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Rapid Responses: Rapid Responses published:
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Gout & renal impairment
- Colin Scott (5 June 2006)
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Poverty of interest in Disease of Abundance
- Kuldip P Anand, Ajit S Kashyap, Surekha Kashyap (8 June 2006)
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Management of Gout.
- GEORGE Y. CALDWELL., SINGAPORE 259858 (9 June 2006)
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More pertinent opinions and observations on Gout.
- GEORGE Y. CALDWELL, SINGAPORE 259858 (10 June 2006)
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Correction:
- GEORGE Y. CALDWELL, SINGAPORE 259858 (12 June 2006)
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Me and My Gout
- A.A.W. Amarasinghe,MD, (12 June 2006)
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Not ice - heat!
- Steven Ford (15 June 2006)
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Re: Me and My Gout
- Burton Abrams (27 June 2006)
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Colin Scott, GP Pease Way Medical Centre DL55NH
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The article on diagnosis & management of gout suggests treatment with NSAI / colchicine or steroids if creatinine is < 167mmol/L. Are there any suggestions as to the best way to treat when the creatinine is higher than this? Some of my patients with gout have a significantly higher creatinene than this. Competing interests: None declared |
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Kuldip P Anand, Head , Dept of Medicine Command Hospital Kolkata 700027,India, Ajit S Kashyap, Surekha Kashyap
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Dear Sir, Congratulations to Dr. Underwood for his excellent review of Diagnosis & management of Gout [1]. Gout is considered a disease associated with abundance and overindulgence like old Roman ways. There seems to be a lack of interest in this disease due to unexplained reasons. Harrison’s Principles of Internal Medicine devotes only 1½ page to this disease [2]. However Davidson’s Principles and Practice of Medicine [3] covers it in 3½ pages. As brought out well by the author, this disease affecting 1% of the world population is likely to become more common in future due to increasing affluence. While working in Armed Forces, we are impressed by large number of cases of gout in Nepali Gorkha soldiers. Perhaps it is due to their fondness for red meat and alcohol. Few conditions can be diagnosed with more certainty or treated more successfully and dramatically than gout. Gout is a prominent member of ‘Club of unilateral diseases’ like Bell’s palsy, Trigeminal Neuralagia, Herpes Zoster, Migraine, Poliomyelitis, Filariasis, wherein the clinical features are predominantly unilateral in majority of patients. What is the cause of unilateralism of clinical features of these diseases is a well guarded secret of nature, but this fact definitely helps in arriving at the correct diagnosis of these diseases. Unilateral acute podagra (painful swelling of great toe) is the usual presenting feature of majority of cases of Gout. Contrary to common belief, normal serum urate concentration does not exclude the diagnosis. In fact this situation is pretty common in clinical practice. Treatment of acute gouty arthritis is well summed up in the box ‘Patient’s story’ of the article [1]. Colchicine is rarely used in treatment of acute Gout because of its not easy availability and marked gastrointestinal side effects. Indomethacin and diclofenac have almost replaced colchicine because of their equal efficacy and few side effects. We have never felt the need to use oral or intra-articular corticosteroids in acute gout. References : 1. Underwood M. Diagnosis and management of Gout. BMJ 2006; 332:1314- 1319. 2. Reginato AJ. Gout and other crystal arthropathies in Kasper DL, Braunwald E, Fauci AS et al (Eds) Harrison’s Principles of Internal Medicine 16th Ed. McGraw-Hill. 2005:P 2046-2050. 3. Doherty M, Lanyon P and Ralston SH. Musculoskeletal disorders. In Haslett C, Chilvers ER, Boon NA and Colledge NR (Eds). Davidson’s Principles And Practice of Medicine. 19th Ed Churchill Livingstone. 2002: P 957-1047. Competing interests: None declared |
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GEORGE Y. CALDWELL., General Practitioner 31 BALMORAL PARK, #18-33,, SINGAPORE 259858
