Gout

Overview

• It is the most common inflammatory arthritis in men also in older women.
• Moreover, The risk of developing gout increases with age and with serum uric acid (SUA) levels, which are normally distributed in the general population.
• Levels are higher in men, increase with age and are associated with body weight.
• Hyperuricemia is defined as an SUA level greater than 2 standard deviations above the mean for the population.
• Additionally, Gout has become more common over recent years in parallel with increased longevity and the higher prevalence of metabolic syndrome, of which hyperuricemia is an integral component.
• Although hyperuricemia is an independent risk factor for hypertension, vascular disease, renal disease and cardiovascular events, only a minority of hyperuricemic people develop gout.

• Besides this, There is currently no evidence to support the use of urate lowering therapy in patients with asymptomatic hyperuricemia. [1]
• Gout is a form of arthritis which can be intensely painful; and it’s caused by having sodium urate crystals in your joints.
• Lastly, It’s characterized by sudden, severe attacks of pain, swelling, redness and tenderness in the joints, often the joint at the base of the big toe.

Onset of pain

• An attack of gout can occur suddenly, often waking you up in the middle of the night with the sensation that your big toe is on fire.
• The affected joint is hot, swollen also so tender that even the weight of the sheet on it may seem intolerable. [2]
• In detail, Gout attacks can come on quickly and keep returning over time, slowly harming tissues in the region of the inflammation.
• It has also been related to an increased incidence of cardiovascular also metabolic disease and can be extremely painful.
• Women become more susceptible to it after the menopause. [3]

Indian epidemiology then other

Diminished renal excretion:

• Increased renal tubular reabsorption
• Renal failure
• Lead toxicity
• Lactic acidosis
• Alcohol
• Drugs: Thiazide, loop diuretics, low-dose aspirin, ciclosporin, pyrazinamide

Increased intake:

• Red meat
• Seafood
• Offal
• Shellfish
• Organ meat
• Sweet juices
• Salt

Over production of uric acid:

• Myeloproliferative and lymphoproliferative disease
• Psoriasis
• High fructose intake
• Glycogen storage disease
• Inherited disorders
• Lesch–Nyhan syndrome (HPRT mutations) [1]

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You’re more likely to develop gout if you have high levels of uric acid in your body.

Factors that increase the uric acid level in your body include:

Diet:

• Eating a diet rich in meat and seafood and drinking beverages sweetened with fruit sugar (fructose) increase levels of uric acid, which increase your risk of gout.
• Alcohol consumption, especially of beer, also increases the risk of gout.

Obesity:

• If you’re higher weight body, your body produces more uric acid and your kidneys have a more difficult time eliminating uric acid.

Medical conditions:

• Certain diseases and conditions increase your risk of gout.
• These include untreated high blood pressure and chronic conditions such as diabetes, metabolic syndrome, and heart and kidney diseases.

Certain medications:

• The use of thiazide diuretics commonly used to treat hypertension and low-dose aspirin also can increase uric acid levels.
• So can the use of anti-rejection drugs prescribed for people who have undergone an organ transplant.

Family history of gout:

• If other members of your family have had gout, you’re more likely to develop the disease.

Age and sex:

• Gout occurs more often in men, primarily because women tend to have lower uric acid levels.
• After menopause, however, women’s uric acid levels approach those of men.
• Men are also more likely to develop gout earlier usually between the ages of 30 and 50 whereas women generally develop signs and symptoms after menopause.

Recent surgery or trauma:

• Experiencing recent surgery or trauma has been associated with an increased risk of developing a gout attack. [2]

Pathogenesis refers to the development of a disease. It’s the story of how a disease gets started and progresses.

This is the entire journey of a disease, encompassing the cause but going beyond it.

Pathophysiology, on the other hand, focuses on the functional changes that occur in the body due to the disease. It explains how the disease disrupts normal physiological processes and how this disruption leads to the signs and symptoms we see.

Imagine a car accident. Pathogenesis would be like understanding how the accident happened – what caused it, the sequence of events (e.g., one car ran a red light, then hit another car). Pathophysiology would be like understanding the damage caused by the accident – the bent fenders, deployed airbags, and any injuries to the passengers.

