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Gout Dugout.Issue #059. Remember probenecid | lead and gout | Uloric (febuxostat) and liver tests
November 30, 2012
Hello and Welcome to the November 2012 issue of the Gout Dugout newsletter. It's the ten minutes' read that gives you ideas that may help you with your gout. If you have difficulty reading it from the screen, by all means copy and print.
First this month, I have an announcement about the frequency of future editions of the Gout Dugout. Beginning 2013 the newsletter will be published every three months (i.e. quarterly), not monthly as at present. I need to release more time to deal with the monster task of upgrading the website after its 5½ years. The changes I discussed earlier this year, mainly the 3 column format, have not yet been done and are a priority so I am afraid the newsletter will be written less in 2013. I hope to make the content longer, and I hope you continue reading.
There will be a reminder about this in the December issue. After that, note the next issue will be in March 2013; then June, August, and December 2013. And I am not joining the Twitterati and bombarding followers with useless info-junk.
And now to the first piece this month, about probenecid for gout. Then, if you take Uloric (febuxostat for gout) make sure you read Uloric (febuxostat) and liver tests, further down.
LET'S HEAR MORE ABOUT PROBENECID FOR GOUT
The other day I was reading about a Finnish cyclist, based in Belgium, who has been suspended from cycling for 2 years because he tested for slightly more probenecid than cycling rules allow. Probenecid is one of the class of drugs, along with sulfinpyrazone and benzbromarone, that encourage uric acid excretion. Whenever I've seen uric acid reduction numbers it's always seemed to me they excrete more uric acid than drugs that reduce uric acid production. I call benzbromarone, Mercedes Benz-bromarone, and it is made in Germany, but it's only available in certain countries.
The cyclist said it could all be explained and that's where the matter is publicly at the moment. He probably does not have gout, despite all that cycling, because, according to reports, he didn't say so. It was thought he was using probenecid as a masking agent. It does have some interesting properties. During World War 2 it was used to make supplies of penicillin last longer since it can improve penicillin's performance by reducing the amount of penicillin excreted by the kidneys, the opposite of its effect on uric acid.
Probenecid has been used in gout treatment since at least 1951, which is 12 years before allopurinol.
The cyclist's story was a reminder that probenecid is an anti gout drug we ought to hear more of these days. Whereas the cyclist seems to have been using it when he shouldn't, many gout sufferers don't use it when they should. In fact some doctors have stopped prescribing it altogether but not it seems because of any side effects. But it seems simply because it’s fallen out of fashion. It can't be because of its cost – I looked this up online and 500 mg tablets were being sold for about $0.90 each, or about half if you bought generic.
Does becoming an unfashionable drug happen? Yes I suspect it does, and probably for no good reason. It will happen to allopurinol one day but in this case a good reason will be that febuxostat has replaced it. Lithium was once a premier gout treatment from the 1860's to 1930's -1940's, but lithium for gout has now virtually disappeared. However there were reasons for this, not linked to fashion.
Probenecid works by getting the kidneys to excrete more uric acid. So you would think that in cases where it's known gout is caused by a failure to excrete (enough) uric acid, (kidney failure, insulin resistance etc.), and these are supposed to be by a long way the majority of gout case causes, then probenecid would be prescribed. But it isn’t. Could it be this is because it requires a creatinine test to find out how well the kidneys are working, and allopurinol/febuxostat usually do not?
If this is your cause, and you're prescribed allopurinol or febuxostat (where available), it's because the doctor or rheumatologist is relying on reducing uric acid production, so that there's less to excrete, rather than encouraging your kidneys to excrete more. It could be thought that this is a somewhat roundabout way of going about it. Why not deal with the problem directly if you know what it is?
The fact that probenecid can't be used in patients with kidney disease isn't the reason why allopurinol (and febuxostat where available) are used so much. It's said 90% of gout sufferers have the condition because they under-excrete, whereas about 20 plus% of gouty folk have kidney diseases, or a serious risk of them. So probenecid is not being prescribed to at least 70% of people with gout who might find it better than allopurinol or febuxostat.
To those readers who are interested in probenecid what I can say is, ask your doctor or rheumatologist to discover (a) what is the true cause of your gout (b) and discuss whether he/she thinks probenecid would be a better drug than allopurinol or febuxostat.
Here are some probenecid brand names: BENCID, BENECID, BENEMID, PARBENEM, PROBALAN, BENURYL, PROBECID, PRO-CID, BENEMIDE, PROBEN.
Probenecid can be purchased on-line but you must have a valid prescription. Always work with your doctor. Don't go it alone. That's not wise. A rheumatologist is more likely to have experience of using probenecid than your neighbourhood (neighborhood) doctor.
Use an internet search term like "buy probenecid online," or "buy probenecid (NAME OF YOUR COUNTRY)," or "probenecid available (NAME OF YOUR COUNTRY)." Branded costs more than generic – most people think branded are better. Use a brand your doctor recommends if you can.
