How to take febuxostat for best uric acid results?

[d q]

So after that paradox result [increase of Febux resulting in increase of UA] things have completed changed. The new test results are in:

366ummol after 20 days of 60mgs Febux.
Haematology numbers seem fine but too early to tell as that takes more time to stabilise. Rheumatologist is relieved and has asked me to go to 80mgs to try and drop it a little more. Not sure if going to 80mgs will make these lower back and abdominal pains worse but we’ll see. It might be useful to try and go to 80mgs for a period just to see these low grade foot pains go. We talked about this in detail and he assured me that if this pains are due to uric acid accumulation then they should slowly settle down now that the levels are coming down. He did mention however that if damage has already been done it may never return to normal and the best thing would be to rub a thin layer of low dose Voltarol gel on the painful area on the bad days to keep mobile. Avoiding the additional nasties of pills I guess. If I remember Voltarol gel actually is diclofenac, not sure of the drug levels however. He gave me a few more blood forms and asked me to get tested again in around 4 weeks.

I’d like your opinion on a few things;

1. Any advice generally on the above?

2. Assuming hemo holds at no more then 60mgs of Febux, will 366ummol be enough to dissolve (even if slowly) and keep gout at bay going forward? For that matter even if hemo and liver are fine at the higher 80mgs dose is there really a need for lower UA levels to warrant adding more of that drug in me.

3. Can cardio based exercises bring about gout attacks (increased blood flow)..? I’m not talking about running that may mobilise crystals in joints causing attacks. Just speeding up heart rate in other ways to reap the health benefits?

Looks like things ‘may’ be heading in the right direction after all.

Cheers

[nobody]

Finally! You had me worried with your previous result.
366 isn’t great but it would be sufficiently low… if it wasn’t only one result. As it is just that, I wouldn’t wait 4 weeks for the next test (assuming you have a choice in the matter).

You’ve gone slow and safe until now. While the small SUA drop 80mg should provide would be useful,
1) you can’t be confident yet that your hemo would remain stable if you kept taking 60mg and should your hemo start dropping after you start taking 80mg, you will be glad to know for a fact whether 60mg is safe
2) your SUA might keep dropping without a dose increase anyway since this result is consistent with your deposits taking a helluva long time to dissolve
3) lowering SUA slowly seems to cause less attacks (in some cases anyway)

Unless this result is a fluke, as I understand it moderate cardio exercises can only help because crystals would dissolve anyway. Increased blood flow will only make them dissolve faster, shortening the attack window for each deposit. But recall that exercise causes an immediate increase in SUA (the general recommendation is to avoid prolonged strenuous exercise).

The notion that symptoms will abate this soon is recklessly optimistic so hang onto your colchicine.
Diclo gel isn’t quite free of the nastiness of pills and isn’t very effective but it might be an acceptable compromise for minor symptoms if you take well to NSAID pills in the first place. Don’t bet on the gel stopping an attack though so keep the pills around!
On the bright side, there’s a good chance that any lingering symptoms might in time go away. You won’t know how much damage is permanent for quite some time.

May I remind you of Keith’s advice regarding pain? Some medical professionals are used to dealing with patients in pain and they know what works.
You may now tell them you are undergoing successful therapy according to your last blood test which would make the source of your pain temporary. That changes the risk picture a bit as far as pain management is concerned.

[Jean Clyne]

Better numbers, good! Sounds like you might have to balance amt of febuxostat with your symptoms, too much gives you side effects, less you can tolerate but will take longer to dissolve existing crystals which have probably building up over 10 yrs plus. It would seem logical to me that any exercise to result in increased blood flow would help eliminate the crystals. I know if I walk a lot 15 to 20000 steps, I am much better than inactive days, good shoes or boots with lots of cushioning help me, because of osteoarthritis too. Any exercise that caused excess flexion of sore joints didn’t work for me, ie. Cross country skiing was awful, snowshoeing not so bad but walking is the best as long as the ground is not too rough. Keep moving if you can, good for overall health I think!

[d q]

Hello again!
I’ve been assigned a new project a little further from my usual place of work so have found it difficult to get my own online time. Anyhow;
Firstly thank you both for your encouraging remarks.

