Disease Index Musculo-Skeletal

Gout

Gout can occur in anyone, irrespective or age or sex, when the level of uric acid or, rather, sodium urate in their blood rises above its ‘solubility limit’ so that crystals from in the body. Gout develops in four stages; asymptomatic, acute, inter-critical, and chronic. Assessment findings vary with the stage.

What is gout?

Gout can occur in anyone, irrespective or age or sex, when the level of uric acid or, rather, sodium urate in their blood rises above its ‘solubility limit’ so that crystals from in the body.

Primary gout is typically seen in men aged 40-60, and the incidence is rising as our Western lifestyle leads to more obesity, heavier drinking and higher blood pressure. Gout symptoms are now found increasingly in women, too, as diuretic drugs are prescribed to more middle aged and older women with high blood pressure.

Gout symptoms may also be seen in people recovering from surgery or other stressful episodes, and gout is a possible complication of chemotherapy for cancer. Lead poisoning was a major cause of gout in the past, but it is much less common now.

What is uric acid?

Uric acid is an end-product – the last chemical in a chain of steps that break down the purines from the genetic material (DNA and RNA) and the related chemical ATP which supplies energy within all our cells. These purine breakdown products are released into the blood from our cells as they die and are replaced, and purines are also released from food as it is digested. In the blood, 99 percent of uric acid is in the form of the more soluble sodium urate. However, in urine, which has a wide range of acidity, the ratio of uric acid to urate varies, and it is almost entirely uric acid when the urine is very acidic. Thus, uric acid crystals and stones may also develop in the kidneys, leading to decline in their efficiency.

Complications of gout

  • Cardiovascular lesions
  • Chronic renal dysfunction
  • Coronary thrombosis
  • Hypertension
  • Atherosclerotic disease
  • Stroke
  • Infection (when tophi rupture)
  • Nephrolithiasis
  • Joint degeneration and deformity

Pathophysiology of gout

When uric acid becomes supersaturated in blood and other body fluids, it crystallizes and forms a precipitate of urate salts that accumulate in connective tissue throughout the body; these deposits are called tophi.

The presence of the crystals triggers an acute inflammatory response when neutrophils begin to ingest the crystals. Tissue damage begins when the neutrophils release their lysosomes. The lysosomes not only damage the tissue, but also perpetuate the inflammation.

Diagnosis of gout

  • Aspiration of synovial fluid (arthrocentesis) or of tophaceous material reveals needlelike intracellular crystals of sodium urate.
  • Monosodium urate monohydrate crystals in synovial fluid taken from an inflamed joint or tophus establishes the diagnosis.
  • Serum uric acid is above normal, although hyperuricemia isn’t specifically diagnostic of gout.
  • X-rays are normal initially; however, in chronic gout, X-rays show “punched out” erosions, sometimes with periosteal overgrowth. Outward displacement of the overhanging margin from the bone contour characterizes gout.
  • Urinary uric acid is usually higher in secondary gout than in primary gout.
  • Erythrocyte sedimentation rate and white blood cell (WBC) count may be elevated, and the WBC count differential shows increased immature neutrophils (bands) in acute attacks.

Assessment findings

Gout develops in four stages; asymptomatic, acute, inter-critical, and chronic. Assessment findings vary with the stage. In asymptomatic gout, serum urate levels rise. The first attack of acute gout is extremely painful, peaks quickly, and generally involves only one or a few joints that become hot, tender, inflamed, and appear dusky-red or cyanotic. The metatarsophalangeal joint of the great toe usually becomes inflamed first, followed by the instep, ankle, heel, knee, or wrist joints. Sometimes, a low-grade fever is present. If the attack is mild, symptoms may subside quickly but recur at regular intervals; if severe, symptoms may persist for days or weeks.

Inter-critical periods are the symptom-free intervals between gout attacks. Most patients have a second attack within 6 months to 2 years, but in some the second attack doesn’t occur for 5 to 10 years. Delayed attacks are more common in untreated patients and tend to be longer and more severe than initial attacks. Such attacks are also polyarticular, invariably affecting joints in the feet and legs and sometimes accompanied by fever.

Chronic gout is marked by persistent, painful polyarthritis, with large, subcutaneous tophi in cartilage, synovial membranes, tendons, and soft tissue. Tophi form in fingers, hands, knees, feet, ulnar sides of the forearms, helix of the ear, Achilles tendons and, rarely, internal organs, such as the kidneys and myocardium. The skin over the tophus may ulcerate and release a chalky, white exudates or pus.

