[nobody]

There are a few things here :
-yes, you should avoid consuming very many purines (although it’s more complicated because there are different purines which have different effects) but it sounds like you might not understand what that involves or achieves
-the main purpose of anti-inflammatory drugs isn’t pain relief (that’s what analgesics are for) but to prevent further damage and stop a self-sustaining (and potentially accelerating) process, and failure to take enough anti-inflammatories for long enough might cause an attack to lack longer than necessary or even to come back
-pain can be caused by the damage done by a gout attack rather than by ongoing inflammation
-I can’t tell what you call 3-4 pain level (how is your scale calibrated?) but it is normal for gout pain to vary and more specifically to peak during the first phase of an attack (whether we should call less intense pain following more intense pain a separate attack or part of the attack which caused the more intense pain is mostly a semantic issue)
-gout can cause chronic low-level pain lasting a lot longer than you’ve experienced so far but that seems to be common only at later stages of the disease

Bottom line: as long as any swelling or redness/hotness affecting much of the foot (as opposed to some small red dots for instance) remains, anti-inflammatories are indicated to the extent that you tolerate them well.

[nobody]

So, diet and drugs…

I’m not sure what you meant by “was to focus on” but the issue here is that, while the effects of dietary changes are different in each case, they are highly unlikely to be sufficient to deal with the troubles of a patient who tests as high as 9.3. While that value could be a fluke, it more likely reflects a problem serious enough that it could only be slowly improved with dietary changes rather than solved entierly (or in a timely manner).
I do not know that decent dietary advice is available anywhere outside of Japan, let alone a complete dietary plan deserving of being called “good”!
If you wanted to try to address your uric acid problem through diet, that would require a thorough assessment of your metabolism and health risks (including mental health risks) because a diet which helps one person may harm another. There are as you might have guessed simple general principles you could try to follow and which would be helpful for many gout suffers but I don’t like to spell them out in full to people who might not be serious about mitigating the risks involved in following a restricted diet because gout pain as well as the debilitating effects of chronic gout are bad enough that they might drive someone to behave unreasonably.
You evidently already know the most basic things to avoid already. At this stage, I would only add that avoiding the consumption of significant amounts of sugar would be helpful in many cases, as would the consumption of generally recommended amounts of vegetables and the maintenance of adequate hydration through the day as well as the year (by drinking enough as well as by avoiding diuretic drugs, drinks or additives). If you aren’t lactose intolerant, also consider consuming plenty of skimmed milk or products made from such (and of course proportionally reducing your consumption of other nutritious foods in order to keep your diet balanced). And finally, be aware that single-celled organisms such as spirulina or yeast as well as some mushrooms can be even more harmful to gout suffers than animal flesh. That’s not the whole picture but I think the above information is pretty safe to share.

Drugs which lower uric acid can in principle be discontinued but, unless perhaps you have made significant lifestyle changes, that would naturally bring back the problems which drove you to take the drug in the first place. That’s why these drugs are often considered lifetime drugs, not because you would become addicted to them or something. Since gout is a slow disease, it sometimes takes a long time to come back after it’s been thoroughly cured so you might end up being able to take breaks from such a drug safely if you wanted or needed to.
There are four main precautions to take with uric acid lowering drugs:
-first, your health risks and in particular your kidney and liver function need to be evaluated ahead of time and followed up as you begin taking one of thses drugs (for instance, the most common uric acid lowering drugs can raise the amount of alanine aminotransferase in the blood non-lineraly with respect to the dose so it’s best to have a baseline value and see if taking a small amount of the drug seems to affect that blood test result before moving on to stronger doses)
-second, you should be aware of the signs of the most serious adverse reaction so that you might report them to a doctor in a timely manner should you notice them (or indeed get yourself to the ER if need be)
-thirdly, it’s important to take a sufficiently strong dose as well as to avoid taking an excessively strong dose… but it’s impossible to put a number of that before trying a drug so you’ll have to get several uric acid tests to make sure a particular dose is right for you (the safest way to proceed again being to start with a small dose before increasing it incrementally if it turns out not to be strong enough)
-finally, there is a genetic test for an especially dangerous form of allopurinol intolerance common among people who have some East Asian ancestries (if you are at risk, consider taking an altrnaive drug if the test is unavailable to you)
This might sound scary but most of these drugs are actually quite safe for most people. However they are a slow cure to a slow disease while doctors often give people dangerous drugs to people in urgent need. As a result, many doctors aren’t always appropriately cautious when there is no emergency which is why I’m trying to give you the tools necessary to make sure resonable steps are taken to ensure your own safety as much as is practical.

