Arthritis

17 August 2011

Gout - from Natural Standard

Gout is an intensely painful form of arthritis that causes the joints to become red, swollen, and stiff. Symptoms are most likely to develop in the big toe. Other commonly affected joints include the ankles, heels, knees, wrists, fingers, and elbows. Individuals typically experience acute attacks of gout. In other words, symptoms develop suddenly and go away after a couple weeks.

BACKGROUND

Gout is an intensely painful form of arthritis that causes the joints to become red, swollen, and stiff. Symptoms are most likely to develop in the big toe. Other commonly affected joints include the ankles, heels, knees, wrists, fingers, and elbows. Individuals typically experience acute attacks of gout. In other words, symptoms develop suddenly and go away after a couple weeks.

This type of arthritis occurs when there is too much uric acid in the blood. Uric acid is a waste product that forms when the body breaks down purines, which are chemicals commonly found in red meat, poultry, and fish. In healthy people, uric acid is continuously broken down in order to maintain normal levels in the blood. A person's gender, genetic makeup, hormonal changes, diet, and some medications may cause may cause the body to produce too much uric acid or prevent it from being properly broken down.

The first gout attack typically goes away after one to two weeks without treatment or one to two days with treatment. If the person does not receive treatment, a second attack may occur anywhere from six month to two years later. If individuals still do not receive treatment, they may continue to have attacks that will probably last longer, affect more joints, and be more painful.

Symptoms of gout can be treated, and medications and lifestyle changes can help prevent gout attacks from recurring.

Pseudogout is a medical condition that causes symptoms very similar to gout. However, pseudogout occurs when there is too much calcium phosphate in the blood, not uric acid. Although the risk of experiencing pseudogout appears to increase with age, most cases have no known cause. Other factors, including genetics, excess iron storage, low magnesium levels in the blood, and an overactive parathyroid gland, may contribute to the development of pseudogout.

CAUSES

Gout occurs when there is too much uric acid in the body. Having high levels of uric acid in the blood is also called hyperuricemia. A combination of factors, including alcohol consumption, gender, genetics, hormonal changes, eating a purine-rich diet, and certain medications, may cause the body to produce too much or excrete too little uric acid.

The excessive uric acid forms sharp crystals (called urate) inside the joints. Urate causes the joints to become swollen, painful, and red.

Uric acid is a waste product that forms when the body breaks down purines, which are substances naturally found in the body and in certain foods (especially anchovies, mushrooms, asparagus, and organ meats, such as liver and kidneys). In healthy individuals, uric acid dissolves in the bloodstream, is filtered through the kidneys, and is excreted in the urine.

RISK FACTORS

Alcohol: Consumption of alcohol, especially beer, increases the risk for gout.

Gender: Gender may also play a role because men are more likely to develop the condition than women.

Genetics: Children of parents with gout have a 20% chance of developing the condition. This suggests that genetics may be involved.

Hormonal changes: Uric acid levels increase at puberty in men and at menopause in women. This means men are more likely to develop gout when they are 30-50 years old, while women are more likely to develop the condition when they are 50-70 years old. Gout is extremely uncommon in pre-menopausal women.

Purine-rich diet: There are many factors that may cause excessive uric acid to build up in the body. Eating a purine-rich diet that includes large amounts of red meat, organ meat, and oily fish (such as salmon, sardines, and herring), may lead to the development of gout. This is because uric acid forms when purines are broken down in the body.

Some medications: Some medications, including certain diuretics, niacin (a B-complex vitamin), aspirin (taken in low doses), cyclosporine (e.g. Neoral© or Sandimmune©), and some anti-cancer drugs, may cause gout.

SIGNS AND SYMPTOMS

Symptoms of gout almost always occur suddenly, especially at night. Gout causes the joints to become red, swollen, and stiff. The big toe is most commonly affected because gout symptoms typically develop in areas of the body that experience the most trauma. When the toe is affected, the symptom is often called podagra. Other commonly affected joints include the ankles, heels, knees, wrists, hands, fingers, and elbows. The pain may be so severe that a bed sheet touching the affected skin is unbearable. Symptoms generally subside after one to two weeks. Once symptoms are gone, the affected joints are not painful. However, if the patient does not receive treatment, attacks will come back (with increased frequency), and they will usually last longer and affect more joints.

COMPLICATIONS

Chronic arthritis and tophi: Some patients with gout develop long-term arthritis. After several years, these patients may also develop tophi, which are discolored deposits of uric acid crystals in the joints. Tophi causes areas of swelling to develop in the joints, particularly the toes, fingers, hands, elbows, earlobes, and ankles. Tophi are usually not painful, but they can help doctors diagnose the condition. Tophi may be painful if they develop inside the fluid-filled sacs (called bursae) that cushion the joints.

