Preventing gout attacks – how high can your uric acid go?               




This article about preventing gout attacks was last reviewed or updated on 29 July 2013.

GOUT IS FICKLE

In the real world gout can be a fickle, difficult, stubborn thing. Here are three of scores of examples.

The standard dose for allopurinol is 300 mg daily, but one expert has said that a number of studies have shown this dosage  gets uric acid down to the 6.0 mg/dL crystal dissolving level in only 40% of those who take it.*

Or, I recall in the trials of the heavy duty, intravenous gout drug Krystexxa (pegloticase) that  it got blood plasma uric acid down below 6.0 mg/dL (for at least 80% of the time after 3 and 6 months treatment), in a combined month's total  of 87% of patients in one study and 67% in another. (1) These are good scores but nothing like 100%. And yet this is the drug that probably reduces blood uric acid more than any other but it's not perfectly reliable even without considering its side effects.

Here's another example of how fickle gout can be. One person goes to the refridgerator (refrigerator) for cherries whenever a gout twinge is felt and it goes away; another eats cherries for months but nothing happens. Maybe the cherry- positive gout sufferer has much lower uric acid, and less to reduce it, than the one who gets no help. But the inconsistency is enormous.

So gout can be inconstant and frustrating. If the inconsistencies of treating gout affect you, it's easy to lose heart and get depressed. When things don't go as planned, you need all the encouragement you can get. Here is some. Read on to learn how a Spanish study, published in the December 2011 issue of  Arthritis & Rheumatism,  found that preventing gout attacks can be done reliably once you have lowered uric acid sufficiently.

What follows is a re-confirmation of the old truth that to beat gout you must get your uric acid (UA) below 6.0 mg/dL, although doing this does not guarantee you can control gout. And if you do, to keep it controlled, note the successful study patients described below, subsequently maintained it below 7.0 mg/dL. If it creeps above 7.0 mg/dL watch out!

This is also a reminder to have your doctor test your uric acid (UA) regularly, for example every two months. Or use a uric acid meter at home and ask your doctor to confirm your self-reading.

Whatever you feel like, just remember under 6.0 mg/dL is the first target for men. For women, it's a little less, about 5.5 mg/dL.

And now, to details about the study which offers encouragement for preventing gout attacks.

THE PREVENTING GOUT ATTACKS STUDY (2)

The study's patients were quite severe gout sufferers. They were in later middle age with an average of almost 60, when they first got gout. Their average UA level at the beginning of gout therapy was 8.8 mg/dL, nearly a quarter had tophi, and just over a quarter had had gout attacks in four or more joints. On the whole, these were pretty advanced cases. In fact they’d suffered gout for at least 6½ years before the study began. So their quite advanced gout was not surprising.

FLARES FOR TWO YEARS, BEFORE THEY END

After gout therapy reduced uric acid to an average of 4.9 mg/dL (an average fall of 3.9 mg/dL) -  this had taken on average 5½ years. Treatment ended after 5 years for those without a tophus, or 5 years after the last tophus had cleared up. Quite a long time for such a reduction. Such a long time in fact,  that there were plenty of opportunities to get depressed. Note those without tophi needed 5 years of treatment, but those with tophi needed 6¾ years to lower uric acid, 1¾ years longer.

I have heard of better progress, but this doesn't really concern us in this article since we're more interested in how uric acid was kept down and in the maximum it can rise before trouble is likely to start again. The study's available report was not very specific about the gout therapy used to lower uric acid.

Flares among all patients  ended  after almost two years. So another 3½ – 4¾ years were spent getting UA down further. Note this if you feel you are making slow progress and wonder whether there'll ever be light at the end of the tunnel. It took two years to end flares. Remember too, your gout may not be as entrenched as their gout, so you may need less time to achieve similar results. And you may be using other methods to lower uric acid.

KEEPING URIC ACID DOWN TO PREVENT GOUT ATTACKS

After the UA target was reached, the patients' uric acid lowering treatment ended. Then began the follow up period – the control uric acid period. It lasted on average another 2¾ years.

How did they get on? Who among the 211 patients could keep their uric acid down to below 6.0 mg/dL and prevent gout attacks?

The 211 gout patients had been divided into 4 groups – named group 0, 1, 2 and 3. The composition of each groups' members depended on UA levels when gout therapy ended. When gout therapy ended, these were their uric acid levels:

-  Group 0  patients:     6.00 – 6.99 mg/dL
-  Group 1  patients:     7.00 – 8.20 mg/dL
-  Group 2  patients:     8.21 – 9.32 mg/dL
-  Group 3  patients:     9.33 – 12.40 mg/dL

The key findings  Among the 27 patients' group whose uric acid was maintained at 6.00 – 6.99 mg/dL, (Group 0), <i> <b> none of them </i></b> had a gout attack during the average of 2¾ years follow up period.

