You've goutta be kidding me
July 6, 2012 10:56 PM   Subscribe

How long should I delay confirmation/treatment of "gout"?

I started having foot pain - base of toe - this week and it was terrible today. I called my doctor, but she's out of town - I can't get into her office until Thursday, and that would be with a Nurse Practitioner. So I went to a walk-in (well, limp-in) clinic where the doctor said I had a textbook case of gout.

The doctor at the clinic based this on a physical exam only, she said they could possibly do blood tests, but it would be better to do them with my PCP. I said this wouldn't be until Thursday at the earliest, and that would not even be with my PCP, but the doctor didn't seem concerned. She gave me a shot of painkillers (which didn't work, nothing really has) and sent me on my way.

Now I'm a big fan of "do what the doctor tells you to do" but:

1. I'm not in the age or sex demographic for gout (female and very much premenopausal)

2. I'm not in the dietary demographic for gout (I can't remember when I last had red meat/wine, and I drink 2-3 cups coffee daily. Straight water intake is about 2-3L a day)

3. There's no family incidence of gout

4. I have no known predisposition for gout (kidney disease, diabetes, etc.)

....and that's where I'm concerned. Given I'm not in the age, genetic, or dietary range for gout it makes me worry that something's wrong - I eat sweets like whoa and take a number of medications that can damage my kidneys (and the recommended painkiller for gout is ibuprofen, which can damage your kidneys).

I don't doubt the doctor's diagnosis - it really is quite textbook - but my question is about the delay in treatment/confirmation.

How reasonable is it to expect me to wait until Thursday to get bloodwork done? Is gout one of those things that will eventually just go away so there's really nothing I can do? Should I just go back to the clinic and request they do the confirmation anyway? Would it be unreasonable to request additional blood test (protein and glucose levels to check for renal function and diabetes) Am I just being a hypochondriac? I am not ruling that out!
posted by Lt. Bunny Wigglesworth to Health & Fitness (27 answers total) 1 user marked this as a favorite
Best answer: For the actually symptoms of gout, i.e. the toe inflammation/pain, they normally just treat that with ibprofen and sometimes corticosteroids if it's bad enough. The medication the prevents gout is what you would need, and yeah, you'd need to get those blood tests to confirm that. Have you talked to your doctor's office after going to the walk-in clinic? If not, call them on Monday and tell them you probably have gout! If you have and they seemed unconcerned, call back on Monday anyway and ask to speak to the NP or nurse to make sure the schedulers know what they're doing by making you wait.
posted by two lights above the sea at 11:15 PM on July 6, 2012

What you need to do is drink lots of water, rest the foot as much as you can, and look at adjusting your diet in the longer term. They probably won't put you on any drugs if this is your first attack. It will pass, and if you're lucky you may never have another.

A few days' delay is therefore not a problem. So far as I know it's unlikely these symptoms indicate any other issue. Gout can hit anyone: you don't have to be a fat old man who drinks port and eats roast ox constantly.

The dietary factors, unfortunately, are quite complex. Port and roast ox would be bad choices, but so would broccoli and mushrooms. There is partially conflicting and incorrect advice on the internet; you want a diet sheet from a proper medical source. If you're overweight it would help to cut down a bit.

In short, bad luck because gout is a complete bastard, but you need not be worried about other stuff.
posted by Segundus at 11:18 PM on July 6, 2012

I'm replying because I have to deal a woman who won't accept that she has gout.

It depends on your age and your situation. Get it looked at early. Often. Get it taken care of.

Because.... Ugh... She denies she has it... Ugh...