Joint damage: Long-term arthritis may eventually lead to permanent joint damage.

Kidney disease and kidney stones: Long-term gout may lead to decreased kidney function and possibly kidney stones. This can happen if the tubes inside the kidneys become blocked with uric acid crystals. In very severe cases, the condition may lead to kidney failure.

DIAGNOSIS

If gout is suspected, a healthcare provider will take a sample of synovial fluid from the affected joint. This sample is analyzed to look for uric acid crystals in the white blood cells. If crystals are present, a positive diagnosis is made.

If gout is diagnosed, a healthcare provider may also take a urine sample to determine how much uric acid is being excreted. This is because some cases of gout occur when individuals do not excrete enough uric acid. The patient is asked to collect his/her urine over a 24-hour period. The sample is then analyzed in a laboratory to determine if the person has higher-than-normal uric acid levels in the urine.

A uric acid blood test may also be performed to determine if the patient has high levels of uric acid in the blood.

TREATMENT

Nonsteroidal anti-inflammatory drugs (NSAIDs): During gout attacks, patients may benefit from nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (e.g. Advil© or Motrin©) and naproxen (e.g. Aleve©). NSAIDs help reduce inflammation and pain associated with gout.

The frequency and severity of NSAID side effects vary. The most common side effects include nausea, vomiting, diarrhea, constipation, decreased appetite, rash, dizziness, headache, and drowsiness. The most serious side effects include kidney failure, liver failure, ulcers, heart-related problems, and prolonged bleeding after an injury or surgery. About 15% of patients who receive long-term NSAID treatment develop ulcers in the stomach or digestive tract.

Colchicine: Patients may also take an alkaloid medication called colchicine. This medication may be taken during a gout attack to reduce swelling and joint pain. It may be taken up to once an hour until symptoms improve, side effects develop, or a maximum of 10 doses is taken. Side effects may include diarrhea, nausea, and vomiting.

Colchicine may also be taken twice a day to prevent attacks from occurring. Although long-term use of colchicines can effectively prevent the symptoms associated with attacks, it does not prevent uric acid crystal from developing. These crystals can lead to joint damage, even if the joints are not swollen or painful.

Corticosteroids: Patients that have severe pain and inflammation that does not improve with NSAIDs may benefit from corticosteroid medications. Corticosteroids, such as prednisone, may be taken by mouth or injected into the affected joint(s).

These drugs are generally very effective when used short-term. However, if these drugs are used for many months to years, they may become less effective and serious side effects may develop. Therefore, injections are generally limited to no more than three each year. Side effects may include easy bruising, thinning of bones, cataracts, weight gain, a round face, and diabetes.

Maintain a healthy weight: Individuals who are overweight may benefit from losing weight. This puts less strain on the weight-bearing joints, such as the ankles. It may also decrease uric acid levels in the body. However, weight loss should be gradual because sudden weight loss has been shown to temporarily increase uric acid levels and worsen symptoms.

Limit consumption of animal protein: Patients may also benefit from eating a diet low in animal protein, including red meat, organ meat (such as kidneys are liver), and oily fish (such as salmon, sardines, mackerel, anchovies, and herring). These foods contain high amounts of purine and may worsen gout symptoms. It is generally recommended that all individuals, including those who do not have gout, eat no more than five to six ounces of lean meat, poultry, or fish a day.

Limit or avoid alcohol consumption: Consuming too much alcohol may prevent the body from excreting enough uric acid. It is recommended that men limit their alcohol consumption to two or less drinks per day, and women limit their alcohol intake to one drink per day. Alcohol should not be consumed at all during a gout attack.

Drink plenty of fluids: Fluids help dilute uric acid in the blood and urine. Individuals should drink plenty of fluids, especially water, to help reduce gout symptoms and to prevent future attacks from occurring.

INTEGRATIVE THERAPIES

Unclear or conflicting scientific evidence:

Ash: Ash has been used in Europe in combination products for more than 40 years. It has been historically noted for its anti-inflammatory and analgesic properties. There is currently little scientific evidence available to support these uses for treatment of gouty arthritis; however, the results of an equivalence trial are promising. Future randomized, placebo controlled studies are necessary to confirm these initial results.

