Homoeopathic management of Gout

Dr Kuruvila Sebastian

Abstract
Gout is a metabolic disease that most often affects middle-aged to elderly men and postmenopausal women. It results from an increased body pool of urate with hyperuricemia. It typically is characterized by episodic acute arthritis or chronic arthritis caused by deposition of MSU crystals in joints and connective tissue tophi and is a risk factor for deposition in kidney

interstitium or uric acid nephrolithiasis. Homoeopathic remedies are effective in treating acute as well as chronic gout and also helps in reducing the uric acid levels, thus preventing further attacks and other complications of hyperuricemia. 

KEYWORDS – Gout, Hyperuricemia, Joint Pain, podagra, Monosodium urate (MSU),

Introduction
Gout has been recorded in the medical literature since ancient times and has also been mentioned in the biographies of many distinguished personalities

It is a metabolic disease that results from an increased body pool of urate with hyperuricemia. It typically is characterized by episodic acute arthritis or chronic arthritis caused by deposition of MSU crystals in joints and connective tissue tophi and carries the risk for deposition in kidney interstitium or uric acid nephrolithiasis.

EPIDEMIOLOGY
Globally, the prevalence of hyperuricemia ranges between 2.0 and 13.2%, and the prevalence of gout is between 1.3 and 3.7%. The higher the serum urate level, the more likely an individual is to develop gout.

In the last few decades, the prevalence of hyperuricemia is increasing rapidly in the world population, not only in the developed countries but also in the low and middle-income countries. Lifestyle factors like obesity, purine abundant diet and alcohol intake have been known to favor the development of hyperuricemia.

CAUSES
The main cause for gouty arthritis is the underlying hyperuricemia. That is serum uric acid level more than 6.8 mg/dl.

Uric acid is the end product of endogenous and dietary purine metabolism which is being excreted by the kidneys.

Hyperuricemia occurs when there is 

• Increased production of uric acid which can be due to:
  • Dietary factors: liver, red meat, organ meat, shell fish
  • Alcohol 
• Decreased uric acid excretion which can be due to:
  • Decreased glomerular excretion
  • Decreased tubular secretion
  • Increased renal absorption 
• Both 

PATHOPHYSIOLOGY

As already told, there will be hyperuricemia due to any of the above mentioned causes.

• This elevated uric acid in the blood is saturated and is deposited as monosodium urate crystals. 
• This crystals usually gets deposited in areas where blood supply is poor like in joint, where it interacts with leucocytes and initiates inflammatory responses resulting in acute gout.
• Further attacks of acute gout result in recurrent or chronic gout.

CLINICAL MANIFESTATIONS 

• ACUTE GOUT
  • Usually one joint is affected first.
  • First MTP joint (podagra).
  • Other common sites are ankle, mid-foot, knee, small joints of hands, wrist and elbow.
  • Extremely rapid in onset.
  • Extreme tenderness. 
  • Marked swelling and redness.
  • Usually it happens at night awakening the patient from sleep.
  • Also there can be fever, malaise and confusion.
  • The attack resolves in 3 -15 days.

• RECURRENT AND CHRONIC GOUT
  • After the acute attack, mostly a second attack occurs within 1 year.
  • Frequency of attacks gradually increases.
  • With more joint involvement and joint damage.

• CHRONIC TOPHACEOUS GOUT
  • Large MSU crystal deposits produce irregular firm nodules (tophi) around extensor surfaces of fingers, hands, forearm, elbows, Achilles tendons and sometimes the helix of ear. 
  • The white colour of MSU crystals may be evident. 
  • Large nodules may ulcerate discharging white gritty material and associated with local inflammation.

INVESTIGATIONS

• Definitive diagnosis requires identification of MSU crystals in the aspirate from a joint, bursa or tophus
• Synovial fluid shows increased turbidity.
• Hyperuricemia (Serum uric acid level > 6.8).
• Assessment of renal function tests, hypertension, blood glucose and serum lipid profile should be undertaken.
• ESR is moderately raised in tophaceous gout.
• X-ray to assess the degree of joint damage.
• USG – can detect subclinical micro-tophi and MSU deposits within cartilage of first MTP joint, even at first clinical presentation.

