Why some gout patients have repeated attacks despite taking treatment ?

A patient in miserable condition with repeated gout attacks – (uncontrolled gout / refractory gout)
We get patients everyday in clinics or on web asking queries like the following,

‘Tell me doctor, I am taking my gout medicines. I have controlled my diet , stopped alcohol and am taking supplements. Eg : tart cherry , krill oil, fancy amazon supplements, turmeric tablets etc). Why do I still get recurrent gout attacks ?

The term refractory gout is often used for these patients. The term refractory is often relative. We have often find these patients to be responsive to adequate treatment. They need inputs from a specialist.

Read more, understand about gout and uric acid by a simple analogy in easy to understand infographic

Everything about gout and uric acid explained by matchstick analogy

First, please understand a bit about drugs used in gout (not all drugs used in all parts of the world).

Drugs used to lower the Uric acid in the body – Allopurinol (zyloric), Febuxostat (Uloric), Benzbromarone, Probenecid, Lesinurad (Zurampic), Pegloticase (Krystexxa).

Drugs used to silence a gout attack (given only when attack occurs) or prevent an attack (given continuously to prevent attacks) – Colchicine, Steroid tablets or injections, NSAIDS (non steroidal anti – inflammatories) [Same drugs can be use to silence or prevent an attack. These drugs do not lower the uric acid.]

Reasons for repeated / recurrent gout attacks
Uric acid target is not achieved. This causes repeated gout attacks despite treatment

(Hence #reachforsix)

This is most common reason found in uncontrolled gout patients in any gout clinic. The patients are on medications, but they are not on the right dose. The dose of the uric acid lowering drug (as above) should be adjusted to keep uric acid below 6 mg/dl (or 350 umol/ litre – #reachforsix)>. Rheumatologists(arthritis specialists) are experts at helping one meet this target. It is better to show one for gout management.

Uric acid levels go low during a gout attack. One should not measure uric acid levels during a gout attack. It is always best to measure them between attacks to get a proper idea of one’s exact levels.

A proper diet is important along with drugs to control uric acid. But in most cases poor gout control has not much to do with diet. If a doctor always blames your diet for your poor gout control, then possibly one should get an expert opinion. Diet in gout is often talked about more than required. More on that later in the article.

Patient has gout tophi causing uric acid release and repeated attacks despite treatment

Gout tophi are like balls of uric acid which have very high concentrations of uric acid (see images 1a and 2a below). They usually form in patients who haven’t controlled their gout adequately over years. If a patient has achieved a target of uric acid below 6 mg/dl, this gout tophi will still release uric acid in blood. This can lead to a gout attack in joints.

The best way to deal with this is to give patients some tablets which will prevent attack. Let’s use analogy of matchsticks to explain this further. Uric acid are like matches. Allopurinol / febuxostat / other drugs above remove the matchsticks (lower the uric acid). Drugs like colchicine, NSAIDS, steroid tablets etc, actually make the matchsticks wet (they prevent or silence an attack). They prevent them from lighting up a fire (gout attack). We give such patients uric acid lowering and attack preventing drugs together. As uric acid remains below 6mg/dl, the gout tophi’s will dissolve. (see images 1b, 2b and compare with 1a and 2a a year back).
Usually we give colchicine to prevent attacks in twice a day doses. It is pretty safe. If not possible, we use a low dose steroid or NSAID (anti-inflammatory).

Sometimes, start of uric acid lowering drug will increase gout attacks to begin with

Many patients stop Allopurinol or Febuxostat saying that it increased their gout attacks. This happens because as uric acid levels go down with drugs, it makes uric crystals deposit into joints and cause an attack. This occurs because the drugs are working. We need the patient to continue with drugs and things definitely improve if uric acid remains below 6 mg/dl.

We give patients cover of attack preventing drugs (colchicine, NSAIDS and steroids) with uric acid lowering drugs (allopurinol, febuxostat).

Sometimes it is still poor diet which is a contributory cause of uncontrolled gout and repeated attacks

The only advice I give to gout patients about diet is to eat healthy. I also tell them to exercise or stay active, control weight and drink lot of water. I tell them to avoid organ meats (kidney, liver etc), high fructose syrup food or colas. I also give advice to decrease sea-food, red meat and alcohol. This is unlike many internet based articles. Many of them promote specific diets, special food, supplements, ask to stop alcohol, red meat etc.

We ask for complete abstinence from red meat or alcohol only in severely uncontrolled gout patients for few months.
The people talking about fancy diets & supplements are usually earning from their recommendations. So it is best to take such advice with a pinch of salt. Most severe gout patients have uric acid above 8-9mg/dl. Even if one goes on strictest diet in the world (which is not at all palatable), one cannot cut uric acid by more than 1mg/dl. This is not good enough to meet target of < 6mg/dl. Why not take medications then and have a better life with less restrictions ? (please refer to link in article given below).

To understand more on gout and its dietary myths, you can read the following article
How to manage gout nicely without miserable dietary restrictions ?
Medication intolerance in gout patients

Many gout patient stop medications citing intolerance or issues and hence keep on having repeated attacks. Except real allopurinol allergy, we have hardly seen any gout patient who cannot be managed with available medications. Most intolerance are due to improper counselling of patients or not waiting enough for patients to get used to drug. Many a times patient stop uric acid lowering drug saying that it increased their attacks. We have already explained why that is not a bad thing and how that can be prevented.

Do you or your relative has recurrent gout attacks which is not responding to treatment ? Do let us know if this article has helped you and do let us know your feedback. We would be happy to help if you have any specific question. We try to reply within 72 hours.

Please read our disclaimer : Many times internet based articles are not written by certified medical writers or doctors. Do not believe them blindly. This article, however is written by a certified arthritis specialist doctor (rheumatologist) and not just any blogger. The information here is genuine and based on verified facts (as per the published post date). However, before taking any decisions based on this article, please make sure that you have read ourdisclaimer here.

Author: Dr Nilesh Nolkha, Rheumatologist
Dr Nilesh Nolkha is a rheumatologist who strongly believes in patient education and empowering patients to make rational treatment decisions. He is a practicing rheumatology consultant in Wockhardt hospital, Mumbai.

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