Avoid if allergic or hypersensitive to ash (Fraxinus species), its constituents, or to members of the Oleaceae family. Reviews note ash pollen allergic cross-reactivities with pollen from the Fagales order (birch, alder, hazel, hornbeam, oak, and chestnut), Scrophulariales order (olive, ash, plantain, privet, and lilac), Coniferales order (cedar, cypress, and pine), and fruits and vegetables. Use cautiously if sensitive to anticoagulants (blood thinners). Use cautiously if susceptible to hypouricemia (condition where the level of uric acid is below a certain threshold), including but not limited to hyperthyroidism, nephritis (inflamed kidneys), multiple sclerosis, and Fanconi syndrome. Avoid if immunocompromised. Avoid if pregnant or breastfeeding.

Traditional or theoretical uses lacking sufficient evidence:

Aconite: The aconite plant grows in rocky areas. It is often found in the mountainous woodlands of many parts of Europe, especially France, Austria, Germany, and Denmark. Based on case study, aconite may help treat gout. However, until well-designed studies are performed, it remains unknown if this treatment is safe and effective.

Aconite is highly toxic and is not safe for human consumption. Based on widespread use, many experts believe aconite to be unsafe even in recommended amounts in otherwise healthy individuals. Aconite is not recommended for children because of known toxic effects; however, a homeopathic preparation containing aconite has been studied in infants with no toxicity reported. Severe poisoning has been reported after ingestion of aconitine (found in aconite) or processed and cured aconite. Avoid with heart disease, irregular heartbeat, hemodynamic instability (abnormal blood flow), or gastrointestinal disorders (such as ulcers, reflux esophagitis, ulcerative colitis, spastic colitis, or diverticulosis). Use cautiously with diabetes or in patients who have suicidal tendencies. Avoid if pregnant or breastfeeding.

Agrimony: Agrimony, which has anti-inflammatory and diuretic properties, is one of the most famous herbs that is used to heal wounds. It has been suggested, but not proven, that agrimony may help treat gout.

Avoid if allergic to agrimony or related species (such as Agrimonia parviflora). When used as recommended, agrimony is considered to be safe. Use cautiously with bleeding disorders. Use cautiously if taking drugs that increase the risk of bleeding or blood pressure-lowering agents. Avoid with diarrhea caused by an underlying illness. Avoid if pregnant or breastfeeding due to a lack of safety evidence.

Bilberry: Bilberry is an herb made from the wrinkled, black berries of a small deciduous shrub. Bilberry fruit has been used as a traditional European medicine since the 12th Century to treat a variety of conditions, including diarrhea, mucus membrane inflammation, and eye disorders. A close relative of blueberry, bilberry is commonly used to make jams, pies, cobblers, syrups, and alcoholic/non-alcoholic beverages. It has been proposed that bilberry may help treat gout. However, studies are lacking in this area, and it remains unknown if this is a safe and effective treatment.

Long-term side effects and safety of bilberry remain unknown. Avoid if allergic to bilberry, anthocyanosides (a component of bilberry), or other plants in the Ericaceae family. Do not consume bilberry leaves. Use cautiously with bleeding disorders or diabetes. Use cautiously if taking anticoagulant/anti-platelet medications or drugs that alter blood sugar levels. Stop use two weeks before and immediately after surgeries or dental or diagnostic procedures that have bleeding risks. Use cautiously in doses higher than recommended. Avoid if pregnant or breastfeeding due to a lack of safety evidence.

Bromelain: Classified as an herb, bromelain is a digestive enzyme that comes from the stem and the fruit of the pineapple plant. Theoretically, bromelain may help treat gout. Until clinical research is performed, it cannot be determined if bromelain is a safe and effective treatment for gout.

Avoid if allergic to bromelain, pineapple, honeybee, venom, latex, birch pollen, carrots, celery, fennel, cypress pollen, grass pollen, papain, rye flour, wheat flour, or other members of the Bromeliaceae family. Avoid with liver disease, kidney disease, or bleeding disorders. Use cautiously with stomach ulcers, high blood pressure, or acute genitourinary tract inflammation. Use cautiously before dental or surgical procedures that have bleeding risks. Use cautiously while driving or operating heavy machinery because bromelain may cause drowsiness. Use cautiously in children younger than two years of age. Avoid if pregnant or breastfeeding due to a lack of safety evidence.

Chamomile: Chamomile is an herb that has an apple-like smell and taste. It is commonly taken as a tea. It remains unknown if chamomile can effectively treat gout.

Avoid if allergic to chamomile or any related plants, such as aster, chrysanthemum, mugwort, ragweed, or ragwort. Avoid with heart disease, breathing disorders, hormone-sensitive conditions (such as breast cancer or prostate cancer), or central nervous system disorders. Avoid if taking cardiac depressive agents, central nervous system depressants, respiratory depressive agents, or anticoagulants. Use cautiously if taking benzodiazepines, anti-arrhythmic medications, calcium channel blockers, alcohol, sedative agents, anti-anxiety medications, spasmolytic drugs (such as dicyclomine), oral medications, or agents that are broken down by the liver's cytochrome P450 enzymes. Use cautiously if driving or operating machinery because chamomile may cause drowsiness. Avoid if pregnant or breastfeeding.

