Long-term treatment of gout aims to reduce uric acid levels; the reason for this is that we know that if we can reduce uric acid levels we can stop acute attacks of gout from happening, we can prevent joint damage from happening in the long term, and we can also cause tophi – which are the deposits of uric acid sometimes found under the skin – we can cause those to shrink and eventually go away. If gout is only treated by treating symptoms that occur during the attack of gout, then we don’t get rid of the crystals and hence those crystals can still go on to cause long term problems.

Reducing uric acid levels in the long term is best achieved by a combination of things that people can do for themselves, and drug treatment. Some people do get gout because they’re overweight, or because they drink too much alcohol, particularly beer, or because they eat too much of certain types of food, such as red meat or seafood. And so for those people reducing those things might help, but for most people who have gout that doesn’t have any effect. And in fact, unfortunately, we know that for most people with gout we don’t lower their uric acid level enough without drug treatment. The most commonly used treatment for gout in the long term is allopurinol, and allopurinol is a very safe treatment, which doesn’t cause many people to have health-related problems.

Last year I was getting too many instances and it was spoiling things because I have a hobby that I enjoy, and if I’d got gout I couldn’t pursue it until the gout had gone. And I actually came round to thinking that I needed to do something more about it than just trying to manage my diet and dealing with episodes when they occurred.

And have you done anything about that yet, then?

Yeah. Went to see my doctor probably this sort of time last year. I can’t quite be certain. Probably March, April time. And I agreed to go on to allopurinol gout medication, although we didn’t go for the maximum dose to start with – started on a low dose.

I was still getting attacks. I went for a six-monthly review with my GP. It’ll be seven weeks ago now. And I was chatting to him, telling him how I’d been, and I said to him, “I am still getting gout.” And I think I’d said to you I’d had probably three or four attacks from somewhere like last autumn through to when I went to see the doctor. Well, my understanding was that the idea of going on the allopurinol is not to have any attacks. So what he did – I was on 200 milligrams – so he upped the dose to 300mg but asked, as I say, for a blood test in six weeks to see what had happened. And I had that test last week and was told that the uric acid levels were now within a normal range, which I don’t think they’ve ever – well, they haven’t been for as long as I can remember. However I did have an attack again after I’d seen my GP seven weeks ago, but I was – or I did take anti-inflammatories as well, because I thought, “Well, weve upped the dose by 30, 33%. I suppose theres a chance it might kick off and make things worse.” And I had a mild attack. I knew I’d got gout, but it didn’t actually stop me doing anything except make it a bit painful to get my shoe on and bend – because it was in the little – the base – the joints in my little toes in – on one foot. And, as I say, I knew I’d got it, but it didn’t actually stop me walking or doing anything. It was just a little bit painful; nothing like it might have been without medication or without the anti-inflammatories. And, touch wood, I haven’t had it since.

I thought, Yeah, it’s something that is painful, it is something that comes and goes, and if I take tablets it will go away, and I was prepared to do that, just to take tablets to ease the pain. Don’t realise when you get it, the effect that it’s having on you, and I had quite some severe attacks in my hands as well as my feet. And that’s left me now with permanent damage which I didn’t realise was going to happen. It was just, Oh, it’ll go away, and yes the pain goes away, but the effects of the attacks of the acid and the crystals doesn’t go away, it remains there. Having said that, since I’ve been on febuxostat, the swellings have gone down. You wouldn’t believe the difference in – particularly in my right big toe, how much it’s decreased in size, over the last year and a half, it’s – it’s virtually back to normal. But my hands are still not right. No. Maybe they’ll go. Bearing in mind that I had gout for 40 odd years, it’s not surprising really that some of the effects of that gout are going to take a long time to go away, but hopefully they will go away.

Since I’ve been properly on the allopurinol which is probably 18 months now – I would have thought, it’s got to be, the full dose – the attacks have been getting less and less and less, thankfully, and less. And, like I say, it was last year, when I had a really nasty attack. Perhaps in October time, will it be? I think it’s probably October time. You get the odd twinge, you know, like I say this little finger, hurts now and again, but, that’s, and the knee will ache a little bit. But, whether it’s the gout, I don’t think it is, or my knee.