Anyway, it won't progress more than incrementally each day. So you can wait.
posted by krisak at 11:18 PM on July 6, 2012

By "So you can wait" I meant that you can work on it and find a plan to reduce it day by day,
posted by krisak at 11:22 PM on July 6, 2012

Response by poster: When I called my PCP initially and they put me off until Thursday I asked them for a clinic rec and told them I was going there. Once the clinic told me to get a blood test I immediately (like, in the parking lot) called the PCP office back and said, "the clinic said I have gout and need to have a blood test confirmation" so the receptionist does know that.... but yes, I will call Monday and make sure the nurse practitioner knows this.
posted by Lt. Bunny Wigglesworth at 11:27 PM on July 6, 2012

Best answer: If it's gout (which is one of those things that does have textbook cases), in my experience it goes away after a couple of days of excruciating pain. As you may have read, it's the buildup of crystals in your joint, so drinking a lot of liquids will both help those crystals dissolve sooner and make you feel like you are doing something.

Rest the toe; I would get blood tests so I could take stronger stuff to combat the gout, and also get them to confirm that gout is not the vanguard of something worse. (In my case, if I hadn't by pure chance caught a bad flu and been hospitalized a couple of years earlier, the gout attacks likely would have been my first warning sign of kidney disease.)
posted by Homeboy Trouble at 11:29 PM on July 6, 2012

Response by poster: Also - not overweight (not "thin" thin, but still "normal"). I totally do not fit the profile in any way, shape, or form. Not even a hair. I haven't changed my diet in years. Which is why I'm worried about underlying metabolic functions (or failures).
posted by Lt. Bunny Wigglesworth at 11:31 PM on July 6, 2012

Some people take colchicine as a preventative, which is one of the oldest known medicines. The Greeks used it. Gout is tricky to figure out because the triggers vary quite a bit for each individual. Lots of water is good, often the first attacks are milder and subsequent attacks can get progressively worse. Many people have one or two attacks and then never again. Others suffer quite a bit for their whole life.

If you wind up having more attacks, you will have to study your diet, and try to be sensitive to which foods give you early symptoms. Once you figure that out, gout can be controlled. It can be a problem for people who would rather have the occasional gout attack because they cannot give up certain foods or drink.
posted by snaparapans at 12:29 AM on July 7, 2012 [1 favorite]

Oh, and if the nurse practitioner was not alarmed enough to say come back next thursday, you are probably ok to wait. The symptoms usually last three days or so. The test is for uric acid in your blood, and it will give you a baseline to work with to lower the level. I never bothered with it but have only had a couple of attacks over the last several years. Only one was really bad. I can feel the oncoming symptoms early on and then I drink lots of water and am careful about what I eat. Also I have colchicine on hand and take it when on the rare occasions that I feel an attack coming on.

I have a friend who has had severe gout, and takes one colchicine tablet (low dosage) every day, and never or rarely has an attack.
posted by snaparapans at 12:40 AM on July 7, 2012

Lt. Bunny, the strange and unfortunate/fascinating thing about medicine is that demographics mean nothing when you are an N of 1. There are no absolutes, and even though you don't fit the profile for a disease, that doesn't mean you are immune to getting it. Those demographics just give you an idea of who is more likely to have gout, and likelihoods are not diagnoses.

I can tell you that regardless of whether you end up having gout or not, you're not likely to be missing anything important by waiting a few days to see someone about this. It's pain at the base of your toe. What else are you worried about? An occult stress fracture? Plantar fasciitis? The differential is fairly limited.

IANYD. But I would also like to add that the blood test that people love so much for gout are not actually very useful. The diagnostic test of choice is joint aspiration to look for crystals.

I shall quote from eMedicine, one of my favorite medical database websites:
"Measurement of serum uric acid is the most misused test in the diagnosis of gout. The presence of hyperuricemia in the absence of symptoms is not diagnostic of gout. In addition, as many as 10% of patients with symptoms due to gout may have normal serum uric acid levels at the time of their attack."

The same article notes: "Radiographic studies of the affected joint are indicated." (as you noted you did not get an x-ray for this). But the x-ray is not emergent.

