Comment on dr mathews case study
Your recovery after 3 month attack from hell was very similar to mineafter 6 weeks attack from hell. But low dose Colchicine and highdose Indomethacin triggered the termination of my problem. I thinkthat the word “trigger” might be relevant.
Although it took you and me several days to recover fully (exactlythe same recovery rate) how much of that is attributable to straightforward recovery of damage to the joints and how much to the goutflare-up diminishing? What I mean is that I wonder if termination ofa gout attack is not in fact remarkably sudden, like turning off of atap, but that the recovery of the actual foot lags the termination ofthe gout attack because of recovery of the damaged joints.
This might seem nit picking but with much lesser attacks in the pastI have felt gout literally ebb away, over a three of four minuteperiod. I had assumed that the crystals were simply dissolving, butcould that be right ? I have seen another comment like this on thisnotice board in the past but in that case the writer assumed that itwas the deposits being removed flushed off I seem to remember werehis words. But as you explain (and I completely misunderstood)deposits aren’t like that. Deposits are as mono sodium urate, uricacid, in the fatty tissue (which I had read several times and thencompletely forgot !). Clearly such deposits in the fatty tissuecouldn’t just flush off.
But in my case I have neither put on nor lost weight so where did thedeposits go to or come from. My shoe size has not altered from 9.My feet were swollen (the gout moved from one foot to the other)during, and for a period after the major gout attack, but they haverecovered to their normal size. Could the deposits really accumulatein the fatty tissue of your feet just because that is where the goutis ? Could the deposits be clearing from around the body (as otherssuggest) ? So that, as the deposits near the other foot (in yourcase) clear, so gout is initiated in that foot ?
Of course the crystals could be just dissolving, as I had previouslyassumed, but I really wonder if it is the crystals causing the pain(as Arnold believes) or if it is a chemical reaction caused by therelease of the enzymes from the phagocytes (I have to go back to myschool biology days to remember these words). It certainly feelsmore like a chemical burning sensation to me. If there are crystalseverywhere in all the joints and it is the physical broken glassnature of the crystals that causes the pain, then why don’t we havepain everywhere ?
Also how can the crystals dissolve ? It is possible, thoughunlikely, that my serum urate level could have been tripping aroundthe magic figure of 416 (the approximate level at which urate issupersaturated in plasma) in my previous attacks but as Arnold pointsout, so what ? The only place that matters is in the synovial fluid could the ph there have been changing so rapidly ?
Maybe I just dreamt this ebbing away thing.
But also, as I say, I have had several minor gout attacks over theyears, what caused this to be the Rottweiler of all attacks. None ofthe normal descriptions of acute gout talk about Rottweiler attackslike your three monther ? But I now discover that it is not rare.
Worst of all your comment that “while taking your Allopurinol youain’t out of the woods by a long site” is prescient. I had a funnyfeeling that that was going to be the case!
Terrance Molock on July 23rd, 2007
Gout attacks are really relative..most of us experience..OR CANthe same thing.If someone has a gout attack..their first..there willbe next to no damage..temporary or permanent..the crystals myirritate temporarily..BUT permanent damage from 1..even a few attacksare RARE..both anecdotally and medically..then at the other end ofthe scale..I knew of 2 people whom after numerous,NUMEROUSattacks..CONTINUED with their method of treatment.I didn’t agree withti..but they had a choice.One person..the next attack..they had tohave part of their foot amputated..the other person..the next attackplugged up their renal tubes..kidneys shut down,a strokeensued,partial paralysis and blindness.This stuff is just thefacts..the longer it goes untreated..the worse the next attack willbe.The more permanent damage.It took me a basically a 3 month stintin bed 20 hrs a day.after an attack.. before I smartened up.The nextattack would have been worse..it always is.