Unfortunately I don’t really have a choice in the matter. I will try and plead with my GP for a blood form but its doubtful since the rhem report mentions to have a blood test in 5-6 weeks because it will give ‘a more accurate picture of my hemo status’. Really annoyed but I guess another 2 weeks wont hurt.

1)Agreed, so on that note I’ve decided to stick with the ± 60mg until my next blood test in 2 weeks. Depending on the result do you think the extra 15-20mgs would nudge me into the safer and lower 340ummol bracket?

2)Every time you mention this in your posts it gives me that little bit of encouragement and motivation that levels were high because of the constant dissolution going and have finally come down a little. I really hope this is the case mate. I guess the second blood test will reveal all and either put me into more misery or out of misery :/

3)It’s strange you say this as some days I have literally no gout pain and some days I get a few bad hours. Normally lying down for 30 minutes or so clears it all up. I think these are mini gout attacks or some sort of mobilisation of existing crystals. I’m not too sure. On the whole though, these bad days seem to be getting less week on week. Podiatrist is very happy with progress and said if things continue like this it may be time to start wearing my support insoles less and less with intention to wean me off them.

I’ve got my colchicine right by my side for sure on those days and moments when things don’t feel right. As it stands it seems I’m treating myself! Yea, I thought the same about the gel. Probably just good for those shopping days or long walk days when you need a little comfort but nothing really more. I think I’ve only ever tried it once and can’t even remember what kind of comfort it gives (if any). The branded ones are really pricey too.

I mean generally everything now depends on the hemo. That’ll be the ultimate determinist in all of this but as you say the pain management should slowly be altered from aggressive to a more relaxed approach. I’m really hoping Febuxostat doesn’t affect hemo. It probably is my last safest shot at this without going into all sorts of combination stuff. Unless I just take a low dose of Febux and try to delay gout as much as possible until a reliable and successful hemo solution comes into play (if ever – however things are in the pipeline).

@Jean, I can also say when I walk a lot I generally feel better overall. I do get a little pain but as you say I think that is a signal of good pain rather then the bad when I had much higher UA levels (blood flow moving stuff out). Well I try to convince myself to believe that anyway 🙂 . I’m really wanting to get into skipping as I hear it is a fantastic cardio and physical work out but I’m just too scared to trigger anything while being on a lower UA.

I really hate gout. It really has taken a little bite into life.

[nobody]

If you were to repeatedly test around 366 on 60mg (which is doubtful), yes: 70mg and especially 80mg should be enough to nudge your test results into safe values.
Obviously if your next test result was around 390, that would be all the more reason to increase take 80mg. Hopefully it’ll be around 350 instead.

The risk of attacks beign increased while on ULT doesn’t mean you’ll get a serious attack every week. It’s what most people seem to report over several months. Your symptoms might improve over a couple of months before you are suddenly be hit by a serious attack. Or maybe you’ll never have another one… all I can tell you is: be prepared regardless of how well you’re feeling. Just in case.

I was actually thinking your situation might warrant more aggressive pain management (meaning stronger drugs). You want to be especially careful with drugs when you don’t know how long you’ll be taking them but when your trouble is temporary…

[d q]

Well I’ll be doing my blood test next week and we’ll see how 60mgs for a month panes out. I have to admit there have been the odd day when the 60mgs have ended up closer to 70mgs with cuttings being imperfect but I’m sure they shouldn’t make too much of a difference. Since 366ummol only ever occurred once whilst being on 60mgs [only tested once whilst being on this dose] I cannot explain just how anxious (and worried) I am.

The opposite is what happened to me when I started Allopurinol, it only took 2 months and dropping into the 350ummol zone before I got hit by possibly the worst attack (which is the lingering pain today). I do get the occasional not so good day and take a colchicine. Funny actually a few more weeks completes my one year anniversary since my last attack. Being on 366ummol is almost identical to where that attack wrecked havoc.

Would a single colchicine tablet every few days give mild and very basic coverage? The reason I ask is I really don’t want anything to disturb my hemo figures whilst we get to a maintenance dose (however long that takes) should Febuxostat work?

