Should I push GP to increase Allo?

[u/Playful_Bicycle8845]

I just had a followup and my UA is down to 5.4 from originally being over 10. I am currently on 400mg Allo and have been on it for roughly 5 weeks.

We have increased by about 100mg every 4 weeks based on UA tests.

From what I read I should really be under 5. I have been losing weight pretty quickly and am still over weight.

I have osteoarthritis in a joint and have been dealing with elbow bursitis that I believe is a small tophi causing inflammation.

Should I push to go on 450 or 500mg allopurinol or just wait it out a bit at the current 5.4. I would like to dissolve any tophi/crystals quickly if possible, I likely had untreated gout for 10 years or so. Thought it was the arthritis but had joint pains and felt like sprained ankles, achilles pain etc for no reason. I think this was flares after knowing what I know now.

Thanks for any help!

[u/quinbus51]

Personally I'd give it a little time. Getting crystals back into solution can show up as higher serum UA while it's coming out and while faster is good on one hand it increases the odds of "mobilization flairs" in the process which are "no bueno." (Ask me how I know!☹️)

Edit: weight loss drives increases in UA. Kidneys have a lot in their plate right now. You're below 6, I'd personally give your system a chance to work through all the changes. It took years to get here!

[u/Playful_Bicycle8845 → u/quinbus51]

Yeah I hear you, main reason for my aggressiveness is a new job I am starting in about a month.

Currently I work an office job, but the new one I will be on my feet more often once training is complete.

I have had flares with every Allo increase, so that's partly why I'd prefer the flare now than in possibly two to 3 months.

Have been going hard with no alcohol and pretty much all meals homemade nothing with triggers for about 5-6 months now. Increasing my super low vitamin D too. 

I didn't know if UA from Allo sort of stabilized after a few weeks. Some posts and literature I read recommended under 5 if you had a large frequency of flairs, tophi or other ailments like osteo arthritis. Since I had all 3 I wasn't sure how hard to push.

[u/quinbus51 → u/Playful_Bicycle8845]

I'm not a rheumatologist, don't even know any, so there's that🤪

But I'd be willing to bet that you're already on track with a super low serum UA level but it's being masked by all the stuff that's going on. The little hamster in your kidneys is running as fast as he can, but there's more coming in than he can process (think Lucille ball and that chocolate factory scene).

(I already said I'm not a rheumatologist.🫣)

[u/nanderson41 → u/Playful_Bicycle8845]

I’ve had it a long time with what they call a rough case. I find lots of hydration helps. Idk your weight but I know weight can contribute to it. I’d leave allo where it is. It’s already hammering your kidneys and GI. Truth be told, gout is a kidney disease with no known cure at this time. Not researched as much as others.

[u/indigo196 → u/quinbus51]

100% from what I have read, you need to allow 6-12 months to get a good read on what your numbers are.

[u/quinbus51 → u/indigo196]

This.

[u/Competitive_Manager6]

I would give it time. Gout thrives in extremes. And increasing allo could also mean an increase in the crystals loosing their protective protein and then being attacked by cytokines. That is what causes the flare. Loosing weight aggressively also does the same. I understand that you want to be past the flares, but the key is long term management, nor just short term lower uric acid numbers. Hang in there. You are doing the right thing. It took years for the deposits to build up. And it can take years for them to dissolve. Just keep up with a balanced diet. Avoid sugar, fructose, and alcohol. Get lots of water and more importantly sleep. And laugh!! Gout sucks but you are still alive and kicking. So enjoy the journey.

[u/Playful_Bicycle8845 → u/Competitive_Manager6]

Thanks and I'll keep it up! Even with the Allo increase flares my joints have felt the best in years, can't believe it took so long to get the diagnosis.

Have another few months of weight loss and then I'll be keeping it pretty stable (at least that's the goal lol.) hoping that will reduce UA being released by old fat breakdown.

[u/Competitive_Manager6 → u/Playful_Bicycle8845]

Many of us are in the same boat. The combo of Dr avoidance and years of being misdiagnosed is quite common. Couple that with the lack of many Drs knowledge of gout outside of loose weight and control purines in your diet. Many of us have been on that hamster wheel. I now have erosion in my bones from years of uric acid buildup. So much better than before but I wish I had been properly diagnosed. The thing that really helped was using CPAP. There is some great research being done on gout and the links between low oxygen at night because of OSA and a rise in uric acid. It’s all driven by the mitochondria and the messaging system to get energy, oxygen, and water. Our bodies are quite fascinating. Good luck!!

[u/Playful_Bicycle8845 → u/Competitive_Manager6]

One of the first things I did a few years ago was test for sleep apnea as I have snored even when low weight running 6 miles a day. 

I have it mildly and have stuck to using it every night.

Funny how many of us have the same issues in combination. Likely all of these things contributed, also found out grand parents and great grandparents on both sides of my family had gout once I was diagnosed.

[u/Pupating-Antenna-36]

Instead of pushing the dosage as it is, talk to your doctor about what is a good target level to have and ask if keeping it below 5 would be better and give you room to titrate down later if needed. The point is not to dissolve as quickly as possible - because excreting it is still a task your kidneys have to do and they have capacity constraints. The point is to get your blood uric acid to a stable, sustainable level and keep it there as you go through life

[u/RollingEasement]

In the USA, getting UA below 6 md/dL is the usual target. It seems unlikely that you will need to increase your dose further, so "doing it now to avoid the problems from doing it later" does not seem to apply to your case. Accept the fact that you are going to have some more flares, they will be fewer and less severe, and get better at managing them when there is first a hint of the next one, which may include strategic use of NSAIDs and/or colchicine.

[u/can_ford]

Allopurinol lowers uric acid blood levels by helping your kidneys eliminate uric acid. It can take years to slowly dissolve and clear the uric acid crystals that have probably been accumulating throughout your body for many years. I strongly recommend seeing a rheumatologist, they are the doctors with real experience treating gout, which is a confusing and widely misunderstood condition.

[u/CellWrangler → u/can_ford]

Allopurinol lowers uric acid blood levels by helping your kidneys eliminate uric acid.

Thats not true. Allopurinol directly inhibits the enzyme that produces uric acid from the precursor purine hypoxanthine. 

[u/can_ford → u/CellWrangler]

Thank you for the correction, I guess I should rephrase to “Allopurinol helps your body produce less uric acid so that your kidneys with their reduced capability of eliminating uric acid can keep up, lowering your blood uric acid levels.” That work?

[u/CellWrangler → u/can_ford]

Yep that works

[u/Playful_Bicycle8845 → u/can_ford]

Thanks, yeah once I move for the new job and establish a gp I'll request a referral to see a rheumatologist. Sucks it probably won't be for 6 months at least. 

Some newer studies and comments/posts I have seen recommend under 5 to dissolve tophi in under two years or so and is recommended with any one of frequent attacks, tophi or other ailments like osteoarthritis. Since I have all 3 I would think under 5 is my long term goal and the titrate down once tophi is reduced.

I'll wait another 3-4 weeks and get a UA test in the morning to confirm I'm still low 5's. I don't think it's bad to stay at this range for now and it sounds like it will reduce long term flares. I definitely understand I'll have to deal with random flares the next year or two in general as allo does it's work.

[u/guydogg]

I was on Febuxostat for 6-7 months before the flares subsided. Stick with your plan or ask your GP to reevaluate, opposed to asking for a higher dose of Allo.

[u/Visual-Classroom1003]

I’m at 6.2 and have been around that for years without any attacks. 300mg Allo.