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Q1: My husband (aged 44) collapsed last November and was rushed to hospital with what turned out to be a serious gastrointestinal bleed caused by Diclofenac tablets he was taking for gout. He was transfused and put on Colchicine and stomach protecting tablets. Several months later he has lost a lot of weight, dares not drink alcohol at all (he enjoyed the occasional glass of red wine) or eat much, and the gout still bothers him. Colchicine isn't much good and the consultant wants him to start allupurinol and take Celebrex if the pain gets too bad. Neither of us is keen on him starting allupurinol and he is prone to allergic reactions (skin rash), so we're worried. The gout isn't going to go away though. Do you have any suggestions? Denise Ryan

The advice your husband has had is excellent. Colchicine has a great many more side effects than allupurinol. As a gout sufferer myself I would hate to be bothered with all the troubles that colchicines can cause and although much older than your husband, with the consequence that I would be much more liable to side effects, I take 300 mgs a day without any problems at all.

I also enjoy the occasional glass of red wine, never eat much but I am careful to take a reasonable carbohydrate diet. Carbohydrates tend to increase insulin levels and thereby lower the blood urate level and hence the liability to gout. This picture can become more confused if a patient has insulin resistance in their tissues, in these cases carbohydrate may increase the risk of an attack of gout. I also avoid the purine-rich foods, such as kidneys, anchovies, game, sweetbreads, except for the occasional treat, but it is impossible to have an interesting and varied diet if the patient wants to have a purine-free menu.

Anybody of 44 who has had a gastro-intestinal bleed needs a thorough assessment as to why their gut wall bled. This can be a response to non-steroidal anti-inflammatory drugs (NSAIDs) at any age group but sensitivity to these drugs increases with age. I take Arcoxia if I need an anti inflammatory but like all the COX2 NSAIDs they may also cause gastro-intestinal inflammation or even haemorrhage, although it is less common than it is with the COX1s, such as your husband took. Some COX2s may increase the risk of cardiac events but so far this has not been shown to be the case with Arcoxia. Celebrex is also considered to be relatively safe.

Q2: I tried the "baking soda cure" for gout and in my case it worked wonderfully and continues to. My blood pressure, which is usually low, has not become elevated as a result of my increased bicarb intake. Now, any time I get a twinge of pain in my big toe, I take a teaspoon of baking soda in an eight-ounce glass of water and the pain and discomfort is almost completely eliminated within just a few hours. Why don't doctors tell patients about the baking soda cure for gout? John Earp

Large numbers of remedies including NSAIDs, both COX1 and COX2s, will help rid a patient of the pain of an occasional attack of gout. I used to find that Arcoxia worked miraculously but eventually the attacks became too frequent and too severe.

Baking soda is an old favourite and in some people with relatively mild gout it is effective. However in the long term it is necessary to reduce blood urate levels. If the patient has more than an occasional attack the danger of getting permanent joint damage, known as gouty arthritis, is an ever present risk. This hazard increases with the length of time that someone has been having gout but unfortunately no one can predict how long it will be safe for any individual to continue with symptomatic treatment for the inflammation. It should also be remembered that a raised blood urate level is endangering the kidneys.

Q3: I've had gout attacks one or twice a year since 2000. However, in the first nine months of 2006, I had FIVE separate attacks. During a desperate search through the internet, I saw a post attributing the acidity of diet sodas - of which I was a prodigious consumer - as a major contributing factor to gout. Between that and reading the book Ultrametabolism I decided to quit my one to two litre a day diet soda habit cold turkey and I haven't had a gout attack since (18 months now)! Question: correlated, or causal? Name withheld by request

Gout is a metabolic disorder that has a strong hereditary factor. Many different factors will increase the liability of having an acute attack of gout in those people who have this tendency. If they avoid the triggers they may remain attack free. Diet isn’t the only factor. Stress, infections, dehydration, diseases such as the leukaemias, lymphomas and even some forms of benign anaemia will trigger an attack. It is known that a high-carbohydrate diet makes gout attacks more likely in some patients but less likely in others. In my own case a sure way of inducing an attack is to go without breakfast, lunch and tea and to call in at a party on the way home and have two or three drinks. Aspirin in small quantities would then make an attack of gout even more certain.

Q4: I’m writing on behalf of my husband, A. (He is an actor, working freelance; I work full time.) He had a heart attack in June 2006, aged 56, and since then has suffered increasing episodes of gout, having previously only had it once or twice in his life. It goes from knee to ankle, to other knee to other ankle, and round again in an almost unbroken cycle. The latest episode was in both feet and required a home visit from his doctor as he couldn’t walk at any pace. He is waiting for a four-week break so that he can take the preventative medication. Is it possible that this is related to the medication for his heart attack? He takes: Allupurinol, dispersible Aspirin, Bisoprolol Fumarate, Furosemide, Naproxen, Olmesartan Medoxomil, Quinine Sulphate and Indometacin for the gout. A. has mentioned this to the heart Consultant who has dismissed it. However, it seems so coincidental, I’d like to find out more. Name withheld by request

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