[nobody]

Sorry for not replying quicker but I had no network.
It’s probably too late to prevent the attack but to make sure it doesn’t get worse than it needs to be, take as much indomethacin (or similar) as you are allowed to. Maybe give your doctor’s office or your pharmacist a phone call about how much you could take if you’ve never discussed this with them. Make sure they understand you are asking about a one-time thing, not how much you could take every day.
Also, the following is less important but drink plenty of water, rest your affected joint and make sure your blood can flow freely into and out of the area (elevate it close to the level of your heart or simply lie down if needed).
I’ll address the other stuff later.

[nobody]

This is looking a lot more like gout. Obviously, I can’t diagnose you and we don’t have much data to go on because this is still early days but 9.3 is a more typical result for gout sufferers. The variation in test results is also suggestive rather than confusing, even typical around the time of a gout attack (see my previous comment about precipitation)… assuming of course this indeed was a gout attack.
We could go over more comprehensive dietary recommendations if you like but this 9.3 result suggests that you’d better focus on a powerful treatment which would reduce the amount of uric acid in your blood. It would be worth re-testing in a few weeks to make sure that wasn’t a fluke, and you would ideally also get a uric acid excretion test (very few people seem to get one because it’s not useful in most cases). But even a single 9.3 is suggestive enough considering you weren’t consuming alcohol.
Let us know if you want us to go over the precautions best taken (but often neglected by doctors) regarding uric acid lowering drugs even though we don’t know yet if you’re going to take any.

Right now, I’d dial down the unwarranted confusion and book another doctor appointment to discuss whether your latest blood test is enough evidence to move on to uric acid lowering drugs or the diagnostic instead needs to be ascertained with a rheumatology appointment, joint imaging or even joint fluid aspiration.
In case you can’t get that appointment quickly, I would also book another blood test before the appointment so that the doctor might have three rather than two test results to work from.

[nobody]

It sounds like the normal flow of blood is impaired somewhere in your foot. I once had something a bit like this after a flareup, except more localized and much less annoying. It went away on its own, but only after many months.
Did the coxib suppress the strange swelling as well as the pain for a while?

If I understand correctly, you got a 7mg/dl test result about 3 months ago. That and the high initial result suggests there still was solid uric acid in your body recently, and perhaps there still is some. In that case, and considering you already have been to several doctors about this swelling, I would simply recommend patience and regular uric acid tests.
In some cases, solid uric acid has been detected in the body of patients years after starting medication. And the last time I used crutches was more than a year after starting medication. So a few months is not much at all.
As long as you are drinking plenty of water and that the amount of uric acid in your blood remains low (4.2 to 5 is fine), your body should progressively get rid of that old uric acid. As a result, if this swelling is directly caused by gout, it will go away for good. And if it is indirectly caused by gout, there is a good chance the damage will heal in time. Either way, if it was to persist much longer (more than 6 more months) or if it was to worsen substantially, I’d try more doctors such as an angiologist or perhaps another rheuma.

I do not know if it is advisable to take that much baking soda. Discuss this with your doctor if you haven’t already.

[nobody]

Hi Sujith,
It would be easier to answer your messages outside of this messy thread but here goes…
What type(s) of doctor(s) have seen your foot in its current condition?
Do you know how much uric acid there is in your blood?
How long have you been on your current allopurinol dose?
What other drugs have you been taking, either on a daily basis or in response to the swelling you describe?
Answers to these questions are necessary in order to understand your situation.