[nobody]

I have no idea what colchicine would do to your hemo given your condition. But I wouldn’t take less than one every other day. And that’s not going to do much.
If you handle NSAIDs well, maybe it’d be best to take a delayed-release anti-inflammatory pill every day for a little while? Or simply to take a fast-acting nti-inflammatory pill whenever symptoms seem to start stirring?

[d q]

With a few days to go until the blood test whilst just being on Febuxostat I’ll just wait to see what overall results I get. From there we’ll decide how to proceed. If the results are safe it may be a case of increasing to 80mgs and starting a low dose of prophylaxis colchicine for a few months.

My last prescription of Febuxostat resulted in identical imported packaging with UK labels stuck on top (from a reputable UK pharmacist). Everything was just written in a different language but text font and sizes were the same. With my blood test so close, I was wondering if any variations can occur? The pharmacy said it was just certain suppliers for certain pharmacies and I had nothing to worry about however I have a friend who takes anti-epileptics and they must be brand specific and preferably same country manufacture. Does Febuxostat have similar requirements?

[nobody]

I have no idea how trustworthy your manufacturers are. If the manufacturers are doing their job (and if they are EU manufacturers, they should be!), the only way brand and location of manufacture would matter would be if the packaging mattered (drugs which are broken down by stomach acid, delayed-release pills and so forth). A molecule is a molecule and I don’t know that the packaging matters for febuxostat. Maybe it actually does though.
Out of curiosity, what have they switched you to? You used to get Adenuric pills, right? There’s nothing on my packaging that says where the pills come from but if I had to guess, I’d say the pills were made in Germany though the actual febuxostat might have been produced in Italy or even further afield.

Often times, people lie about the difference between brands. There’s quite a bit of money in this game and little accountability.

[d q]

There has been no actual switch. It’s exactly the same packaging and Adenuric is written on the box but just written in a different language. The first box I was ever given looked was the new box looks like

With the UK label stuck on top of the back part where the translation takes affect It does say manufacturer: Menarini – Von Heyden, Germany
The Marketing Authorisation Holder is somewhere in Luxembourg and the Distributed and Repackaged by is Kosei Pharma UK.

I’m sure its fine though.

Could you post a picture of what your package looks like?

[d q]

I’m not sure why the images haven’t come up so I’ll just post them here.

Originally Prescribed:

How is your UK febuxostat packaged?

Pharmacy Prescribing:

How is your European Adenuric packaged?

(ignore the watermark logo on the picture)

[nobody]

So the pills are indeed made in Germany. I bet all pills for the European market are made at the same factory.
I had misunderstood you earlier and assumed the pills themselves were different, not merely the cardboard. The shape and color of the pills could vary without changing their effectiveness but it looks like you’re getting the exact same pills anyway. Mine look the same as well.

[d q]

Perfect, thanks.

[d q]

Is Febux progressing Gout Recovery or not?

I did my blood test a few days ago and the results are in..!!
UA test a month ago was 366ummol (60mgs Febux).

Update:
This time 388ummol (so +20 from my last result)..!
Liver markers are fine, hemo seems fine so far too!
Are we finally stable? (366 / 388 being small difference)

I haven’t seen my doctor or rheumatologist since these results but they originally recommended I go straight to 80mgs and I was definitely not going to do that so that advice probably wouldn’t change if they did see me anyway.

So I guess that brings us to the cross roads with a few options;

1. Stick with 60mgs for another month to see how it goes?
[I believe no new crystals will form at 366-388..? am I safe..?]

2. Move up to 80mgs for a month and see how it goes?
[Is this actually necessary..?] [are crystals dissolving anyway at 388..?]

I’m sure I’ll have another few questions based on your advice.
Thanks guys!

[nobody]

Very good news.

You could begin by trying for 70 mg, without paying much attention to the exact amount you shave off the pill before taking it. A couple of mgs won’t make a difference at this stage.

Your SUA is above the recommended value and, assuming side effects aren’t an issue, we would generally recommend aiming lower anyway. I expect future tests would in time yield lower results on 60mg but you can’t rely on that.
Your liver markers and so forth being OK, it comes down to how you feel about the unmeasurable side-effects.

