Stubborn Gout Misdiagnosis
If your gout isn't responding to therapy, you may have something else.
Q: I am 29 years old and have gout, for which I take allopurinol (Lopurin, Zylpoprim), indomethacin (Indocin) and colchicine. I don’t drink alcohol, and I have tried to limit the purine-rich foods in my diet, because I’ve heard these can make gout worse. But the bad attacks are becoming worse. What should I do?
A: The treatment of gout is plagued by multiple misconceptions. Most people with gout do not over-indulge in either alcoholic beverages or purine-rich foods, and even for those who do, eliminating these items is seldom enough in itself to improve gout symptoms.
I can think of two possible reasons your treatment has not helped. The first is that you may not really have gout, which occurs when a waste product called uric acid builds up in the blood and then is deposited as crystals in the joints and other tissues. Did your doctor draw fluid from an affected joint and find urate crystals in it? If not, you may actually have some other type of arthritis, one that would require a different type of treatment. Conditions that are often confused with gout include:
- Pseudogout, a condition in which calcium – not uric acid – forms crystals that deposit in the joints, causing pain and swelling
- Reactive arthritis, which occurs as a reaction to an infection elsewhere in the body, generally in the gastrointestinal or genitourinary tract
- Psoriatic arthritis, which occurs in 4 to 6 percent of people who have the skin condition psoriasis
- Infectious arthritis, caused by an infection within the joint itself
The second reason you may still be having trouble is that you do have gout, but your dose of allopurinol (a uric acid-lowering drug) is not sufficient to control the problem. A recent study showed that 50 percent of patients treated with “standard” doses of allopurinol do not reach the therapeutic target of lowering serum urate levels to less than than 6.0 mg/dl.
If the diagnosis of gout has been confirmed with lab tests, talk to your doctor about increasing your dose of allopurinol. Because it often takes six to 12 months even after the uric acid level is suppressed below 6.0 mg/dl for the symptoms of gout to stop, it is important that you take indomethacin or colchicine once or twice daily to help minimize or eliminate your flares.
N. Lawrence Edwards, MD
Rheumatologist, University of Florida, Gainesville