MANAGEMENT 

GENERAL MANAGEMENT 

• • Weight loss.
  • Reduction of excess alcohol intake, especially beer.
  • Diuretics should be stopped if possible.
  • Purine diet should be tempered – sea food, red meat.

HOMOEOPATHIC MANAGEMENT
What approach a homoeopath has to take while dealing with a gout patient depends upon in which stage the patient presents to the physician.

So if the patient is coming in an acute stage, as it is a very painful condition, the purpose of the treatment should be to manage the pain. So an acute remedy which covers the symptom totality should be given. 

And if the patient is coming in a chronic stage of gout, our treatment should be mainly to reduce the uric acid levels and the tendency for uric acid formation along with symptomatic management. So a constitutional remedy covering the uric acid diathesis or gouty diathesis should be ideally given to such patients. 

RUBRICS RELATED TO GOUT IN SYNTHESIS REPERTORY

EXTREMITIES – PAIN – Joints – gouty
Abrot. adren. aesc. agar. AGN. Alum. am-be. am-c. am-m. am-p. ambr. ambro. anac. anag. ant-c. ant-t. anthraco. Apis_. apoc-a. arb. ARG-MET. ARN. Ars. ars-h. Ars-i. Asaf. asar. asper. aur. aur-ar. aur-i. Bapt. Bar-c. bar-i. BELL. bell-p. Benz-ac. berb. bism. borx. bov. BRY. Bufo. cact. caj. cal-ren. CALC. calc-f. calc-i. CALC-P. CALC-S. canth. caps. carb-an. carb-v. Carbn-s. carl. CAUST. cedr. cham. Chel. Chim. Chin. Chinin-ar. chinin-s. chr-o. Cinnb. Cocc. COLCH. Coloc. Cupr. daph. dros. Dulc. eucal. eup-per. Ferr. ferr-ar. ferr-i. ferr-p. Form. frag. gast. gent-l. get. gnaph. Graph. grat. Guaj. hell. Hep. hera. hydrc. Hyos. Ign. ins. Iod. irid-met. jal. Kali-ar. kali-bi. KALI-C. Kali-i. kali-n. kali-p. kali-sil. Kalm. kiss. lappa Laur. LED. lith-be. lith-c. LYC. lycpr. lysd. m-ambo. MAG-C. mag-m. mag-p. malar. Mang. mang-act. med. meny. MERC. Mez. Nat-ar. Nat-c. nat-lac. Nat-m. nat-ox-act. nat-p. Nat-s. nit-ac. nux-m. NUX-V. ol-j. Ox-ac. pancr. petr. Ph-ac. Phos. Phyt. pin-s. pipe. plat. Plb. plb-xyz. prim-v. PSOR. Puls. pyrus, querc-r. querc-r-g-s. rad-br. Ran-b. ran-s. Rhod. RHUS-T. ruta SABIN. sacch-l. Sal-ac. samb. Sang.Sars. sec. SEP. Sil. solid. spig. SPONG. squil. Stann. STAPH. stel. stram. Stront-c. sul-ac. sul-i. SULPH. tarax. tax. tep. thlas. Thuj. ur-ac. urea Urt-u. valer. verat. verb. vichy-g. viol-o. viol-t. Visc. wies. wildb. zinc.

GENERALS – PAIN – gouty
acon. agar. AGN. alum. am-c. am-m. ambr. anac. ang. ant-c. ant-t. ARG-MET. Arn. ars. Asaf. asar. aur. Bar-c. BELL. bism. borx. bov. BRY. Calc. camph. cann-xyz. canth. caps. carb-an. carb-v. Caust. cham. chel. Chin. cic. cina clem. Cocc. COLCH. coloc. con. cupr. cycl. dig. dros. dulc. euph. euphr. Ferr. Graph. guaj. hell. hep. Hyos. Ign. iod. KALI-C. kali-n. kreos. laur. LED. lyc. m-ambo. mag-c. mag-m. Meny. MERC. Mez. mosch. mur-ac. Nat-c. Nat-m. nit-ac. nux-m. nux-v. olnd. par. petr. ph-ac. Phos. plat. plb. Puls. ran-b. ran-s. rheum rhod. RHUS-T. ruta sabad. SABIN. samb. Sars. sec. Sep. sil. spig. SPONG. squil. Stann. STAPH. stram. Stront-c. sul-ac. Sulph. tarax. teucr. Thuj. valer. verat. verb. viol-o. viol-t. Zinc.

