Gout
1. What is gout?
Western medicine
Gout
is a metabolic disorder of purine metabolism and later result in uric acid
crystals deposits inside the joint. This causing acute, intense pain,
swelling, and inflammation in the joints, which usually occurs at the big
toe joint.
Due
to the high density of uric acid which flows through the blood, uric acid
crystals form. This process is known as hyperuricemia. However, hyperuricemia
might not develop gout, and maybe other factors distribute to this disease.
Traditional Chinese
Medicine
The name “gout” is not
completely equivalent to the “gout” disease in modern medicine as the
discussion of "gout" in ancient books mainly refers to diseases of
polyarticular swelling and pain but not limited to the pain caused by the
deposition of urate crystals in joints. Hence, “acute arthritis” (历节风) or “severe and
migratory arthralgia” (白虎风) in the “Synopsis of Prescriptions of the Golden Chamber” (金匮要略) is more
equivalent to “gout” in modern medicine and is classified in the classes of
“bi-syndrome”.
The ancient TCM classic “Suwen” (素问) explains that “bi-syndrome” is an
obstructive disorder that combinates invasion of cold, wind, and dampness
pathogen. Meridians in limbs which located in superficial areas of the body are
the common site attack by the combination evils and then cause stagnation of
“qi” as well as blood circulation. As a result, patient will feel acute and
intense pain.
Correlations
Both modern medicine and TCM have pointed out that gout is an
obstructive disorder and describing the pain is excruciating and acute.
However, in clinical, TCM physicians prefer to use gout instead of “acute
arthritis” as it is more comprehensive.
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| Summary of gout from western medicine & TCM |
2.
What causes gout?
Western medicine
As
we concern, compounds known as purines which in both human cells and foods,
such as adenine (C5H5N5) and guanine (C5H5N5O),
are ultimately decomposed into uric acid (C5H4N4O3).
Normally, nearly all uric acid will be filtered out of bloodstream in kidneys
and drain in urine. But when lessen filtration and uric acid stay in the bloodstream, hyperuricemia occurs, leading to gout. This will happen when a
malfunction of the kidney.
 |
| Formation of Uric Acid |
Besides,
uric acid transporter 1 (URAT1), one of the mutations located in membrane
proteins in kidney that transports uric acid, also distribute to hyperuricemia.
Before uric acid is excreted with urine, URAT 1 reabsorbs uric acid from
filtrate and further transports uric acid into bloodstream. Increasing the
activity of transporter will cause hyperuricemia and the high concentration of uric acid develops into small clusters of uric acid crystals in the
joints.
Traditional Chinese
Medicine
Based
on TCM, the main factors are the shortage of healthy “qi” and the invasion
of pathogens, which are dampness, heat,
wind, and cold. According to “Treatise on Blood Trouble”, the capability
of spleen which is transportation and transformation is relevant to gout.
Because of insufficient “spleen qi”, digestion system occurs stagnation
and waste such as uric acid form in the blood. Moreover, dampness evil will cause partial swelling and
pain in joint. Due to different pathogens and individual unique body
constitution, there are various types of “bi- syndrome”. For
instance, combination pathogens of wind, cold, and dampness usually affected
people with yang-deficiency constitution and causing a “bi-syndrome” of
cold-dampness type. On the other hand, “bi-syndrome” of damp-heat type occurs
when people with yang-hyperactivity and yin-deficiency constitution attack by
wind, dampness, and heat pathogens.
Apart
from this, one’s lifestyle also an acquired factor of gout. For
example, one engaged in life at sea or have a cold diet will cause him/her more
susceptible to exogenous cold, leading to illness caused by exogenous cold, gout.
This because his/her lifestyle has hurt the healthy-qi and internal organs,
leading to a weak constitution. Besides,
parents’ genetic factor probably causes one to suffer from gout.
Correlations
From the cause aspect, modern medicine is more inclined toward kidney disease while TCM is more squint towards spleen
disease. But both have agreed that the root cause of gout is the malfunction
of transportation and transformation.
Despite TCM is more squint
towards spleen disease, it does not represent that doesn’t matter with the
kidney. In TCM, the cause of disease is complex and the relationship between
zang-fu organs is closely related. Lesions on the bones are often related to
the kidney while lesions on the joints relevant to the liver.