I don’t think you can rule out crystals forming completely considering the variations in SUA and temperature but the main point of lowering your SUA from here is to speed up the dissolution of existing crystals (they can still cause damage, and the drugs you take for gout symptoms have side effects as well). There seem to be benefits in lowering SUA slowly but you’re doing it slowly enough already.

[d q]

Thanks @nobody – top man.

Yep, I think it’s best to go for 70mgs for a few weeks and see how that goes. By the looks of things it may be a case of 80mgs for the full safety net but I want to do this slower then the doctors want me to.

The question I did have (in addition to a few more that will crop up) is at 388ummol, are crystals actually dissolving in retrospect to scientific findings and understandings..? The reason I ask is because if they need to be far lower then my current highest result which is 388ummol then I’m worried if the extra 20mgs won’t be be enough?

What if the 80mgs isn’t enough? Do I have to cut a pill and a bit from another one? From what I understand the only next increment is 120mgs!

Thanks guys.

[nobody]

Crystals dissolve at higher values than 388. But crystals aren’t all equal with respect to temperature and isolation from the blood. More importantly perhaps, SUA varies from day to day as well as throughout the day. The generally recommended target value is lower so as to afford a safety margin, not because crytsals can’t dissolve above 400. Indeed, tophi shrinkage has been measured when patients tested no lower than you do now (though shrinkage happens faster with lower values).
There’s also the matter of largish crystals being suddenly exposed to consider: dissolving crystals will raise your SUA, potentially saturating your blood so that the crystals in question may stop dissolving until your body is able to get rid of enough UA through urine and so forth. That may be bad news in terms of attack duration and joint/bone damage, especially if you excrete uric acid slowly as I suspect.

80mgs should be enough.
There are diminishing returns to increasing one’s dose and the maximum dose recommended by the original manufacturer is only 60mg. Of course people take more than that all the time but I wouldn’t push it unless it actually was necessary.

[d q]

Totally understand – thank you.

I have noticed on so many occasions when I get pain in the area drinking large doses of water seems to really dampen the pain. I think as you say these might be a large deposits or clusters of them breaking off and the water comes in just in time to flush it all out. I haven’t tried waiting it out without drinking large volumes of water in case it turns into a nasty attack.

Hypothetical here, let’s say 80mgs drops me to a maximum of 340ummol at most. Now from what I understand from you is crystals can dissolve at slightly higher UA values then this but assuming in the darkest of places where the lowest UA value is required for dissolution, what would this number be? The reason I am paranoid or panicking is the worry that the number required will always be lower in order to de-bulk fully then I can achieve with monotherapy.

I mean if its a question of time, then I guess one can just wait it out, the question is if at all its possible in those really dark die hard stubborn areas?

Statistically, does one eventually require less medication after all crystals are flushed from the body (like going from 80mgs back to 60mgs for e.g.)?

There is always a chance I might need less one day too if my hemo condition gets a medical advancement I guess.

[nobody]

The generally recommended target is 350 or 360 so you should be OK. Barring exceptional circumstances, all crystals are supposed to be eliminated in due course by dropping SUA to such values, with some safety margin to spare.
As far as I know, this is what most studies find. I remember one study showing ongoing bone damage in some cases but I guess this might be OA or something rather than persistent uric acid crystals.

You might benefit from lower SUA values than 340, and I’m confident you’ll achieve them in time.
But don’t let our host’s bullishness about dosage get to you: in most cases, lower values are to be filed under “nice to have” rather than “necessary”.

I’m not aware of any stats about treatment vs. maintenance doses but some guidelines mention lowering the dose after symptoms have gone away.

Not to confuse you but it might be drinking water affects acidity in your body. I’ve been somewhat simplistic above and in my last few posts, talking as if it was all about SUA but acidity is a complicating factor, and is part of why diuretics trigger attacks (SUA can decrease slightly while the amount of uric acid in the whole body as opposed to the blood increases). Hence people promoting baking soda as a gout cure and so forth.

Ultimately, we will only know whether 60mg or some other febuxostat dose works for you by its effect on your symptoms over the years. Blood tests are our best guide in the short run but they aren’t the whole story.

