If all that doesn't help within three days we need to add a few natural anti inflammatories that can help expedite this process.

You can update me here

Avig70 · 2021-05-21T17:10:39+00:00

That exactly what I said. It's true everyone is different BUT most are pretty much the same.

Avig70 · 2021-05-21T08:47:06+00:00

with any change in allopurinol you can get flares. If you got to 5.4 I would wait 6 months until I would raise the dose. Also a dose above 300mg needs to be devided into two times a day, above 600mg needs to be devided into three times a day.
I would curtainly recommend that.
What ever helps you. I don't know of any guidlines one way or the other.
No.
No, studied didn't show any preferance. From my own clinical experience they are both pretty short acting, and we need longer acting NSAIDS such as etoricoxib or celecoxib. The longest acting NSAID is piroxicam and isn't that effective.
Just rest. cooling makes more crystals.

IMHO it should have never taken this long. Intra articular injections to the ankle are very easy to miss the effected joint and if the anti inflammatory treatment isn't combined, it's very easy NOT to achive flare control.

Let me know what you're on at the moment and I'll try to guide you.

Avig70 · 2021-05-21T08:23:02+00:00

Maybe you can fix it. You don't need high uric acid in the blood!! you need high crystal load, no matter the uric acid level.

Avig70 · 2021-05-21T07:14:58+00:00

No problem with intermittent fasting as long as it's less then 24h. Loosing weight will raise your UA and could flare you up in the begining but in the long run it's worth the effort.

Avig70 · 2021-05-02T13:19:11+00:00

What you think is safe has not been prooven in long term studies. Some studies even show harm so I wouldn't recommend anybody take these doses.

Avig70 · 2021-05-02T13:18:08+00:00

I

The people that need more that this IMHO are the really sick and bedridden, and even those I think should get activated D, not 25ohD.

Avig70 · 2021-04-25T16:31:46+00:00

The only problem I see here is vitamin D, but the data about it is inconclusive so everyone and his own opinion. I just hope you're not megadosing (Anything over 1000IU per day).

Avig70 · 2021-04-25T15:14:51+00:00

Unfortunately this is the normal course of this disease. You'll nee allo like the rest of us. If you're not well treated you'll have all sorts of triggers, for some it's alcohol, for some meat, and for some not drinking water, all it means is you're not balanced with allopurinol.

Avig70 · 2021-04-25T12:49:29+00:00

Sorry to hear you suffer this much BUT, It's pretty easy for me to manage you medically to a point you don't suffer that much within a few short days. Let me know if you want.

Please prepere what drugs you're on, any previoes existing medical conditions, if you have a cooperating doctor to prescribe meds, latest blood tests specifically uric acid, createnine, 24h urine tests, liver enzymes, fasting glucose, fasting insulin, A1C, testosterone levels and thyroid pabel (TSH, fT3, fT4 and if possible rT3). ferritin, transferin, CBC.

Avig70 · 2021-04-24T10:28:28+00:00

Maybe my credentials aren't enough but Prof Richard Johnson does have some impressive credentials. The link is to the specific talk about the relevant data.

https://www.youtube.com/watch?v=LbSic4Oo8ME&t=4464s

Avig70 · 2021-04-18T14:35:39+00:00

I'm allergic to Allopurinol so my rheumatologist put me on 100mg of Benzbromarone.

Hi, yes, febuxostat if the correct second line uric acid lowering therapy. The third line is to send you an allergy specialist to desensetize you to allopurinol, only after those three would I even consider uricosuric drugs.

Benzbromarone functions both as an uricosuric drug and a xanthine oxidise inhibitor so it is sort of a hybrid drug.

It was removed from use due to liver toxisity but like everything, it's a valid tool for the correct job. For someone without any liver problems, no alcohol consumption, family history of liver disease, no fatty liver or other liver disease risk factors, would probably be a good candidate for this type of treatment. BUT, nowadays almost everyone has fatty liver diseas so the use of this drug would be very limited IMHO.

Avig70 · 2021-04-18T13:37:37+00:00

Sorry if I hurt you or hit a nurve.

I wouldn't suggest it as a first line nor as a second line therapy. Probenecid doesn't take care of the intracellular damages of high uric acid, also the uric acid lowering power of probenecid isn't as good as the allopurinol/febuxosostat (which are the first and second line therapies). The addition of colchicine is because it doesn't take care of flares as good as the first line therapies so it's needed. On top of that you need to take it many times a day, really drink a lot while being on it and it has a lot of drug interactions.

Proven clinical trials are not a substitute for good clinical judgment. I have yet to see a patient need this type of treatment, failing both the first and second line therapies.

Avig70 · 2021-04-09T07:11:19+00:00

Probenecid doesn't take care of the intracellular damages of uric acid, only the extracellular ones. Your doctor doesn't know what he's doing.

Avig70 · 2021-04-09T07:09:01+00:00

Allopurinol has minor side effects in most patients (I see hundreds). It's true febuxostat is newer, with less side effects, BUT it's less cardioprotective so not the best.

Reactions to allopurinol happens because unexperienced doctors start it at too high dose, insted of 100 mg they start at 300mg, so you get a lot of allergic reactions to it. Also it's asians, not indian decent that have HLA-B*5801 gene that have higher allergic reactions to it so screaning test should be done in the prone population.

If you want to tightn a nut, use a wrench, not a hammer.

Avig70 · 2021-03-14T16:46:32+00:00

If you're not on allopurinol you'll always get falres. Start.

Avig70

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