In simpler terms, pathogenesis is about the "why" of a disease, while pathophysiology is about the "how" of the disease’s effects.

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The signs and symptoms of gout almost always occur suddenly, and often at night. They include:

Gout Affecting The Big Toe

Intense joint pain:

• Gout usually affects the large joint of your big toe, but it can occur in any joint.
• Other commonly affected joints include the ankles, knees, elbows, wrists also fingers.
• The pain is likely to be most severe within the first four to 12 hours after it begins.

Lingering discomfort:

• After the most severe pain subsides, some joint discomfort may last from a few days to a few weeks.
• Later attacks are likely to last longer and affect more joints.

Inflammation and redness:

• The affected joint or joints become swollen, tender, warm also red.

Limited range of motion:

•  As gout progresses, you may not be able to move your joints normally. [2]
• The classical presentation is with an acute monoarthritis, which in over 50% of cases affects the first MTP joint.

Other common sites are;

• Ankle
• Midfoot
• Knee
• Small joints of hands
• Wrist
• Elbow
• The axial skeleton and large proximal joints are rarely involved.

Typical features include:

• Rapid onset
• Reaching maximum severity in 2–6 hours,
• Often waking the patient in the early morning
• Severe pain
• Often described as the ‘worst pain ever’
• Extreme tenderness, such that the patient is unable to wear a sock or to let bedding rest on the joint
• Marked swelling with overlying red, shiny skin
• Self limiting over 5–14 days, with complete resolution

During the attack, the joint shows signs of;

• Marked synovitis
• Swelling
• Erythema

There may be accompanying;

• Fever
• Malaise and even confusion
• Especially if a large joint such as the knee is involved.

As the attack subsides;

• Pruritus and desquamation of overlying skin are common.

The main differential diagnosis is septic arthritis, infective cellulitis or reactive arthritis.

Acute attacks may also manifest as bursitis, tenosynovitis or cellulitis, which have the same clinical characteristics.

Many patients describe milder episodes lasting just a few days.

Some have attacks in more than one joint.

Others have further attacks in other joints a few days later (cluster attacks), the first possibly acting as a trigger.

Simultaneous polyarticular attacks are unusual.

In others, several years may elapse before the next attack.

In many, however, a second attack occurs within 1 year and may progress to chronic gout, with chronic pain and joint damage, and occasionally severe deformity and functional impairment.

Patients with uncontrolled hyperuricemia who suffer multiple attacks of acute gout may also progress to chronic gout.

Tophi On Ear

Urate Crystals

Crystals may be deposited in the joints and soft tissues to produce irregular firm nodules called tophi.

These have a predilection for the extensor surfaces of fingers, hands, forearm, elbows, Achilles tendons and sometimes the helix of the ear.

Characteristics of Tophi

Tophi have a white colour, differentiating them from rheumatoid nodules.

Tophi can ulcerate, discharging white gritty material, become infected or induce a local inflammatory response, with erythema and pus in the absence of secondary infection.

They are usually a feature of longstanding gout but can sometimes develop within 12 months in patients with chronic renal failure.

Occasionally, tophi may develop in the absence of previous acute attacks, especially in patients on thiazide therapy who have coexisting OA.

In addition to causing musculoskeletal disease, chronic hyperuricemia may be complicated by renal stone formation and, if severe, renal impairment due to the development of interstitial nephritis as the result of urate deposition in the kidney.

This is particularly common in patients with chronic tophaceous gout who are on diuretic therapy. [1]

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Tests to help diagnose gout may include:

Joint fluid test:

• Your doctor may use a needle to draw fluid from your affected joint.
• Urate crystals may be visible when the fluid is examined under a microscope.

Blood test:

• Your doctor may recommend a blood test to measure the levels of uric acid and creatinine in your blood.
• Blood test results can be misleading, though.
• Some people have high uric acid levels, but never experience gout.
• And some people have signs and symptoms of gout, but don’t have unusual levels of uric acid in their blood.