EXTREMITIES – WEAKNESS – gout, after bell-p.

EXTREMITIES – SWELLING – Knee – gouty “BENZ-AC. CALC. KALI-I. LED. LYC. PLB.

EXTREMITIES – SWELLING – Fingers – Joints – gouty agn. anag. Kali-i. LYC. stel. Sulph.

EXTREMITIES – STIFFNESS – Fingers – gouty

AGAR. Carb-an. Lyc. petr. sulph.

EXTREMITIES – STIFFNESS – Joints – gouty caps.

EXTREMITIES – PAIN – tearing – Toes – gouty Benz-ac. Graph.

EXTREMITIES – PAIN – tearing – Toes – First – gouty ant-c. benz-ac.

EXTREMITIES – PAIN – tearing – Feet – gouty graph.

EXTREMITIES – PAIN – tearing – Fingers – Joints of – gouty nodosities; in agn.

EXTREMITIES – PAIN – drawing – Knee – Patella – gouty crot-h.

EXTREMITIES – PAIN – drawing – Knee – gouty Ant-c. crot-h. sep.

EXTREMITIES – PAIN – drawing – Fingers – Second – gouty bamb-a.

EXTREMITIES – PAIN – drawing – Upper limbs – Joints of – gouty caust.

EXTREMITIES – PAIN – Toes – First – Joints – gouty
acon. am-c. ambr. ammc. apis apoc-a. Arn. ars. asaf. aster. bell. Benz-ac. Bry. calc. Calc-p. canth. carb-v. Caust. Cimic. con. Dulc. elat. eup-per. Gnaph. graph. guaj. kalm. LED. LYC. m-ambo. mosch. Nux-v. olnd. par. ph-ac. phos. plat. ran-b. ran-s. Sabin. sep. Sil. squil. staph. sulph. Tarax. thuj. Verat. zinc.

EXTREMITIES – PAIN – Toes – Joints, of – gouty ambr. arn. asaf. calc. calc-p. Caust. Dulc. graph. kali-bi. lyc. Mang. nat-p. positr. ran-s. Sabin. sulph. thuj.

EXTREMITIES – PAIN – Foot – Heel – gouty calc. kali-i. led. lyc. med. meph. sabin.

EXTREMITIES – PAIN – Foot – gouty Led. lyc. nat-p. Nat-s. urt-u.

EXTREMITIES – PAIN – Ankle – gouty abrot. ambr. arn. LED. petr. stel.

EXTREMITIES – PAIN – Leg – gouty anan. Apis Bry. psor. sars.

EXTREMITIES – PAIN – Hip – gouty am-p. bell. coloc. Led. Nit-ac. petr. Sil.

EXTREMITIES – PAIN – Knee – gouty :BENZ-AC. CALC. caust. con. Eup-per. Guaj. Lach. Led. Nux-v. petr. verat.

EXTREMITIES – PAIN – Lower limbs – gouty Bry. led.

EXTREMITIES – PAIN – Thumb – Joints – gouty carb-v. lyc.

EXTREMITIES – PAIN – Fingers – Joints – gouty berb. Calc. calc-p. Hep. LYC. sabin. stel. Sulph.

EXTREMITIES – PAIN – Hand – Joints of – gouty pin-s. plb.

EXTREMITIES – PAIN – Hand – gouty Carbn-s. gins. lyc.

EXTREMITIES – PAIN – Wrist – gouty abrot.

EXTREMITIES – PAIN – Elbow – gout ars-h. caust. kali-i.

EXTREMITIES – PAIN – Upper limbs – Bones – gouty lach.

MIND – FEAR – touched; of being – gout; in ARN.

MIND – ANXIETY – alternating with – Joints; pain in – gouty asaf.

URINE – ALBUMINOUS – accompanied by – gout am-be.

RESPIRATION – ASTHMATIC – alternating with – gout benz-ac. lyc. Sulph.

STOMACH – GOUTY metastasis ANT-C. benz-ac. cinnm. colch. Nux-m. sang.

FACE – PAIN – gouty Caust. ruta

HEARING – IMPAIRED – accompanied by – gout Ferr-pic. ham. kali-i. led. sil. sulph. visc.