Consider taking naproxen/Aleve, a common treatment for gout. It may not relieve the pain immediately - it takes 5 half lives to reach steady state... it is unlikely to hurt the situation.
posted by treehorn+bunny at 12:50 AM on July 7, 2012 [3 favorites]

P.s. An electrolyte panel, which includes glucose and kidney function tests, is likely to be part of the standard blood work you would get at your follow up visit. It is not emergent. It does not sound from your description like you have any symptoms of renal failure or diabetes (not that it isn't possible these tests will be abnormal, but it is unlikely they would be very abnormal if you have no other symptoms). Hope that is helpful.
posted by treehorn+bunny at 12:58 AM on July 7, 2012

My moms gout turned out to be bone cancer. I think waiting to Thurs will be fine, but honestly if she hadn't waited on getting her bloodwork done (she presented as such a perfect candidate for it that her and her doc were lax about diagnosis) she'd probably still have a toe. Get the bloodwork sooner rather than later.
posted by spunweb at 1:59 AM on July 7, 2012

You need testing to be finalized before you agree with this conclusion, I think.

I recently was told, when I had similar pain at the base of my left toe, that it was either gout or a pulled ligament. It sort of receded, but now I have intermittent pain in the same location on both big toes. I saw the doctor yesterday and she was skeptical of gout (lack of other symptoms, as you noted) and I'm going for xrays so she can get more info. She said possibly rheumatoid arthritis.

Just remember, you haven't really had a diagnosis yet. So don't try to analyze the theory-- spend you energy pushing the medical team to get your tests, results, and appointments done STAT!
posted by miss tea at 2:57 AM on July 7, 2012

* your energy *

Sorry, too early in the morning...
posted by miss tea at 2:58 AM on July 7, 2012

I just looked at your recent posts and I would also wonder about septic arthritis if you have just had dental work? Personally I am not a big fan of pain and would make myself a nuisance until I was fixed.
posted by superfish at 4:45 AM on July 7, 2012

I was having very severe gout attacks at the rate of once every month or so and none of the usual food avoidance measures seemed to have any effect, until I discovered that my blood sugar was spiking after meals and I was borderline diabetic. When I adjusted my diet to keep my blood sugar below 140 mg/dl as much as possible, the gout went away (as did the hemorrhoids, about 40 lb of excess weight, and several other unpleasantnesses).

Meanwhile, before I figured that out, I had a doctor advise me that the starting dose for ibuprofen for treating gout was 2400 mg/day, generally 4 200 mg tablets 3 times per day. What, you say, the label on the bottle tells you not to do that? When I mentioned that my doctor laughed. Sure enough, the huge ibuprofen dose generally kept the inflammation manageable until I figured out the diabetes problem, and it doesn't seem to have killed me.
posted by localroger at 5:34 AM on July 7, 2012

Gout per se is horrifically painful but a single attack is unlikely to cause you much permanent damage. The base of the big toe ("podagra") is indeed pretty classic in terms of location; you are absolutely correct however, in that you are not the typical patient, in terms of risk factors and demographics.

The main issue is that the clinic should have (in my opinion) ruled out other causes of an arthritis, some of which may progress much more quickly than gout: infections like gonococcus or other bacteria, versus autoimmune or other crystalline arthropathies. This is ordinarily done by tapping the joint to remove some synovial fluid for analysis. It's harder said than done for the big toe (vs. say, the knee, which more or less anyone should know how to tap), but Thursday sounds still rather far away to me.
posted by NucleophilicAttack at 5:44 AM on July 7, 2012

Purely anecdotal. A few years ago I had a first attack and, following some internet site advice, drank about a quart of unsweetened dark cherry juice over several hours. I don't know if that was the actual cause, but the pain lessened considerably and was gone within about 24 hours. And cherry juice is pretty tasty.
posted by uncaken at 6:17 AM on July 7, 2012

My Kaiser doctor (who is usually up on whether tests are needed or not) did not do any tests. No blood test, no aspiration of the joint, etc. Basically the progress of the disease (not a doctor, etc.) is that either the first attack goes away forever, or else they will come back periodically, sometimes worse than before. It's excruciating, yes. Colchicine is the medication of choice for acute attacks, but it will seriously make you feel sick. The good news is that allopurinol, for many people, will keep gout completely under control, but is very bad to take for an acute attack, because it can cause the uric acid to "crash" out of your system.