X-ray imaging:

• Joint X-rays can be helpful to rule out other causes of joint inflammation.

Ultrasound:

• Musculoskeletal ultrasound can detect urate crystals in a joint or in a tophus.

Dual energy CT scan:

• This type of imaging can detect the presence of urate crystals in a joint, even when it is not acutely inflamed.

This test is not used routinely in clinical practice due to the expense and is not widely available. [2]

Complications are what happen after you have a disease. They are the negative consequences of the disease process.

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Oral NSAIDs:

• They are effective for pain relief in the acute attack and are the standard treatment, but have to be prescribed with caution in old age.
• Patients with recurrent episodes can keep a supply of an NSAID also take it as soon as the first symptoms occur, continuing until the attack resolves.

Oral colchicine:

• It works by inhibiting microtubule assembly in neutrophils, is also very effective.
• It is usually given in doses of 0.5 mg twice or 3 times daily.
• The most common adverse effects are nausea, vomiting also diarrhoea.

Joint aspiration:

• It can give pain relief, and may be combined with an intra articular steroid injection if the diagnosis is clear also infection can be excluded.

Urate Lowering Therapy:

• Patients who have more than one acute attack within 12 months and those with complications should be offered urate lowering therapy.
• Acute flares of gout often occur following initiation of urate lowering therapy.
• The patient should be warned about this and told to continue therapy, even if an attack occurs.
• The risk of flares can be reduced by administration of oral colchicine (0.5 mg twice daily) or NSAID therapy for the first few months.
• In the longer term, annual monitoring of uric acid levels is recommended.
• In most patients, urate lowering therapy needs to be continued indefinitely.

Allopurinol:

• This is the drug of first choice.
• It is a xanthine oxidase inhibitor, which reduces the conversion of hypoxanthine and xanthine to uric acid.
• The recommended starting dose is 100 mg daily, or 50 mg in older patients and in renal impairment.
• The dose of allopurinol should be increased by 100 mg every 4 weeks (50 mg in the older people and those with renal impairment) until the target uric acid level is achieved, side effects occur or the maximum recommended dose is reached (900 mg/day).

Febuxostat:

• It is a xanthine oxidase inhibitor that is useful in patients who fail to respond adequately to allopurinol, and those in whom it is contraindicated or has been poorly tolerated.
• It undergoes hepatic metabolism and so no dose adjustment is required for renal impairment.
• This is more effective than allopurinol at reducing uric acid levels and, as a result, commonly provokes attacks at the recommended starting dose (80 mg daily).
• In view of this, treatment with colchicine or NSAID should be considered for the initial 6 months.

Uricosuric drugs:

• Such as probenecid or sulfinpyrazone, can be effective but require several doses each day and maintenance of a high urine flow to avoid uric acid crystallisation in renal tubules.
• Salicylates antagonise the uricosuric action of these drugs also should be avoided.
• Uricosurics are contraindicated in overproducers, those with renal impairment and in urolithiasis (they increase stone formation).
• The uricosuric benzbromarone can be very effective and safe in mild to moderate renal impairment, but can cause hepatotoxicity.

A short course of oral or intramuscular corticosteroids can also be highly effective in treating acute attacks.

Local ice packs can also be used for symptomatic relief.

The long term therapeutic aim is to prevent attacks occurring by bringing uric acid levels below the level at which monosodium urate monohydrate crystals form. [1]

Homeopathic Treatment of Gout

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis. 

Which includes

• The medical history of the patient,
• Physical and mental constitution,
• Family history,
• Presenting symptoms,
• Underlying pathology,
• Possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions. 

What Homoeopathic doctors do?

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. Now a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improve with homeopathic medicines.

Homeopathic Medicines:

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy, potency and repetition of dose by Homeopathic doctor.

So, here we describe homeopathic medicine only for reference and education purpose. Do not take medicines without consulting registered homeopathic doctor (BHMS or M.D. Homeopath).