[nobody]

Both indo and prednisone are anti-inflammatories. If the effect of whatever you’re taking now isn’t satisfactory, show the swelling to your doctor and ask whether the dose should be increased or the medication changed.
Assuming this really is gout, my guess is that the risk of lasting damage is low if there is only pain when you are putting weight on the joint(s) as long as you are able not to put weight too often on the joint(s). I suspect the risk of lasting damage would increase progressively over the years if you were to keep suppressing symptoms with drugs without adressing the root cause.

Slight imbalances in your body could cause uric acid to accumulate in one area over time and when your body finally reacts to this accumulation, that can precipitate more accumulation at the same location. The reaction itself is partly localized as well.
As a result, it’s not unusual for gout to affect the same joint(s) several times in a row and/or for several months. At the same time, it is also not unusual at later stages of the disease for the pain/redness/sweeling to move between different joints.

[nobody]

There are other tests that can be done to rule out other diseases as well as to make sure this is gout. Some of these tests are in my experience only ordered by specialists.
But doing the uric acid test again is by far cheaper and easier. So whatever else you do, doing it again is an easy choice when the first result was only slightly higher than we’d like. While you’re at it, do make sure that result really was 7 and not 0.7 or 700 (both of which would be much worse than 7).

[nobody]

Hi,
How do we know that Don has gout? And if he does, how do we know he requires uric acid lowering drugs?
Maybe there is a basis for a gout diagnosis that Don hasn’t disclosed. Mabye Don has had more than one uric acid test. But we can’t assume.
My opinion based on the information above: this is premature. Don’t take dangerous drugs based on the most likely cause and treatment but start by getting more tests. The relevant medical speciality is called rheumatology. Start by getting an appointment with a specialist if at all possible.

[nobody]

Yes, I have found the night (specifically, the end of the night) to be a time when serious attacks tend to start. Ongoing symptoms are something else and I do not remember that they got worse at that time with any regularity (though that might of course happen to others).
There are still other reasons why inflammation might be worse during some parts of the night (lookup cortisol for instance). I didn’t want to provide you with a whole catalogue.

And yes, gutting it out during the day leads to worse nights in my experience. However the effect depends on the particulars. For instance I found that interfering with blood circulation for long periods (for instance by sitting normally) to be problematic while short bursts of slightly painful physical activity might actually be beneficial, perhaps because they promote blood circulation.

Finally, no: icing has failed to produce good results in my case. In fairness I didn’t give that trick much of a chance and may not have iced for long enough to get the expected benefit since letting your extremeties get cold is risky. Elevation is in my opinion a safer way to deal with swelling since you can regularly lower your foot to allow more blood to flow to it before putting it back up (as long as you don’t plan on sleeping).

[nobody]

I think you should pay more attention to the inflammation and less to the pain. I can’t tell if the inflammation is serious at night based on your description.
Inflammation should be better controlled anyway, whether it be by splitting the dose (I’ve not taken that drug so I don’t know it if would work) or simply by increasing it or taking another drug.
If your foot is swelling at night, I would definitely tell a doctor this happens a certain number of hours after taking the 60mg because you don’t want serious swelling to happen, during the day or at night.

If on the other hand the foot doesn’t look very bad at night but only feels painful, it’s probably for the best if the drug is most effective when you’re active and there are other reasons than the time when you take the drug which might make the pain worse in the evening and at night.
The same “raw amount” of pain would probably bother you a lot more at night than during the day for psychological reasons but what you describe also seems somewhat consistent with my experience with mild inflammation: while I wouldn’t want to be sitting normally with serious inflammation, sitting can numb a mildly inflamed foot and you’re only going to feel the damage from sitting too long when the blood can flow properly again. You can also walk on a mildly inflamed foot but this sort of stress is going to build up as the day goes on and result in a painful evening (and night if you can’t sleep).

[nobody]

Tylenol alone isn’t much help but if the prednisone has already done enough work, it could do the job. It’s worth trying as long as you don’t end up taking a strong dose every day.
Obviously a proper painkiller would work better but even then sleeping through the whole night may be an unrealistic goal if the prednisone isn’t effective enough.
You probably noticed elevating the joint a bit decreases the pressure.
You could also try a hot foot bath before going (back) to bed or simply a hot (or cold/hot) shower.
But at the end of the day, pain is something you deal with mentally. It’s a message telling you to take care of the inflammation. Don’t fear it or push it away and pay attention to your other bodily functions such as your heartbeat and breathing as well as the details of the pain… or whatever else works for you.
If you’ve had enough of your bodily sensations, painful sleepless nights are a good time to take a relaxing podcast break, eyes closed.