3. Symptoms of gout?
Both
modern medicine and TCM have the same description in symptoms of gout, which is
sudden, inflammation, lingering discomfort, limited range of motion, often at
night, and big toe.
 |
| Acute, intense pain, swelling, and inflammation in the big toe joint |
In
fact, the formation of uric acid crystals is painless. Uric acid crystals
indirectly cause pain only when trauma or sudden swings in uric acid
concentration and make uric acid crystals start to dislodge. For example,
enjoying a meal containing plenty of purines. Macrophages (large immune cells)
swallow up the crystals and released an inflammatory signal protein known as
interleukin 1β. Due to interleukin 1β, other immune cells will be activated and
enlisted to the joint, leading to inflammation and pain. It is a build-in
response as dead cells released uric acid crystals which represent infections.
Inflammation is required to kill the pathogens. Despite there is no inflection, inflammation occurs
anyway in gout. Inflammation is redness, swelling, and pain and often happens
in big toe but it can occur in any joints, including ankles, knees,
elbows, wrists, and fingers. The most severe pain period is within the
first four to 12 hours after it begins and normally the attacks last for a
week. Acute gout eventually subsides but sometimes some joint
discomfort lasts longer and affects more joints. The lower temperatures at
night will lower solubility and relatively increase crystallization. Due to
this reason, gout often attacks at night. In TCM, migratory arthralgias gout is the clinical
manifestation of pathogenic wind. The characteristics of pathogenic wind
are the position of disease is not fixed, rapid onset, and rapid change.
Besides, lower temperatures at night which are considered as the pathogenic
wind causes frigidity in the joint. In this regard, gout often attacks at
night.
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| Gout attack location |
Why usually in big toes?
The reason for gout usually attacks the big toe of feet are feet
are more likely to get injured versus have lower temperature contrast with
other parts of body, resulting in liberated crystals. From TCM aspect, the
internal cause of gout mainly due to the stagnation of “qi” and impede
blood circulation. Both flow of “qi” and blood circulation are relevant to spleen
versus liver. Spleen Meridian of Foot-Taiyin, SP and Liver Meridian
of Foot-Jueyin, LR run in
the big toe. Meridian is the passage of “qi” and blood, so it causes pain in
the big toe.
The stages of gout progression
Hyperuricemia will advanced develop to acute gout, intercritical
gout, and even chronic gout if hyperuricemia had not been treated. When the
uric acid crystals rub in the synovium which is the soft lining of joint,
causing severe pains and inflammation, this is considered an acute gout attack.
While chronic gout will form a large cluster of uric acid which is known as
tophi. Tophi will lastingly destruct bone versus disfigure joints. In
TCM, partial swelling is due to
dampness evil.
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| The stages of gout progression |
4. Treatment
& prevention?
Regrettably, there is only prevention, medication to control and
relieve pain for gout. Hence, it is better to have integrated TCM and Western
Medicine Treatment.
Anti-inflammatory drugs
In modern medicine, the main treatments are preventing
inflammation or treat the underlying hyperuricemia. Ibuprofen (Advil), naproxen
(Aleve), colchicine, and steroids, which are anti-inflammatory drugs,
effectively prevent inflammation. Although Aspirin is a common
anti-inflammatory drug, it cannot treat gout effectively under low doses.
Instead of preventing inflammation, Aspirin at low portion block uric acid to
be removed from blood and cause hyperuricemia.
Uricosuric drugs
Besides, uricosuric drugs can be used to treat gout as they can
prevent reabsorption of uric acid transporters such as URAT1 and increase
excretion of uric acid and relatively reduce uric acid levels in the blood.
Lifestyle
Both
Chinese and Modern medicine have reached a consensus that changing one’s
lifestyle will significantly help with treating gout and hyperuricemia.
Firstly, maintain a balanced diet and avoid excess consumption of meat, seafood, alcohol
which rich in purine or activation of purine breakdown. Secondly, prevent
the hazard factors of gout, for instance, obesity, eat cold, strenuous exercise.
This will reduce the stress on joints and effectively decrease the frequency of
gout. Thirdly, drink a lot of water in order to boost the excretion of waste.