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Many cases of "arthritis" could well be re-classified as Gout. The condition is caused by the deposition of Urate crystals on joint surfaces, in tendon and ligamentous insertions, paricularly when they have been recently stressed or strained. Hence Achilles tendonitis, Calcaneal Spur, Golfer's forearm (L), tennis elbow, olecranon bursitis, carpal tunnel ("mouse") syndrome and sacro-iliac strain. To just prescribe for the pain the latest NSAID (Non-Steroidal Anti- Inflammatory Drug) is too easy. It does not get at the cause, is only palliative and may have side effects. The cause lies in the source of that Uric Acid. Though it can and has come from the breakdown of one's own specialised tissues when debilitated, as amongst the inmates of Changi Gaol and Camp in the last War, the origin is more likely in one's own diet. Such a diet that is rich in DNA (Deoxyribo-Nucleic Acid) which will of course be found in the highly nucleated tissues of rich meats, and offal, liver, brain, kidney, tongue, sausage and close-fibred fish and all shell-fish. Also in the young growing-tips of vegetables as found in Asparagus and bean-sprouts, and bamboo shoots. All show a similar histological pattern of closely packed nuclei with little cytoplasm in proportion. Hence from this nucleo-protein the enzymes break down that DNA through Adenine and Guanine to Hypoxanthine to Uric Acid. It seems wrong therefore to see repeated from time to time the advertisement that "diet plays little or no part in the causation of Gout". Which is just a promotion of Allopurinol to be taken for the rest of one's life. When Uric Acid cannot be blamed then Oxalic Acid will replace it, and a watch must be kept on some vegetables, spinach for instance, and fruit such as Raspberies, Strawberries, Gooseberries, Rhubarb, Apricots, Persimmons and Peaches. Mango has no Oxalate but in susceptible and particular people will cause Gout. The list is long. Alcohol in any form plays its part by blocking the kidney's ability to excrete the Uric and Oxalic Acids. All such drinks must be stopped during any treatment. An important part of the treatment will be an adequate intake of water (not iced), enough to produce urination at least six times a day, as clear as a mountain stream. Urate excretion can be accelerated, even ridding the kidney of offending recent stones and crystals, by taking three times a day a soup of the large white radish (Raphanus Sativus), called "Moolie" in supermarkets and "Daikon" in Japanese restaurants. Stones will either dissolve away or be passed in two or three days. It may be mentioned that this was noted by Nicholas Culpeper in his 17th Century "Herbal". It has been part of Indonesian family lore for far longer. Chocolate and coffee are both strong in Oxalates and strongly-brewed English tea more in Urates, from those growing tips of the tea-bush. Treatment of Gout then is with the well-tried Colchicine (500 mcg,) taken as two tablets (1,000 mcg.) to begin and repeat one after an hour. Four tablets in one day will probably produce bowel looseness and patients shouod be so warned. And in combination with Benzbromarone ("Narcaricin"), found more on the European continent. Two tablets to be taken at night-time followed by two Colchicine tablets each morning. In very severe attacks of Gout then recourse must be to intramuscular injections of Steroids, and then tail them off with tablets on a reducing daily dosage. Competing interests: None declared |
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GEORGE Y. CALDWELL, General Practitoner 31 BALMORAL PARK, #18-33,, SINGAPORE 259858
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It would not be unusual for Gout to attack unilateraly since, if one is right-handed then Tennis Elbow will occur in the Right-sided Flexor origin. A Right-handed golfer will suffer his Gout in the Left forearm. All people walk or stand lop-sided so the strains and pressure will be to one side or the other. Therefore Left Podagra or Right Podagra for instance. It is quite true, as Dr. Kuldip P. Anand (8th June) has well pointed out that a "normal Urate Concentration" does not exclude a diagnosis of Gout. It is my opinion that "there is no normal figure". That each of us has an inherited threshold over which one gets an attack and below it will be pain-free. That is a personal matter bequeathed by one's parents and grandparents' parents. Choose them well. For example, 25 mgm.% may produce no evidence of Gout or kidney stones in one patient, whereas any higher than 3.2 mgm.% in another could bring on pains in practically every joint. It would be of interest to know if Dr. Kuldip P. Anand had any experience of Ayur-vedic prescriptions for arthritic pain. Such as those containing Ginger, Turmeric, Frankincense and Japanese Wild Cherry? This seems to work very well and Chinese people will say "Of course we knew that Ginger was good" for arthritis! Safer to keep away from long-term use of Diclofenac things and Indomethacin and Celecoxib in any of their forms. The Spanish and French will usually prefer them as suppositories. Colchicine is so much cheaper too. The restrictions in diet will also save money. In India patients should avoid eating gourds, if they do, that is. And many other unkown Oxalate and Urate containing vegetables and fruit (Durian for instance and Alphonse Mango) and what one knows not what of. Competing interests: None declared |