Read carefully on the triggers for gout, though. Since it's such an old disease, there's a lot of folklore.
posted by wnissen at 7:32 AM on July 7, 2012

Yes tart cherry juice (black cherry) is very good because it is strong alkaline. One product I also like is Bauman's Cherry Butter. Oddly enough one of the foods that set my gout off is spinach. An alkaline diet is good for avoiding gout attacks.
posted by snaparapans at 7:54 AM on July 7, 2012

There's no urgency for treatment. I'm an orthopaedic surgeon but I hate feet! I also hate gout as a diagnosis because it can be very hard to diagnose. The best way is to tap the joint (artrocentesis) and look directly for crystals. Most PCPs these days don't do this but an orthopaedic surgeon or maybe a podiatrist (not sure of their scope of practice) would. But it has to be hot and angry for it to be diagnostic and it may be done by the time you get a referral. They will draw a urate level but the value of that test is such that I don't really know why we bother. If it's high, they will say yup, gout. It is rarely high. If it's normal, your doc will explain that the crystals can precipitate even with normal urate levels. Which is true, but that means that urate levels are kind of worthless to measure.

If your pain is worsening, septic arthritis would be a rare possibility. Yes, infections following dental work are possible but still super rare in an immunocompetent patient. But if it's getting worse, don't ignore it until your PCP can squeeze you in.

Finally, an anecdote from me. I am a living and breathing example of someone who should (or will) have gout. I drink too much and I love meat of any kind. One day I wake up and I feel a little tingle in the base of my great toe. As the morning progressed I developed a limp and the toe began to swell. The pain wasn't horrible (gout is reported to be severe) but it did hurt. The resident that I was working with took one look and said "dude, you have gout." Being a guy, I said no freaking way. But as it got worse, I started to think, crap, I have gout. One of my partners, a foot and ankle specialist, was in the OR that day and I showed it to her, she did two things and diagnosed it as turf toe. And she was right. I taped it for a week and all better. And then I ate a huge steak. I would be less worried about seeing your PCP and push for a referral to a foot and ankle specialist.
posted by karlos at 8:40 AM on July 7, 2012 [1 favorite]

And I want to add, double check with your insurance plan but you may not need a referral to see an orthopaedic surgeon. Where I practice, most of the plans do not require a referral but no patients seem to know that. And arthrocentesis above, hate typos.
posted by karlos at 8:44 AM on July 7, 2012

following some internet site advice, drank about a quart of unsweetened dark cherry juice over several hours.

This is a well-known and age-old folk remedy/alleviation for gout. Plus it absolutely cannot hurt! If you have a natural-foods store anywhere nearby, pick up as much unsweetened 100% cherry juice as you can afford. No need to drink a quart in a couple of hours, but several glasses a day can really help. There is some research on this:

Of course, you should get thoroughly tested and diagnosed as soon as medical care is available. The cherry juice is just an "in the meantime" sort of thing.
posted by RRgal at 8:47 AM on July 7, 2012

My mom, though post-menopausal, is also a woman (obviously), not overweight, doesn't drink a bit, no family history, eats the healthiest diet of *anyone* I know, and has had horrendous issues with gout.

Entirely anecdotal, of course, but if all your symptoms fit with gout, don't just assume that because you don't fit the typical profile your dx is wrong.

You will want to stay away from potatoes and seafood, as well as fructose and caffeine if you can (I'm dead to the world without my caffeine, but it can dehydrate you and up uric acid as a side effect, while anything with fructose messes with your liver enzymes so it will take longer to get your uric acid levels in balance).

Also note any supplements you might be taking (like Iron or multivitamins with Iron in them) that could affect uric acid. And of course iodine supplements usually come from sea creatures, though I doubt anyone takes those any more. You may need to change those supplements out to avoid a recurrence of gout.