[nobody]

Sorry for the misunderstanding. Doctors can be so expensive that I often want to be my own doctor…

[nobody]

Taking charge of serious inflammation on your own might result in a bad reaction to a drug. Even if the doctor only recommends what you already knew, you may be treated differently if you need emergency care because you followed a doctor’s advice as opposed to self-medicating.

Unfortunately the needle in the joint isn’t always definitive. Imagery could provide clues.
Otherwise formal diagnosis tools rely on some specifics about the symptoms as well as on the symptoms coming back after stopping completely several times. They also rely on the amount of uric acid in the blood of course (which looks high enough for gout in your case but which should be repeated before jumping to conclusions to make sure it wasn’t some kind of outlier).
It’s not necessary to wait for symptoms to come back if you trust the experience and discernment of a doctor who claims to be able to recognize gout, especially if they’ve used an MRI or ultrasound. No one can tell you over the web if a particular doctor is trustworthy but I’d definitely see a specialist if it was practical (not too far away, too expensive and so forth).

In any case, don’t start allopurinol without careful consideration and planning. It’s a long haul drug which treats a slow disease. What matters is not to let the disease fester for years if you have it. But it’s well worth delaying such a treatment a few weeks to do things properly.
Yes, there is an extra risk with some East Asian ancestries. Both febuxostat and the genetic test have only become available relatively recently, allowing people to take fewer risks. I don’t know what the risk is for any of the ethnic groups of the Philippines but I expect many islanders would have some “foreign” ancestry anyway. So consider going with febuxostat instead of allopurinol if you can’t get a genetic test to rule out this risk. But this is premature, and only one of the matters to consider before starting such a drug… you’ll hopefully be able to talk about this in good time with a specialist.

[nobody]

I was waiting for an answer to 1) but on second thoughts, there’s a matter which can’t wait: what to do about pain that comes back?
Pain isn’t the most pressing issue actually. You should get the inflammation causing the pain looked after without delay. A GP can take care of that. Taking more steroids or non-steroidal anti-inflammatories are the main options. Which (if any) is more appropriate is up to your doctors but what’s up to you is making it very clear this is bad. Don’t allow them to let inflammation fester without a damn good reason!
You can also take pain killers while waiting for the inflammation to come down but don’t use painkillers to live with inflammation unless you’ve made damn sure the doctors did all they could to stop it.
And be sure to drink plenty of water if your kidneys can handle it!

[nobody]

Sorry for all the meta stuff. Yes, water and so forth isn’t controversial (in most cases).
And yes, when to start uric acid lowering drugs is the real issue. It’s more complicated than just the standard of care because there are the difficult matters of diagnosis and relucatance but as far as I can tell, the standard is unsurprisingly: in the presence of recurring symptoms and hyperuricemia resistant to lifestyle intervention, start allpurinol or febuxostat if there is no suspicion that the patient is especially at risk for serious side effects.
Some of the problems include: failure to evaluate this risk rationally, useless lifestyle advice, failure to follow up said advice with regular testing, failure to follow up the symptoms and failure to identify said symptoms. I would also add: failure to refer to a specialist in the absence of clue.

[nobody]

You do listen to me as a matter of fact and it’s not my business why you do. But once again: do not trust me! You do not have to trust peer review either. It’s pointless and harmful to do so.
You have of course not used statistics in this n=1 thread so I find it rather hypocritical that you would now turn to hypothetical stats. And you well know, it is not the case that people assess a statistically significant number of claims or that random claims are equally pertinent.

By the way, while cherry picking is the larger issue by far in my experience, there’s no shortage of climate non-science that gets published… and not only in crap journals since high-visibility publications such as Nature* are a prime target for bullshit.

[Author]

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