Chondroitin sulfate: Chondroitin was first extracted and purified in the 1960s. Today, it is manufactured from natural sources (such as shark or beef cartilage) or by artificial means. Until scientific studies are performed, it remains unknown if chondroitin sulfate is an effective treatment for gout.

Use cautiously if allergic to chondroitin sulfate products. Avoid with prostate cancer or if at risk of developing prostate cancer. Use cautiously with asthma or bleeding disorders. Use cautiously if taking blood-thinners. Avoid if pregnant or breastfeeding due to a lack of safety evidence.

Detoxification therapy: Detoxification is a broad concept that encompasses many different modalities and substances used in cleansing the body's systems and organs. Many different techniques, including chelation therapy, colonic irrigation, supplementation, herbs, cleansing foods and diet, hydrotherapy, probiotics, sauna, and exercise, may be used during detoxification therapy. Theoretically, detoxification therapy may be a beneficial treatment for patients with gout. However, until studies are performed, it remains unknown if this is a safe and effective treatment for humans.

In cases of illness, the various forms of detoxification should be used under professional guidance. See specific monographs for precautions and warnings associated with modalities of detoxification.

Nux vomica: Nux vomica is the dried, ripe seed of Strychnos nux-vomica L., a native tree of Burma, China, Eastern India, Thailand, and Northern Australia. Traditional Asian medicine includes nux vomica as a remedy. Although it has been suggested that nux vomica may help treat gout, studies have not tested its effectiveness in humans. Therefore, it remains unknown if this is an effective treatment.

Avoid if allergic to Strychnos nux-vomica or other members of the Loganiaceae family. Use cautiously as a traditional Asian remedy because there are reports of poisonous outcomes with traditional use of the seeds or fruit of Strychnos nux-vomica L. Use cautiously with seizure disorders. Avoid oral doses of nux vomica seeds because the seeds may contain toxic amounts of strychnine. Avoid if pregnant or breastfeeding.

Pycnogenol: Pycnogenol© is the patented trade name for a water extract of the bark from the French maritime pine, which is grown in coastal southwestern France. It has been suggested, but not scientifically proven that Pycnogenol© may be of benefit for gout prevention.

Avoid if allergic to Pycnogenol©, its components, or members of the Pinaceae family. Use cautiously with diabetes, hypoglycemia (low blood sugar levels), or bleeding disorders. Use cautiously if taking lipid-lowering agents, medications that may increase the risk of bleeding, blood pressure-lowering medications, immunostimulants, or immunosuppressants. Avoid if pregnant or breastfeeding due to a lack of safety evidence.

PREVENTION

General: There is no known method of prevention of gout. However, individuals can reduce their risk of experiencing gout attacks.

Medications: Individuals who are diagnosed with gout should take their medications exactly as prescribed in order to manage symptoms and lessen the severity of attacks.

A medication called colchicine may be prescribed to help prevent attacks from occurring. This medication is usually taken twice a day. Although long-term use of colchicines can effectively prevent the symptoms associated with attacks, it does not prevent uric acid crystal from developing. These crystals can lead to joint damage, even if the joints are not swollen or painful. Side effects may include diarrhea, nausea, and vomiting.

Lose weight gradually: Individuals with gout should lose weight gradually to help reduce uric acid levels in the body. If individuals lose weight too quickly, it may trigger attacks.

Diet recommendations: Patients may benefit from eating a diet low in animal protein, including red meat, organ meat (such as kidneys are liver), and oily fish (such as salmon, sardines, mackerel, anchovies, and herring). These foods contain high amounts of purine and may worsen gout symptoms of gout. It is generally recommended that all individuals, including those who do not have gout, eat no more than five to six ounces of lean meat, poultry, or fish a day.

Individuals who have gout are encouraged to eat low-cholesterol and low-fat diets to reduce the risk of developing heart disease.

Fluids help dilute uric acid in the blood and urine. Individuals should drink plenty of fluids, especially water, to help reduce gout symptoms and to prevent future attacks from occurring.

Limit or avoid consuming alcohol, especially beer. Alcohol has been shown to increase uric acid levels, which increases the risk of experiencing gout attacks.

AUTHOR INFORMATION

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

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Copyright © 2011 Natural Standard (www.naturalstandard.com)
 

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