The members of the other three groups had NOT lowered their uric acid below 7.0 mg/dL. So what subsequently happened to them?

-  Group 1 13 of 61 (21%) had an attack recurrence
-  Group 2 31 of 61 (51%) had an attack recurrence
-  Group 3 38 of 62 (61%) had an attack recurrence

A CONTROLLED URIC ACID LEVEL

Even in these three unsuccessful groups, the lower the uric acid, the lower the risk of the subsequent gout events, after uric acid treatment had ended. And the lower the uric acid, the longer the time period before a recurrent attack (flare). If they had suffered tophi, or had attacks in four or more joints.….. these conditions too meant a higher risk of attacks happening again.

Lose weight And how did the successful 27 keep their uric acid below 7.0 mg/dL, after treatment ended and for an average of 2¾ years? Those who maintained uric acid below 7.0 had lost an average of 3.3 kilos (about 7 lbs). It is not very difficult to lose 7lbs. It's widely thought that losing, and maintaining lost weight, will reduce and keep uric acid down.

Similar patterns were found in the febuxostat (Uloric, Adenuric etc.) research. 

As far as gout medicines are concerned in the period of the study, the use of the medications losartan and fenofibrate was associated with maintaining uric acid below 7.0 mg/dL.

Losartan  (brand name:  Cozaar, also available as a generic) is not a top-of-the-range gout medication but an anti-hypertensive drug that was probably given to those group members who suffered high blood pressure. Losartan controls blood pressure and lowers uric acid somewhat, which makes it useful for hypertensives who need to control uric acid.

Fenofibrate (brand names include: Tricor, Triglide, Lofibra) isn't a front line gout drug either but it too can lower uric acid whilst it deals with hyperlipidemia. i.e. excess triglyceride fat and cholesterol, again a not uncommon gout co-morbid condition.

Or, and I'll say this as an example to illustrate the point further although it wasn't in the study -  if 300 mg of allopurinol daily is needed to get uric acid to 6.0 then 100 mg daily  may keep it below 7.0.

But use of diuretics was associated with uric acid levels above 7.0 mg/dL. Danger!! It's already known that diuretics (for hypertension/high blood pressure) raise uric acid. Watch out!

In the world of gout treatment, the more quoted target for maintaining uric acid is 6.0 mg/dL. But the message of this study is that 7.0 was found to be reliable once 6.0 has been breached and flares ended.

So if the target can be 7.0 mg/dL, once you have gone below 6.0 mg/dL, and gout flares have ended, what might this mean for your control gout dietary efforts? If you are on a low purine gout diet, or restricting purines in addition to another type of diet, perhaps your methods can be less rigorous. Every week you might be able to have a few beers or some liquor (spirits), or wine. Or a few more. Or eat some, or more, medium purine food. These could be enjoyed as long as you regularly self-measure your uric acid and know how much it usually moves. The sort of self knowledge that comes from experience of dealing with gout.

As long as you, and your doctor, feel confident you are the master of your uric acid level, preventing gout attacks could be easier than you think.

THE GOUT ALERT ZONE

This study supports the idea that there is a Gout Alert Zone where your uric acid is between 6.0 mg/dL and 7.0 mg/dL. When reading it you must take account of the direction it has been travelling, (the trend), that you’ve learnt from previous readings. Simply put, is it on its way up above 7.0 (bit less in women) or is it going down below 6.0? (About 5.5 in women).

In this zone, when the trend has been up, you are on guard for signs of an impending attack such as tingling sensations, stiffness and itching. When it’s down, good news about preventing gout attacks may be on the way to you.

* Maybe they needed a drug to encourage uric acid excretion, not prevent its production.

(1) Arthritis Advisory Committee of the U.S. FDA meeting. Krystexxa briefing document. June 2009. Table 8. 

(2) Fernando Perez-Ruiz, Ana Maria Herrero-Beites, Loreto Carmona. <i>A Two-Stage Approach to the Treatment of Hyperuricemia in Gout: The “Dirty Dish” Hypothesis.</i> Arthritis & Rheumatism. Vol 63 No.12, December 2011. Pages 4002-4006.

Related topics. You might also enjoy:

Tips and techniques for preventing gout. Go to our gout prevention page.

More tips for preventing gout. Go to our preventing gout page.

Here's a page of dealing with gout tips - tips to help you beat it, not live with it.





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