[d q]

“Host’s bullishness dosages!” – That had me laughing in tears!
No way – not this time. I’m doing this slowly and carefully.
I’m sure the express method has it’s benefits but I unfortunately I am not one who got to experience them.

I really hope your right in the possibility of achieving 340 at some point. If I remember correctly I think my rheumatologist mentioned something about adjusting the dose after values settle in general. So when they mention 360 as the upper figure, does that include the buffer or is that + a little buffer?

Like you say, all these blood tests are snapshots and don’t illustrate the full picture. I mean take my abdominal pain. I didn’t have any pain at all for a whole week! Yesterday on the other hand it knocked on my door step again. Although, that is when I increased to 70mgs! Psychological or Side effect of the increase, who knows! Maybe it has nothing to even do with Febux and I’m slowly wittering away! 🙂

2017 was a challenging year. 2018 has been so far softer. I just want all this crap behind me. There is so much I’d like to do yet every time I get some pain in my foot I just feel shit again. Let alone start worry of what may come.

Not too sure I completely understand the acidity part by the way, another example would be helpful..?? 🙂

Thank you so much for your last reply by the way. I don’t say this much but your detail and clarity really does help.

[nobody]

360 is supposed to include an adequate buffer but it looks like there is a growing recognition that a lower target is beneficial or even necessary in some cases. Obviously there is more of a safety margin at lower values but 360 seems to be low enough in most cases. And you should in principle be able to reduce the need for a safety margin by behaving carefully.

Don’t worry about the acidity thing. This stuff often goes above my head so if you’re curious, best read the literature yourself. Bottom line: SUA isn’t the whole story, beware of diuretics, be sure to eat veggies and drink lots of water.

You’ll probably still have a few bad days but your average day should get better over the course of the year. In time you will stop being paranoid about every foot ache.

[d q]

Thanks – Hope your well mate.

I’m assuming you mean by watching my diet (behaving carefully)?

Interesting the acidity thing. I’m going to have a read of it. On another note,
this brings me to what I believe is a good question, this water thing.
If Febuxostat blocks UA formation, health benefits aside here, does one still have to drink vast amounts of water? I know this might be necessary in the initial stages (as I have witnessed [debulk, flush out, etc.]) but is this something that needs to be constantly maintained. The reason I ask is I have noticed some weight loss since starting Febux and I am aware this could be the drug but I also think it could be my serious increase in water uptake..?
I’m carrying water with me everything and frankly its getting obsessive!

I have had a few bad days recently actually. My podiatrist required to do a few modifications to my insoles which resulted in me having to use the ones that come with my shoes and after just two days of using them my weak foot is killing me. It get’s better here and there but generally its been pretty bad. I mean can just using different insoles cause such pains? I’m assuming a few things here though; change of weight distribution, change of comfort cushioning; etc. etc. but I was also thinking that it could be the change of bone movement/positioning causing crystals to break off causing this pain affect?

believe me nobody, I am counting each day by day and hoping this stupid pain will eventually disappear. I’ve been keeping as patient as I possibly can but it’s just tearing me apart how long this stuff can take! This slow constant pain is just debilitating on some days. I mean how long can this chronic pain last! How long can it take to dissolve these nasty things!

Sorry for the rant!

[nobody]

Careful behavior goes further than diet. Look up general recommendations for gout sufferers if you need a refresher. That would include drugs, clothing, physical activity and indeed water intake…

I’ve also been carrying water around. Obviously you can overdo anything, even water.
How much you might need water, I have no idea. Other than to carry out an excretion test and read up on what the result implies, I don’t know how a doctor would go about making that determination. But you could try experiming on yourself. Write everything down and before long you should be able to take a good guess at what does and doesn’t make a difference in your case. Keep in mind it’s kind of early for you to take chances though.
In my case I noticed that, rather than having to drink a set amount, water intake needs to balance water loss. Typically, I would drink when I’m kind of thirsty (which means I would still be drinking quite a lot). But when it’s especially hot and I’m sweating for instance, then I force myself to drink.