These next and future attacks become HIGHLY complex..whatinitially starts as excessive uric acid collecting in thejoints..THEN crystalizing..and the first attack does NOT ENDTHERE..NO! all is NOT WELL..and fiddling around until the next attackis NOT just the same process repeating itself..the attack does notend and the excess uric acid goes happily away along with thecrystals.The excess uric acid that is still there..AND the resultingmess from the phagocyte of white blood cells used in the attack(whichincidentally release MORE uric acid into this mess as they degrade)PLUS the other chemicals AND the remains of crystals..hang on to formtophi.This mess can have crystals in it..and of course more uric acidwaiting to be crystalized.The white blood cells have a real toughtime penetrating this mess to do their work..so it is leftbe.UNTIl..until who knows what happens..I have read that there isjust no answer as to how a MONSTER attack can develop from thismess.It can have nothing to do with triggers..rise in uric acidlevels..simply the degradation of the white bloodcells/crystals..and of course the degradation of the crystals..ADDSto the uric acid level..but HOPEFULLY by the time they startdegrading and adding to the mess..the uric acid level is now at apoint BELOW the saturation level.Monster,untriggerd gout attacks area LOT more common than believed..and the simply happen with greaterfrequency and severity the longer gout goes untreated. The turning on and off..INSTANTLLY!! I have been there..laying inthe hospital emergency room..AS an expert observed..one foot wouldSWELL up..UNBELIVEABLLY!!..man it was UNREAL..INSTANTLLY..and I meanlike NOW..and just as fast..it would shrink to normal..THEN the otherfoot would do this..back and forth..The Dr. said this wassimply..SIMPLY??? HUNH??? a matter of fact that there were ALREADYMASSIVE deposits of uric acid in both feet..and it was..or hadcrystalized..and the swelling was simply caused by the bodyrecognizing one foot as the problem and mounting an all outattack..fine then..hey wait a mintue..let’s check this out..ahhforget the first foot..let’s leave that for now..my body was simplyunable to produce enough..or more..fast enough..white blood cells..todeal with both feet at the same time.
I don’t think anyone really knows what happens to thecrystals..whether they actually dissolve..IN THE synovial fluid..ORthey end up dissolving/degrading in a phagocyte of white bloodcells..doesn’t matter to me..the uric acid level in the joint dropsfar enough..condititons ain’t ripe for the manufacture ifcrystals..WOO HOO! NO GOUT!..bring it on brother!!HOWEVER ya gotta doit..where is that tailpipe anyway??
Deposits..in the fatty tissue and then released..leached?into thesynovial tissue?..I don’t think anyone knows this either..the actualtransport of uric acid across the interstitial membrane..into thejoints/fluid/area.Shotgun approach..take more uric acid out of theblood..hey it works..There are CLEARLY deposits INSIDE the jointsthemselves..AWAY from any fatty tissue
The crystals cause the pain..it is the swelling and more whiteblood cell attack that shoves them against the joint lining..almostall gout sufferers don’t refer to a swelling pain..overall..BUT AFOCUSED!!! NEEDLE(S) like pain..a pain(and I have had LOTS from otherstuff!)that is simply SO FOCUSED AND INTENSE..I often reach forwords/ways to describe it..
It is simply not known where the deposits are..where there iscrystalization..what will happen next
Sabina Shamel on July 24th, 2007
In my opinion, and by the way, consistent with what Arnold haswritten often, you are exactly correct that the cessation of the -here I go with my own interpretation-allergic reaction that your bodyis having to the crystals, is very fast, literally within an hour oftaking the proper medication I can tell the pain is under control andwill get completely better within 8 hours.
The pain is, I am sure, classic inflamation. Like if you were to cutyour foot in the same area with a dirty knife. Let is sit there withbacteria and germs in that area and within 8 hours there will beterrible red soreness, swelling and pain. There will be bacteria inthe area that are growing but the pain comes from the inflamationthat the body causes.
A very dangerous treatment for cuts that can end up being fatal is totreat a badly cur area with 1% hydrocortizone and forget to put in anequal amount of antibiotic. (A nurse practitioner in our Hospitalforgot to all the antibiotic and ended up causing the patient to losehis leg.) The bugs continue to grow, get strong and consume a leg, orwhatever, and the patient keeps treating the discomfort withhydrocortizone. The cortizone supresses the inflamation and thepatient does not know they have an infection untill the area turnsblack.
Our pain is our own bodies reaction to the crystals. The fact that wehave such a reaction that causes us so much doscomfort, does notmitigate, in any way, the fact that we have the crystals that have tobe dissolved to stop the body from reacting.
One more point that I have stated here often but is not wellunderstood by very many.
Uric acid and mono sodium urate are not in any way alike. Arnolddoesn’t like to think about the difference and in the overallpicture, he is correct that you have to get rid of the uric acid aswell as the urate. However, keep in mind that we are an ionicsolution that exists in contact with an organic solution ofcompounds.
