Your First Gout Attack: Symptoms, Treatment, and Management

First gout attack?

Hello Doctor, I visited the clinic at the beginning of April due to ankle pain.
At that time, I had been lifting heavy objects for half a day due to work.
The next day, my ankle became red, swollen, hot, and painful, so I went back to the clinic where the doctor diagnosed it as a sprain.
After taking the medication, the symptoms subsided, and the doctor also ordered blood and urine tests.
Two weeks later, the same area flared up again with similar symptoms of redness, swelling, and heat in the ankle.
This time, the doctor diagnosed it as gout, reviewing the previous test results which showed a uric acid level of 6.6 (previously it had been as high as over 9).
The doctor then prescribed gout medication, stating that once the pain subsides, it would indicate gout.
(The medications included allopurinol, febuxostat, and possibly other anti-inflammatory pain relievers, totaling five pills.) After consistently returning for follow-up visits and taking the medication for about a week, the ankle pain ceased after starting the third pack, although there was still slight discomfort when pressure was applied.
The doctor advised me to continue follow-ups and medication.
However, I have been observing the swelling between my ankle and heel; sometimes it reduces and sometimes it swells again.
Recently, it has decreased significantly and compared to the other foot, it is still slightly swollen but not very noticeable.
I would like to ask about this condition.
Additionally, after taking the uric acid-lowering medication, I have experienced occasional mild pain in the big toe joint, but it is not persistent.
Is this what is referred to as "gout flare"? Regarding uric acid, should I request the clinic doctor to prescribe long-term uric acid medication for me? Online articles suggest that for gout, uric acid levels should be lowered to below 6.

Tai Tai, 30~39 year old female. Ask Date: 2024/04/25

Dr. Gao Jiankai reply Internal Medicine

Hello, thank you for your question.
If I understand correctly, both (Probenecid and Allopurinol) are medications used to lower uric acid levels.
Generally, we prescribe only one uric acid-lowering medication, and we only consider combining them in patients who are more difficult to treat.
Additionally, at the onset of a gout attack, we primarily focus on symptom control; we will only check uric acid levels once the symptoms improve, as the uric acid levels will be more accurate after the pain subsides.
Uric acid-lowering medications are not pain relievers, so they are typically added only after gout symptoms are under control, followed by regular monitoring of uric acid levels and adjusting the medication based on those results.
Uric acid-lowering medications differ from pain relievers in that they need to be taken long-term, with the treatment goal being to maintain levels below 6 mg/dL.
Whether to take uric acid-lowering medications long-term is something you should discuss with your physician.
Best regards from the Allergy, Immunology, and Rheumatology Department of Changhua Hospital, Ministry of Health and Welfare.

Reply Date: 2024/04/25

More Info

Gout is a form of inflammatory arthritis characterized by sudden and severe pain, redness, and swelling in the joints, often affecting the big toe. It occurs when there is an excess of uric acid in the blood, leading to the formation of urate crystals in the joints. Your recent experiences with ankle pain and swelling, along with your elevated uric acid levels, suggest that you are indeed dealing with gout.

From your description, it seems that your initial ankle pain was misdiagnosed as a sprain, which is not uncommon, especially if the symptoms appeared after physical activity. However, the recurrence of pain and swelling in the same area, along with the lab results showing elevated uric acid levels, points towards gout as the underlying issue. The medications prescribed by your doctor, including allopurinol (普利酸錠) and possibly other anti-inflammatory medications, are standard treatments for managing gout and lowering uric acid levels.

The fluctuation in swelling you are observing in your ankle is not unusual in gout. Gout attacks can vary in intensity and duration, and the inflammation may subside only to return later. The fact that you are experiencing some mild discomfort in your big toe could indeed be a sign of what is known as "dissolving pain," which occurs when urate crystals are being dissolved and can lead to temporary discomfort as they move in and out of the joint.

Regarding your question about long-term management of uric acid levels, it is generally recommended for individuals with gout to maintain uric acid levels below 6 mg/dL to prevent future attacks. Since your uric acid levels have previously been as high as 9 mg/dL, it is advisable to discuss with your doctor the possibility of starting a long-term uric acid-lowering medication. This will help prevent future gout attacks and manage your condition more effectively.

In addition to medication, lifestyle changes can also play a significant role in managing gout. Here are some recommendations:
1. Dietary Changes: Limit foods high in purines, such as red meat, organ meats, and certain seafood. Increase your intake of low-fat dairy products, fruits, and vegetables. Staying hydrated by drinking plenty of water can also help dilute uric acid levels.

2. Weight Management: If you are overweight, losing weight can significantly reduce uric acid levels and the frequency of gout attacks.

3. Limit Alcohol: Alcohol, especially beer and spirits, can raise uric acid levels. It may be beneficial to limit or avoid alcohol consumption.

4. Regular Monitoring: Keep regular appointments with your healthcare provider to monitor your uric acid levels and adjust your treatment plan as necessary.

5. Medication Adherence: It is crucial to take your medications as prescribed and not to stop them abruptly without consulting your doctor, even if you feel better.

6. Recognize Symptoms Early: Being aware of the early signs of a gout attack can help you seek treatment sooner and potentially reduce the severity of the attack.

In summary, it is important to continue working closely with your healthcare provider to manage your gout effectively. Regular follow-ups, medication adherence, and lifestyle modifications will help you maintain your uric acid levels and reduce the risk of future attacks. If you have any concerns or questions about your treatment plan, do not hesitate to reach out to your doctor for clarification and guidance.

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