Sure, in principle changing the way you walk could affect crystals. But it could also be unrelated.
I think that you should be able to pick up clues to determine if any pain is (partly) caused by gout or a gout-like condition. For instance: redness (even if it’s slight, the location ought to be telling). You’ve suffered from this long enough to make a good guess, haven’t you?

As you probably know, in some cases it can take years at the recommended SUA level for crystals to go away entierly.

Drugs can deal with this type of pain, especially when there’s reason to assume it’s temporary. I don’t know your history and so forth so I can’t balance the risks and benefits in your case but if there is no particular reason why you have to endure this, you should talk to people about how to go about getting proper care in your country. I think Keith suggested talking to an experienced nurse.

[d q]

Hello again! I think the gout knowledge I’ve accumulated between reading, yourself and Keith has made me into half an unqualified rheumatologist 🙂

Drugs, never took em, never will. Shoes can be tricky at times and this could be one of the reasons I get pains every so often. Physical activity isn’t much at all. Only walking and nothing more. I really want to get into skipping as that is a serious all round yet simple workout but I think it’s early days to push the toe joints and that ultimately is where all the weight will be applied. Do you do any exercise? If so what do you do to keep healthy? Water intake is mammoth. For my size and weight anyway, it is A LOT. I will however start to taper down once I get my next blood test done in about 2 weeks or so. That will probably be amongst the most important.

I have to accept the excretion test is just not going to happen through the government health care system. I’ll have to do that privately but either way it will not really give a clear indication any more since the UA levels are now in the 360-380 range so I am assuming enough is leaving to maintain that level. I use to keep a diary of nearly every change I make but as time passed I became less and less involved. You are right, maybe I should expand on this again. I believe you drink more water because of the Diabetes..? p.s. how much do you get through in an average day? Just a general average day?

No redness is found on the actual troubled joint and foot ball but redness can be found somewhere on the middle toe joint but it is absolutely painless. Maybe some sort of UA collection? Yes, I have suffered enough but the pains all vary to be honest nobody. Sometimes its a concentrated pain and sometimes its the entire foot which is in a dull pain. It’s sort of ‘tired foot pain’ or a ‘weighted foot pain’ despite not much activity on it. I mean the other foot doesn’t get the same feeling anyway. I need to relax it every so often. Maybe its permanent damage and I just need to live with it…. or maybe as you say its a question of time…

I’ve discussed this with very good rheumatologists and the answers have always been so similar. Either its;

a) “if its gout pain as a result of UA build up then after a “while” on ULT it should eventually clear up”.

b) “if its permanent damage you may have to just have to apply a thin amount of Voltarol on the foot on the bad days”.

or near enough anyway.

It’s definitely not low grade inflammation because the foot doesn’t look inflamed at all.. Something else is wrong and I just cant work it out.

Just over 2 years ago I was working abroad and holidaying in such beautiful places. Now walking is a chore and worry is a norm. Sometimes I ponder how can youth health turn so sour so fast. Gout is insidiously evil.

[nobody]

I drink more water than anybody I know. Or at least I’m the only one who doesn’t hide my empties.
I’m not counting liters.

Even assuming you don’t have access to a swimming pool, a bike or exercise machines, you have an upper body. And even if you couldn’t exercise your upper body for some reason, you could still get a workout by lifting your own weight without moving your feet (hang onto something with your arms for balance if needed to avoid using your toes at all). I was advised to balance “shallow” and “deep” flexing to exercise the muscles on both sides of the thighs/knees. Not as fun as swimming and so forth obviously but you could hit a podcast or something while you do it.
If you can’t even do that because of an attack, my fave subsitute to get my heart going has been hot showers. Sauna might be better but if you have access to that, you probably also have access to attack-friendly exercise gear you can use while lying down.

What I call gout-type pain comes with specific feelings and/or redness patterns which have occured together with (what looked like) regular gout attacks as well as less serious symptoms. I don’t recall ever having uniform pain over the entire foot.
Non-specific foot pain/tiredness, I would hesitate to associate with gout: if it could be anything, it could be anything.
Maybe you’ll start noticing more clues over time. Better yet: maybe you’ll stop worrying as these symptoms fade away.

[Author]

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