Look at it like a bottle that has oil and water in it. You shake upthe oil and the water and some oil will go into the water and somewater will go into the oil but, in reality, damn little of the oilgoes into the water and even less of the water goes into the oil.Your fatty tissue is oil based and your blood is water based.
Now, add uric acid to that bottle. Almost all of the uric acid willgo into the oil. Some will dissociate and make urate ions but damnlittle will do that. If you add a small amount of sodium hydroxide tothe oil, water and uric acid mix, you will make sodium urate thatwill all go into the water, nurtalizing the hydroxide. Add aceticacid and the sodium urate will go back to uric acid and in allprobability it will percipitate out at first and then slowlyredissolve in the oil.
Uric acid is benign in our bodies. All of us have it, in reasonablylarge quantities, dissolved in, and sometimes percipitated out aspure uric acid-trophi-and uric acid dissolved in adipose tissue. Asyou suspect, you can alter the amount of urate in your blooddramatically by altering the Ph of the blood and if you were tosurvive the dramatic Ph change- you could alter your goutprogression. For example, it is known that Cherries, Vitamin C andeven vinegar are good for temporary relief of gout symptoms. When youdrink vinegar-acetic acid, Cherry juice-ascorbic acid, or vitamin C,ascorbic acid, all acids that are very water soluble and move freelythrough your aqueous tissue in your body, anyway, these acids,surpress the ionization of uric acid into the urate ion and thereforewill slow down or in many cases will stop the crystallizationprocess. Adding an organic, water soluble, acid to a saturatedsolution of mono sodium urate, will dramaticzally lower theconcentration of the urate ion and it will cause that urate ion torevert to the acid form, that is uric acid. Moreover, uric acid isalmost completely insoluble in water and will therefore percipitateout of solution. Uric acid itself is almost completely ignored by thebodies defense mechanisims and in my opinion, cherry juice, vinegarand or vitamin C will end up making the urate percipitate out as uricacid and it probably ends up depositing itself on the surface of thecrystals which protects us from the crystal and will provide somerelief from the inflammation.
I apolagise for the long winded explanation but it important tounderstand that your blood level of urate does not reflect, in anyway, your overall uric acid load that your system is under. It onlyrepresents how much ion is in equillibrium with the free uric acid inyour system. Rumatologists believe that you have been accumulatingyour uric acid load for 15 to 20 years and that it will take three ormore years to get that load down once you start taking allopurinol.
Columbus Luthe on July 25th, 2007
Regarding joint damage- my physician described a gout attack as being like having broken glass in the protective tissues between joints. He showed me pics of uric acid crystals under a microscope and they are indeed jagged- like skinny multi-pronged quartz crystals. He asid that when you are in the middle of an acute flare-up, every time you move the affected joints, these crystals cut and scrape at the tissues. I know from my own experience that every attack I suffer leaves me less mobile, and my shoe size (as well as my ring sizes) have increased. The tophi on my elbows and knuckles give my once muscular arms and “artist” hands a “knobby” appearance now. My left index finger has rotated about 60 degrees at the middle knuckle due to accumulation of protective tissue (or tophi). I know that time is ticking away at me to begin the allopurinol therapy before I get permanently deformed and disabled. In my case, the gout has been the trigger effect in me developing what appears to be rheumatoid arthritis. I wish I had the access to the information here many years ago, as I am now only capable of running “damage control”. I know I will never recover 100% of my mobility. I am 38 years old, used to bench press 360 lbs, and now my wife (or daughter!) opens jars and cola bottles for me.  My experience bears out his description- but I do not have NEAR the knowledge of this disease that Arnold or Walter do, I can only tell you what I have been through.
Sabina Shamel on July 26th, 2007
You don’t need much knowledge to take allopurinol. Make sure you areon at least 300 mg a day, also take vitamin C, 1000 mg, and vitaminE, 1000 mg, a day and my bet is you will be rewarded with adramatically improved mobility in 6 months and, in a year or two, youwill probably regain most of what you have lost. Your body isremarkably resiliant and if it does not have to deal with the excessuric acid, it can repair and make allowances for your years ofproblems.
I only wonder why you are waiting to get started with Allopurinol…