People often find that when they start to take allopurinol, that they can get an attack of gout. The reason that this happens is because crystals of uric acid are normally found tightly packed within the cartilage that lines the bones, and when they start taking allopurinol, their uric acid is lowered so the crystals start to dissolve and start to become smaller meaning that they can be more easily shaken loose into the joint, which is when that leads to inflammation and to an attack of gout. So although people often see having an attack of gout after starting allopurinol as a side effect of allopurinol, and clearly that’s something that from the patient’s point of view is unwanted, we should actually be seeing attacks like that as a sign of successful treatment a sign that treatment is working because it is telling us that uric acid levels are starting to be lowered, and that crystals are starting to dissolve. This also explains why people can continue to have attacks of gout for up to two years after starting allopurinol, because it takes up to two years for the crystals to dissolve completely.

They did say that, once I went on allopurinol, I would be on it for the rest of my life, but I mean it’s one tablet a day. There has been occasions when I’ve missed, but it’s very, very rarely that I miss more than a couple of days. If I’ve missed it, it hasn’t caused any problems. But I’ll, you know, I’ll quickly get back on it, I remember what the pain was like. It hurts [laughs].

The fact that I was in my 40s and they say you take this tablet every day for the rest of your life, but it’s one tiny tablet once a day not like, you know, people that’s on all these drugs having to take 10 and 20 tablets a day. I was having to take one to solve the problem and, you know, so it’s nothing is it, you drink more cups of tea, more cups of coffee, just have one tablet that’s it, you know, brilliant.

Once gout is diagnosed it’s important to check for other conditions that are linked with gout, such as diabetes, high cholesterol, or kidney disease. In terms of keeping an eye on people once they’re on treatment for gout, it’s important to check uric acid regularly, as that gives a marker of how the treatment is working, and we aim as doctors to make the uric acid level quite low, so we monitor this. It’s also important to check kidney tests and these are done usually through blood tests. We know that people who have gout are more likely to have other health conditions, such as heart disease, and so people with gout are often invited for extra health checks, to check things like blood pressure and to screen for things like diabetes.

What are your thoughts about taking allopurinol?

[Laughs] I think he frightened me when he said it’d give me a bout of gout first. Taking allopurinol apparently kicks in a gout attack and then from then on it’s gone, or so they say. But yeah I’d give it a go. I’ve actually had a prescription for it, but then I had a gout attack. The week I got the day I got a prescription for it, on a Wednesday, but then on Thursday I was laid up in bed with damned gout. So I thought, Well, theres no point in taking it. This is just wasting money.

Is that what the doctor told you to do?

No, I decided I went back to the doctor and said, Look, I won’t take it because I’ve got an attack. I don’t want to waste the money.

And to start off with I was getting attacks two, two and a half year intervals. As time went on, from ’66, the attacks got a bit more severe, and a bit more frequent, until ultimately I had to go back to the GP, and we tried to get on to some sort of permanent medication. And the medication, I’ve forgotten the name of it again, didn’t suit me, I was totally allergic to it, and I only ever had two of these tablets before I had this violent allergic reaction to it, and had to stop taking it. From then on it was a question of taking painkillers of all sorts of varieties, and different tablets such as diclofenac, I had probenecid, I had all sorts of tablets to try and keep it under control, nothing seemed to work, it was always just a firefighting exercise, that I’d get an attack, I would take tablets to get rid of it, and sit back and wait for the next one. At the end I suppose I was getting an attack about every six months, until 2010, when I went to see a specialist in this field and we sorted out febuxostat, which I now take, along with the colchicine, I take one colchicine each day, and since middle of 2011, I haven’t had an attack of gout at all. Seems to be well under control. And – if that’s the regime that it requires to keep it under control, then I will swallow these three tablets each morning for the rest of my life and be quite happy to do it.