Gout

Western Clinical Diagnosis
Recurrent acute arthritis of peripheral joints from the deposition of monosodium urate crystals from hyper uricemic body fluids in and around joints and tendons Crystals deposited in avascular and relatively avascular tissues -Severe disease in kidneys

Etiology
1) sustained hyperuricemia from decreased renal clearance of urate - decreased GFR 2) increased purine synthesis in lymphoma, leukemia, psoriasis 3) Uric acid from purines 4) Some enzyme abnormal 5) Unknown 6) Dietary purines include uric acid, especially with alcohol alcohol - lactic acid - blocks urate secretion high purines - organ meats, anchovies, sardines moderate - meat, seafood, legumes, spinach

Signs & Symptoms
1) Acute - sudden onset 2) Trauma, excess food or alcohol, fatigue, emotional or physical stress 3) Nocturnal mono or poly articular pain: excruciating pain 4) Edema, erythema, warmth, exquisite tenderness 5) Overlapping skin is tense, warm, shiny, red, purple 6) Tophi: urate cryst aggregates, initially lesions on x-ray then subcutaneous nodule 7) M-P joint of great toe; also ankle, knee, wrist, elbow 8) Fever, tachycardia, chills, malaise, leukocytosis 9) Few days initially - untreated later attacks may last weeks 10) w/ disease progression, asymptomatic intervals shorten 11) permanent erosive joint deformity 12) decreased ROM

Labs
1) Elevated serum urate 2) urate crystals in tissue or synovial fluid

Imaging
1)Punched out lesions in subchondral bone 2) Always precedes the appearance of tophi

Diagnosis
-Clinical -Supported by urate but not specific -Crystals pathognomonic

Prognosis
-Good if diagnosed early -Later can achieve re-function of joint -more severe if symptoms before age 30 -10-20% develop urolithiasis -Renal dysfunction is greatest threat to life

Treatment
1)Colchicine: pain decreases in 12 hours an gone in 36; 1mg. q2h until response or D,V; colchicum autumnale -autumn crocus 2) NSAIDS 3) Prednisone 4) Rest, fluids 5) Once acute symptoms controlled, then uricosuric treatment: a. colchicine: 1-4 0.6mg. tabs/day b. probenecid c.sulfinpyrazone d. allopurinol: blocks xanthine oxidase, responsible for uric acid formation; decreases excess purine synthesis de novo 6) High fluid intake - >3 L/day 7)Alkalinization of urine: sodium bicarbonate 8) Low Purine diet 9) Increased alkaline ash foods: vegetables, fruits 11) avoid acid ash foods: cheese, meat, legumes, grains, cranberries, plums 12) no alcohol 13) folic acid up to 25mg./day: inhibits xanthine oxidase 14) vitamin C 5gm/day: inhibits xanthine oxidase 15) No niacin, coffee, tea 16 bing cherry juice

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Dietary Recommendations
Reduce consumption of rich food and alcohol.

Basic Phytotherapy Treatment
The hyperuricemia that causes gout can be treated by gemmotherapy.

Prescription
Morning: Birch Sap D1, 100 drops on an empty stomach Evening: Fraxinus Excelsior D1, 50-100 drops