Treatment of gout

  • Maintenance dosage of allopurinol may be given to suppress uric acid formation or control uric acid levels, preventing further attacks (use cautiously in the patient with renal failure).
  • Colchicines is given to prevent recurrent acute attacks until uric acid returns to its normal level (doesn’t affect uric acid level). It’s effective in reducing pain, swelling, and inflammation in acute attacks. Other effective therapies include bed rest; immobilization and protection of the inflamed, painful joints; local application of heat or cold; and non-steroidal anti-inflammatory drugs.
  • Uricosuric agents promote uric acid excretion and inhibit accumulation of uric acid, but their value is limited in patients with renal impairment.
  • Obese patients should try to lose weight because obesity puts additional stress on painful joints.
  • Dietary restrictions include the avoidance of alcohol and purine rich foods, such as organ meats, beer, wine, and certain types of fish.
  • Surgery may be necessary in some cases to improve joint function or correct deformities and to excise and drain infected or ulcerated tophi.
  • Oral corticosteroids or an intra-articular corticosteroid injection may be ordered to relieve pain due to resistant inflammation.

Special considerations

  • Encourage bed rest but use a bed cradle to keep bedcovers off extremely sensitive, inflamed joints.
  • Apply hot or cold packs to inflamed joints according to what the patient finds effective.
  • Give pain medication, as needed, especially during acute attacks
  • Administer anti-inflammatory medication and other medications, as ordered.
  • Monitor for adverse effects of medications. Be alert for GI disturbance with colchicines.
  • Watch for acute gout attacks 24 to 96 hours after surgery, because even minor surgery can precipitate an attack. Before and after surgery, administer colchicines as ordered, to help prevent gout attacks.
  • Provide patients education.

Homeopathic treatment of gout – Homeopathy is one of the most popular holistic systems of medicine. The selection of remedy is based upon the theory of individualization and symptoms similarity by using holistic approach. This is the only way through which a state of complete health can be regained by removing all the sign and symptoms from which the patient is suffering. The aim of homeopathy is not only to treat gout but to address its underlying cause and individual susceptibility. As far as therapeutic medication is concerned, several remedies are available for gout which can be selected on the basis of cause, location, sensation, modalities and extension of the complaints. For individualized remedy selection and treatment, the patient should consult a qualified homeopathic doctor in person. Some important gout remedies are given below which are much helpful in treatment of gout symptoms:

  • Bryonia Alba. -pain with inflammation which is aggravated by movement and relieved by moderate pressure and rest. There is inflammation of joints which are hot and swollen. The patient feels chilly.
  • Ledum pal. – Remarkable remedy helpful in treatment of osteoarthritis, gout and rheumatism which is of ascending nature, better by cold application, there is deposition of chalk stones in finger joints, wrists and toes. Irritable patient with desire to be alone. Pain may be caused by alcoholism, insect stings, and punctured wound. Pain worse by warm applications.
  • Colchicum – A general remedy for gout. There may be aversion to food which smells as soon as served. Swelling of joints which may be red or pale. Abdomen bloated with wind. Albumin in urine which becomes black like ink, scanty urine with dropsical swelling, marked irritability from pains or odors. Worse by motion, touch or mental effort. Better by warmth, rest or sitting. Gout and rheumatism in smokers.
  • Guaiacum. – Rheumatic and gout engrafted on syphilitic or tubercular constitutions. Sore swollen joints more painful from warmth and motion. Gouty abscesses of joints. The leg and ankle bones are especially affected shooting pain in legs from feet to knees. Pains in tibia. Better by cold bath and cold application.
  • Formic Acid and Formica – gouty and rheumatic pains due to urates and albumin in urine. Inflammation of joints which are very painful. They are worse on motion, by cold or before storm; better on pressure.
  • Lithium Carb – chronic rheumatism due to uric acid. Palpitation and shocks about the heart the heart. Painfulness of the soles of feet and small joints with a sense of burning therein.
  • Kali Carb – pains stitching, stabbing and burning character relieved temporarily by cold application and not by rest or motion. The patient shrieks on account of pain. Backache accompanied by great weakness and profuse sweating. If he covers the painful part, the pain goes to the un-covered part. Aggravation after eating and uncovering.
  • Sticta Pulmonaria – right shoulder blade or joint, wrist joint, ankle joint and knee joint are mainly affected. It also reduces fluid in the joints.
  • Berberis Vulg. – pain in heels relieved by putting most of the weight on them. Arthritic and rheumatic affection if attended by renal sticking pain and backache.
  • Chelidonium – rheumatism with edema, heat, tenderness and stiffness. Constipation and whitish stools. Pain is aggravated by slightest movement or touch. The only relief is constant bathing with hot water.
  • Asclepius Tub – Acts well in cases of osteoarthritis when pains run diagonally.
  • Calcaria Carb. – Arthritic swelling, knee pain especially in fleshy people which is worse by cold.

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Ashish Sharma

Ashish Sharma

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