Gout & Uric Acid?

This is an inborn error of metabolism (purine) characterized by pain and swelling of first metatarsophalangeal joint (big toe) initially, followed by other joints with an abnormal elevation of urate level in the body. In gout there is excess of uric acid in the blood and urine. There is also deposition of urate in the articular surfaces of the joints and sometimes in the periarticular structures. Commonly, the joint of the big toe is first affected and in acute attack there appears sudden swelling of joints, which are extremely painful. The blood uric acid (which in the normal subject is about 4 mgm per 100 ml) rises to about 30 to 60 mgm per 100 ml. The urate deposit which occurs in the joints, fingers, in the helix of the ear, etc, are known as tophi.

Gout may arise from the following conditions:

(a). Increased synthesis of uric acid.
(b). Due to starvation.
(c). Over production of uric acid (as occurs in glycogen storage disease).
(d). Increased nucleic acid turnover (in polycythemia, granulocytic leukaemia).
(e). Decreased excretion of uric acid which might arise from interference with secretion of it from kidney tubules.

Predisposing factors or etiology:

Primary gout is a hereditary metabolic disease. Predisposing factors are trauma to the joint, acute infection, surgery, exposure to cold, injection of foreign proteins, drugs, excess of alcohol, high protein diet, diuretics, chemicals like urografin, allopurinol, etc. Sometimes it is associated with changes in the atmospheric pressure.

Clinical symptoms:

(a). In acute gout:

General features are anorexia, malaise, headache, tachycardia and fever which may come with slight chill. Locally there is excruciating pain, tenderness, swelling and violaceous colour of the joint involved. Lymphangitis and cellulites may occur. Local veins are very much prominent. The skin over the joint becomes scaly and itchy. An attack may last for two weeks after which the joint becomes completely normal till another attack occurs.

(b). In Chronic gout:

The pain becomes persistent along with stiffness and deformity of the joint. The condition becomes polyarticular involving wrist, ankles, knees, elbows, shoulders and hips. Sodium biurate crystals begin to be deposited in the periarticular tissue and cartilages specially in the ear giving rise to swelling called tophi.

Variation of uric acid excretion with different types of food:

Daily output of uric acid is 0.75-1.0 gm, of which nearly half is endogenous and the other half is exogenous. Muscular exercise increases uric acid output.

Proteins, purines (purines are present in meat extracts, meat soup, tea, coffee, cocoa, etc), high carbohydrate diet and high calorific value of food raise the formation and output of uric acid, while fats diminishes it. To diminish uric acid formation, therefore, the diet should be of low calorific value, poor in proteins, purine, and carbohydrates but rich in fats. But, one should remember that these food stuffs exert an opposite action on the blood uric acid. For instance, protein and carbohydrates increase uric acid excretion and lower the blood uric acid level. While fat diminishes its output and raise its blood level. These facts should be carefully kept in mind while prescribing diet for gout patient.

Investigations:

(1). Blood test: To detect leucocytosis, high E.S.R, and uric acid level. Normal level of uric acid in blood is 2mgm-6mgm %).
(2). Urine: Volume is diminished and it has a high color. Urine may show urate crystals.
(3). X-ray: X-ray of the involved joint show punched out area.
(4). Needle biopsy of the tophi may show birefringent crystals of uric acid.
(5). Murexide test with crystals of tophi is positive.

Complications:

1. Deposition of urates in renal parenchyma leading to chronic pyelonephritis and progressive renal failure.
2. Renal calculus giving rise to renal colic (10-20%).
3. Hypertension.
4. Atherosclerosis.
5. Diabetes mellitus.
6. Acute inflammation of other joints, etc.

Supplements:
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Homeopathic Treatment:

Aconitum napellus: This medicine is used in problems of acute gout. The patient is restless & anxious. The joints are swollen and painful. There is intense pain which becomes worse at night and with warmth, but better with fresh air and rest.

Arnica: Sore, lame, bruished feeling all over the body, as if beaten. Everything on which the patient lies seems too hard. Oversensitive to least touch due to excessive pain in the body.

Bryonia: Bryonia is a good remedy for joint pains and backaches, and is frequently used in cases of rheumatic fever. Joint is swollen, red and hot. More than one joint may be involved. Pain becomes worse by motion, touch or pressure. Better by lying on painful side.

Causticum: Deforming type of gout with stiffness of joints. Tearing pain with burning and soreness in the joints.Symptoms are worse in clear weather and better in damp weather and by warmth.Affects mainly right side of the body.

Colchicum: It is a good remedy for gout and rheumatism. Pain with or without swelling; pain moves from one joint to another joint; swelling of joints that pit on pressure; Inflammation of great toe, gout of heel, cannot bear to be touched or moved.

Ledum: Joints affected in ascending manner; lower limbs are affected first; gouty stones in the joints, which are very painful; pain is better by cold application and aggravates by motion and at night in bed.

Other medicines are: Belladonna, sulphur, calc flour, berberis vul, guaiacum, pulsatilla, rhus tox, rhododendron, Sabina, hypericum, calc carb, lycopodium, urtica urens, cimicifuga, kalmia, lithum carb,etc.