Relieve pain
Apart from prevention, TCM has herbs and acupuncture to relieve
pain. The basic concept is to promoting blood circulation and removing
obstruction in channels and also to enhance the excretion of toxins. The
most significant herb is Plantago Asiatica (车前草). It has the effects of clearing
away heat, detoxifying, and diuresis. In addition, it can alleviate and inhibit
purine accumulation, so it has a certain effect on alleviating gout. It
can simply soak in water and drink it as tea or apply it on the affected area
to reduce pain.
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| Plantago Asiatica (车前草) |
Some significant acupuncture points are SP 9 (阴陵泉) for expelling
internal dampness. SP6 (三阴交) strengthens the spleen and stomach, TB6 (支沟) can regulate Qi and clears Heat, ST36 (足三里) for tonify deficient Qi and blood,
ST43 (陷谷) for tonify deficient Qi and blood.
 |
| Acupuncture points |
Besides,
the Chicory and Gardenia Tea (菊苣栀子茶), the prescription in “Prescriptions Worth a
Thousand Pieces of Gold for Emergencies” (千金药方), has function of detoxification, can
treat heat toxin sore, sprain, swelling and pain, gouty arthritis. Modern
research has found that cichoric acid, chicory root polyphenols in chicory,
geniposide and crocin in gardenia, reduce the effects of uric acid and
triacylglycerol. They are all commonly used herbs in the TCM treatment of gout.
To achieve the best therapeutic effect, patients can have modern
medicine to prevent inflammation while having TCM medicine to reduce pain.
5. Summary:
- Gout occurs due to hyperuricemia.
- Gout considers in the category of "Bi-syndrome".
- Cause by :
- Damage to kidney
- Increase the activity of URAT
- Deficiency of spleen-qi.
- Lifestyle
- Genetic factor
- Symptom: Acute, intense pain, swelling, and inflammation in the big toe joint (ankles & etc)
- Prevention:
- Anti-inflammatory drugs
- Ibuprofen (Advil)
- Naproxen (Aleve)
- Colchicine
- Steroids
- Aspirin (not suggested at low doses)
- Uricosuric drugs
- Lifestyle changes
- Maintain a balanced diet
- Avoid excess consumption of meat,
seafood, alcohol
- Prevent the hazard factors of gout
- Obesity, eat cold, strenuous exercise
- Reduce the stress on joints
- Drink a lot of water
- Relieve pain
- Plantago Asiatica (车前草)
- Chicory and Gardenia Tea (菊苣栀子茶)
- Acupuncture:
- SP 9 (阴陵泉)
- SP 6 (三阴交)
- TB 6 (支沟)
- ST 36 (足三里)
- ST 43 (陷谷)
6. References:
1 herbal
medicine, 1 prescription, treatment of gout, secret traditional Chinese
medicine. (n.d.). Retrieved November 11, 2020, from
https://m.sohu.com/n/494679465/?wscrid=95360_6
Admin. (2020,
May 05). Gouty Arthritis (Gout) and Uric Acid. Retrieved November 11, 2020,
from https://motivatorkerja.com/2020/05/gouty-arthritis-gout-and-uric-acid-2/
baihufeng.
(n.d.). Retrieved November 11, 2020, from http://mip.wiki8.com/baihufeng_18904/
Bi-Syndrome
(Arthritis). (n.d.). Retrieved November 11, 2020, from
http://www.acupuncture.com/Conditions/bisyndrome.htm
Gout. (2019,
March 01). Retrieved November 11, 2020, from https://www.mayoclinic.org/diseases-conditions/gout/symptoms-causes/syc-20372897
Gout. (n.d.).
Retrieved November 11, 2020, from
https://www.versusarthritis.org/about-arthritis/conditions/gout/
lijie. (n.d.).
Retrieved November 11, 2020, from http://mip.wiki8.com/lijie_12472/
Spleen 6.
(n.d.). Retrieved November 11, 2020, from
http://www.acupuncture.com/education/points/spleen/sp6.htm
ST 36 - Acupuncture Point - Zusanli. (n.d.).
Retrieved November 11, 2020, from https://theory.yinyanghouse.com/acupuncturepoints/st36
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