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GEORGE Y. CALDWELL, General Practitioner 31 BALMORAL PARK, #18-33,, SINGAPORE 259858
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In my response of 9th June I suggested that Tennis Elbow was due to gouty elements in the "FLEXOR" origin of the muscles of the forearm. As every schoolboy knows, this is wrong. It is the "EXTENSOR" origin of those muscles which is the Gouty lesion. Competing interests: None declared |
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A.A.W. Amarasinghe,MD,, Consultant Psychiatrist 102 Bayberry Hills, McDonough, Georgia 30253 USA
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Two decades ago, after a prolonged intercontinental flight where at every meal I helped myself to the free wine, I developed my first attack of gout.The left big toe was acutely inflamed.Stayed home for a fortnight till it subsided. Blood reports were unremarkable. Colchicene was taken.Drank plenty of water.Read lot about food items that can initiate or exacerbate the misery. Subsequently, every 12 - 18 months I would be bed ridden with an attack of gout.It was the same process. Always it was the left big toe. I would hop around the house with the help of crutches. During a casual conversation a Rheumatology colleague informed that if at the first hint of a pain in the big toe, an NSAID is swallowed, the attack could be aborted. I followed his advice. A miracle it was! No gout attacks since then, which is 36 months. The NSAID of my choice was Naproxen sodium 220 mgs.- just one oral dose when pain initiates. I still enjoy an occasional glass of wine.The seventieth birthday was few months ago. The pair of crutches are collecting dust in the garage. Why is that gout always visits my left big toe? Competing interests: None declared |
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Steven Ford, GP Haydon & Allen Valleys Medical Practice
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Sir It's been a long time since I studied physical chemistry but surely the basic physical processes of crystalisation must be exploited in the management of acute gout attacks. Greatly increased water intake and the application of heat to the affected joint will increase the rate of clearance of the crystalline solute from the affected joint. My advice to sufferers is analgesia, colchicine 500mcgm TDS, lots to drink and soak the foot in a bucket of hot water. Yours sincerely Steven Ford Competing interests: None declared |
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Burton Abrams, engineer self employed, Elkins Park PA 19027
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I suffered from irregular recurrent attacks of gout (diagnosed by polarizing microscope examination of aspirated joint fluid) every few weeks for a period of 15 years. When my sleep apnea was diagnosed and resolved 3 years ago, my gout attacks ceased immediately and completely. Through my reading of medical journal literature, I was able to find the physiological explanation for the connection of gout with sleep apnea. The intermittent hypoxia from sleep apnea causes the cells to begin a catabolic process in which the ATP disintegration begins a chain of chemical transitions, the irreversible end product of which is the excess generation of uric acid. The hypoxia also results in hypercapnia, causing acidosis that makes the precipitation of monosodium urate more likely. Although these processes were well-described over 15 years ago in medical literature, it appears that no one connected them with gout attacks until now. During my fifteen years of suffering, I avoided eating foods with high purine content. That regimen had little benefit for me. Now the foods that I used to avoid, I eat with relish, and I have had no attacks. What matters is not how I eat, but how I sleep. Competing interests: None declared |
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