Do what the doctor says, and take larger doses of ibuprofen or alternate with acetaminophen (NO alcohol any time near taking the acetaminophen! seriously, none at all if you value your liver) until you can go in on Monday.
posted by misha at 10:07 AM on July 7, 2012 [1 favorite]

Lots of people who don't fit "the profile" of various diseases still get the disease in question. Gout is often described as a "lifestyle disease" but actually the majority of people who get gout do so because they have a genetic variation that makes it difficult for their body to process purines. Yours may be so extreme that even your generally low-purine diet is too high for your body to process.

So. It's not going to hurt you to do the self-treatment steps for gout while you're waiting for your tests to come back. Unsweetened cherry juice is something you can start right now (it's not just a folk remedy--our average-weight teetotaler mostly vegetarian friend who has gout had it recommended to him by his doctor!) Ibuprofen and acetaminophen will help with the pain a bit. No alcohol. Ice and elevation on the affected bits. Lots of water (if you're living in one of the zones where it's been super hot lately, you may have become dehydrated enough to kick-start your first gout flare-up?)

One of the problems with the media messages about health is that there's so much oversimplified profiling that people just don't believe they have things if they don't fit the media stereotype of the average patient with that issue. I know someone who had a massive heart attack who delayed seeking treatment because he was a slender athlete and therefore "couldn't" have a heart attack. My BFF has had a couple of patients who thought she was lying to them about their having Type 2 diabetes because they were slender, and "everyone knows" diabetes is a fat people's disease.

I hope this doesn't turn out to be gout, because it's a hassle to deal with. But the good news is that there are much better meds than there were even a couple of decades ago. My best wishes to you for good treatment and diagnosis, and a quick as possible end to your pain. Pain sucks.
posted by Sidhedevil at 10:53 AM on July 7, 2012

Response by poster: - Answers saying not to question the doctor are unhelpful. It's very textbook gout - I have no reason to doubt the doctor and never implied I did in the original question.

- The question is not about how to home-treat gout. Thank you for the tips, but as I said my diet was already an "anti-gout" diet. I don't eat ANY foods linked to gout. NONE. I'm not overweight and I already consume food linked to reducing gout as part of my normal diet (cherries are in season). I already consume tons of water - increasing my water intake would likely lead to water poisoning.

- The question is about how quickly I need medical treatment/tests considering the underlying medical aspects that might be in play, considering I don't fit the obvious profiles. Instead of saying "1, 2, and 3, don't fit, I must be an outlier!" I want to know how much better it to rule out 1,2, 3 AND 4.... before saying I'm an oulier. I don't want to harp on this AGAIN, but it lowers the signal to noise ratio.....

localroger - thanks for that info. I have some prescription ibuprofen left over from the dental work, 800mg tabs - so it's nice to know that's still not an awful dose. I am taking a few other "worry about your kidneys!" meds, though, which is why I worry. Times like these I wish I'd taken an anatomy course instead of, like five micro courses....

karlos - my self-diagnosis had originally been turf-toe, but it got much, much worst after binding it (I think through normal progression, not due to the binding). I've decided to keep binding it (because apparently I have very twitchy toes when I sleep....which is excrutiating now).

Homeboy trouble, spunweb et. al. - thank you for the advice...that is exactly what I was worried about. I know I can't change what's going on - so I won't freak out - but at least now I know that I'm not being a hypochondriac for thinking that since I don't fit the profile there might be something else going on. I'm going to monitor my temperature for possible infections and when I talk to my doctor I'll see what she thinks. She's very good - it's really a shame this happened while she was out of town.
posted by Lt. Bunny Wigglesworth at 4:20 PM on July 7, 2012

When I had my first attack (excruciating knee pain, swelling, redness) I was told to take NSAIDs (naproxen, indomethacin) because the attack had to subside before I could start taking allopurinol. If it's gout it's not a big deal to wait a couple of days.

FWIW, I got my first attack at age 24 -- at 6 feet tall and 135 lbs (I was a racing cyclist).
posted by phliar at 4:18 PM on July 9, 2012

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