Benzoic acid:

• This is use for gout, especially of the knee or big toe.
• Tearing and stitching pain in the affected joint, for acute rheumatism and gout with stiffness, swelling and lameness.
• Also, symptoms of gout associated with highly colored and offensive urine.
• Symptoms are worse in open air and from uncovering the affected parts.

Berberis vulgaris:

• This remedy is indicate when there are sudden twinges of pain stitching pains in gouty joints, which are worse from motion.
• Furthermore, the pains often radiate out from the affect part or move to a different area all together.
• All in all, the person has a tendency towards kidney stones and may ache all over.

Urtica urens:

• This remedy helps specifically in the elimination of uric acid from the body.
• The patient has a tendency to gout also uric acid formations.
• Additionally; the joint symptoms are associate with hive-like eruptions.
• There is pain in the shoulders (especially deltoid region), wrists also ankles.
• The patient is worse especially from exposure to cool moist air, snow-air, water and touch.
• Lastly, Select the remedy that most closely matches the symptoms.

Colchicum:

• Gout in the big toe or heel so painful that the person cannot bear to have it touched or moved.
• Joints are red, hot and swollen.
• The pain is often worse in the evening and at night.
• Pains are worse in cold, damp weather and flare-ups may occur with weather changes or in the spring.
• The person often has a feeling of internal coldness

Ledum:

• This remedy is indicate when the gouty pains shoot through the foot, limb and joints especially the small joints.
• The foot and ankle are extremely swollen.
• Cold or ice cold applications relieve the pain and swelling.

Lycopodium:

• This remedy is for chronic gout, with chalky deposits in the joints.
• There is a pain in the heels on treading, as from a pebble.
• One foot feels hot and the other cold.
• The urine is slow to produce and has heavy, red sediment.
• There may a backache, which relieve by passing urine.
• The right side of the body is particularly affect and all the complaints seem to be worse, especially between 4pm and 8pm.

Rhododendron:

• This remedy can useful for gouty swelling of the big toe joint that flares up before a storm.
• Other joints may ache and swell, especially on the right side of the body.
• Pain usually is worse toward early morning and after staying still too long.
• The person may feel better from warmth and after eating.

Calcarea fluorica:

• When this remedy is indicate, the finger joints may become enlarge because of gout, and the knees and toes may involve.
• Stabbing pain is experience, and the joints may make a cracking sound on movement.
• Discomfort is worse during weather changes, and warmth may bring relief.

Belladonna:

• Symptoms that suggest this remedy are sudden onset.
• Joints are swelling, red, throbbing also extremely sensitive.
• It’s worse especially from touch and jarring.
• The person may feel restless, flushed also hot.

Arnica:

This remedy is use when the pain is sore and bruise, such as it hurts to walk.

The person may afraid to touched or approached because of pain. [5]

During symptom-free periods, these dietary guidelines may help protect against future gout attacks:

Drink plenty of fluids:

• Stay well-hydrated, including plenty of water.
• Limit how many sweetened beverages you drink, especially those sweetened with high-fructose corn syrup.

Limit or avoid alcohol:

• In general, Talk with your doctor about whether any amount or type of alcohol is safe for you.
• Furthermore, recent evidence suggests that beer may be particularly likely to increase the risk of gout symptoms, especially in men.

Get your protein from low-fat dairy products:

• Low-fat dairy products may actually have a protective effect against gout, hence these are your best-bet protein sources.

Limit your intake of meat, fish also poultry:

• Basically, a small amount may be tolerable, but pay close attention to what types and how much seem to cause problems for you.

Maintain a desirable body weight:

• Choose portions that allow you to maintain a healthy weight.
• Losing weight may decrease uric acid levels in your body.
• But avoid fasting or rapid weight loss, since doing so may temporarily raise uric acid levels. [2]

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1. Davidson’s Principles and Practice of Medicine (22nd edition)
2. https://www.mayoclinic.org/diseases-conditions/gout/diagnosis-treatment/drc-20372903
3. https://www.healthline.com/health/gout
4. https://www.versusarthritis.org/about-arthritis/conditions/gout/
5. http://homeopathyclinic.co.in/10-best-homeopathic-medicines-treatment-gout/