EYE – INFLAMMATION – arthritic
Ant-c. ANT-T. Apis Ars. arum-m. bell. Borx. Bry. cact. CALC. Cham. Chin. Cocc. Colch. Coloc. dig. Euphr. FORM. Graph. Hep. ilx-a. kali-i. Kalm. Led. LYC. med. Merc. Mez. nat-m. Nux-v. PHYT. Psor. Puls. RHUS-T. SEP. spig. Staph. Sulph.

HEAD – PAIN – gouty asar. Bry. chin. coloc. guaj. Ign. ip. mosch. NUX-V. Rhus-t. Sep.

HEAD – PAIN – alternating with – Joints – gouty pain in eup-per. sulph.

FACE – PAIN – gouty Caust. ruta

HEARING – IMPAIRED – accompanied by – gout Ferr-pic. ham. kali-i led. sil. sulph. visc.

EYE – INFLAMMATION – arthritic
Ant-c. ANT-T. Apis Ars. arum-m. bell. Borx. Bry. cact. CALC. Cham. Chin. Cocc. Colch. Coloc. dig. Euphr. FORM. Graph. Hep. ilx-a. kali-i. Kalm. Led. LYC. med. Merc. Mez. nat-m. Nux-v. PHYT. Psor. Puls. RHUS-T. SEP. spig. Staph. Sulph.

HEAD – PAIN – gouty asar. Bry. chin. coloc. guaj. Ign. ip. mosch. NUX-V. Rhus-t. Sep.

HEAD – PAIN – alternating with – Joints – gouty pain in eup-per. sulph.

Here are some remedies which are usually prescribed for gout.

Urtica urens: It’s almost a specific remedy for hyperuricemia. Can be used to reduce uric acid levels even in the absence of symptoms. Pain associated with urticaria like symptoms. Pain in the right deltoid. Pain is worse by rotating arm inwards. Also the affected part is very much sensitive to touch.

Arnica Montana: Complaints arising after an injury or trauma. Constant fear of being touched. Pains unbearable during night. Bed feels so hard. Sensation as if the foot were compressed by a hard body.

Abrotanum: Remedy for gouty deposits around finger joints. Pain is worse during cold and stormy weather. Painful, sore and hot at that time.

Belladonna:  Remedy mainly suited for acute stage of gout with much inflammation, with erysipelatous redness and swelling of the joint. Pain is worse during night and cold and it is better by pressure.

Benzoic acid:  Useful remedy for acute gout as well as recurrent gout. Gouty attacks going from left to right or commencing in right great toe. Old nodes become painful and as the pains abate palpitation sets in, ceasing only when pain increase. Urine is of highly offensive odour, depositing a reddish cloudy sediment.

Colchicum: Pain shifts from one joint to another. Burning and tearing kind of pain worse from any external impressions, noise, odour, touch or bright light. The joint becomes inflamed, dark red, hot and intensely painful, patient beside himself with agony. Uric acid diathesis. Gout in persons of vigorous constitution.

Ledum: For cases which are maltreated by excessive dose of colchicum. Lancinating, tearing pains which are worse by motion than by touch and at midnight, when joints feel so hot that he throws off all covering. Oedematous swelling of joint, which may feel cold to the touch. Affects chiefly left shoulder and right hip-joint. Habitual gout in the articulations of hands and feet. Ball of great toe swollen and painful. Soles very sensitive, tendons stiff. Gouty nodosities in joints; fine tearing pains in toes. After abuse of alcoholic drinks. 

STAPHYSAGRIA: Arthritic nodes from deposition of urates of soda. Pain from the eyes to the teeth, face sallow. Chronic gout of men advanced in life, corpulent with feeble pulse, palpitation, dyspnoea on exertion.Pains in smaller joints of hands and feet, with much swelling and hardness; skin affections alternating with pains in joints; weakness of knees; soles of feet tender. 

REFERENCES

• Davidson’s principles and practice of medicine
• Harrison’s principles of internal medicine
• Synthesis repertory
• Boericke’s materia medica 
• Dictionary of practical materia medica – Clarke
• RADAR

Dr Kuruvila Sebastian, BHMS
PG Scholar, MD part I, Dept of Materia Medica
GHMC, Bengaluru