So consider probenecid if possible, but should you enter a cycling competition, make sure the organisers know you have gout, and the name of your doctor! I'll always be glad to read your probenecid experience.
Read more about
probenecid and its side effects:
LEAD AND GOUT
Back in the 19th century, Sir Alfred Garrod, who discovered the true cause of gout, thought that lead in the blood was a cause of gout. And so did doctors before him. But studies have never been conclusive.
However, earlier this year a study gave solid indications that lead is indeed strongly linked to gout. Data from two U.S NHANES trials amounting to 6153 U.S. residents over 40 years was analysed (analyzed) to discover any link between lead in the blood and the risk of gout. That's a lot of data over a long time.
And find a risk they did. Those with the highest amount of lead in the blood (average 3.95 ug/dL) had six times more chance of getting gout than those with the lowest. And even those with low levels of lead (1.2 ug/dL) were associated with a higher prevalence of gout. And 3.95 ug/dL the researchers
said is not that high. High is 25.0, and 1 in 10 of U.S. residents are at that level. Hmmm.....
Click on the Flamasil ad to go to the Flamasil website
ULORIC (FEBUXOSTAT) AND LIVER TESTS
Somebody wrote to me recently and said I never write anything about febuxostat for gout. And that is almost true. I have tried to report when it has become available in "new" countries. People have been reporting success with it around the Internet. Febuxostat is here to stay and will one day probably knock allopurinol off its perch. At 80mg daily dosage, three trials showed it is better at reducing uric acid to below 6.0 mg/dL (about 71% average success rate) than allopurinol at 200 or 300 mg (about a 36-42% success rate, about the same as febuxostat at 40mg).
On the other hand you can see the failure rate was about 29% at 80mg. And in some other trials it hasn't done quite as well - APEX and FACT trials 51% (combined score) to under 6.0 mg/dL in the last 3 months visits. But in the FOCUS study over 5 years 80+% got to below 6.0 mg/dL at final visit. Nothing is perfect in treating all gout cases.
This month there has been new prescribing information for uloric, the brand name of febuxostat in the U.S. (In the EU it's Adenuric, other name: Feburic). What I am going to say applies to Uloric and so to U.S. residents, but other users/potential users of febuxostat should find this useful and I'll try to cover Adenuric/Feburic next month.
Few drug medications, if any, are completely safe in all who take them. But to keep things in perspective I should say that febuxostat is of course considered safe. It's had lots of studies, including extra trials after it was approved.In people with mild/moderate liver impairment no dose adjustment is necessary.
New Uloric prescription information is about the need for liver testing when taking it. In febuxostat's trials liver problems were found in a small percentage of trialists, and they were the biggest adverse reaction. But it wasn't clear that febuxostat caused them.
Previously regular liver tests were automatically recommended at 2, 4, and later months. Now the recommendation is to test your liver before starting uloric; to test when gout patients report symptoms that may mean liver injury; to avoid/discontinue if liver ALT and Bilirubin levels are raised (three times/twice) and there is no other explanation.
So the responsibility to report is now yours. Of course a good doctor will test on his/her own initiative. And there is nothing here that would not crop up in a good chat with a gout-informed doctor.
But whilst that's true, I am not sure it is the point. If the label is diligently followed after Uloric initiation you'll need to ensure you tell your doctor about any symptoms you notice which might lead him/her to think a liver test is required. So I think you should be alert about the need for a liver test, along with kidney and uric acid tests. The doctor should also look out for signs of heart problems or stroke.
Symptoms that might mean liver injury include: fatigue, anorexia, right side upper abdominal discomfort, dark urine, jaundice.
Click on this link for a complete briefing about Uloric and its side effects/adverse reactions.
The UASure is a DIY home uric acid test kit. It measures the level of uric acid in the blood. Click on the link below to visit a company who can ship it world-wide, including to the United States and Canada, from Britain.
GOUT ONE LINERS – NEWS FROM THE FRONT LINE
I am always writing about gout on the rise world-wide. In the past month I've heard about its rise in Vietnam (growing prosperity = growing gout, the problems of getting richer and eating more processed carbohydrates); Japan (again) and in the English county of Sussex, where treated gout cases at Sussex hospitals have doubled in the past 2/3 years….. No, having sex doesn't get you gout – one woman was worried about her husband - gout is only caused by uric acid and no one has ever thought intercourse raises uric acid.….. But yes, you can get gout if you have pre-existing arthritis because gout has a different cause and one of these diseases does not mask or control the other.
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Thanks for reading, and all the best of health.
799, Infantry Street,
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NB. The contents of this newsletter contain medical information, not medical advice. Please always discuss gout remedies with a doctor, or other health care professional, before implementing any treatment.
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