In gout, monosodium urate crystals are deposited in tissue, causing
inflammation and sudden severe pain, usually in a single joint. It occurs in
three or four out of 1,000 persons, and 90% to 95% of patients are men over age
30. One in four have a family history of gout. Once called a rich man's disease
because of its association with overindulgence in food and alcohol, this
metabolic disorder can be exacerbated by poor diet. Primary gout is the result
of overproduction or underexcretion of uric acid. Secondary gout is the result
of myeloproliferative diseases, lead poisoning, enzyme deficiencies, or renal
failure. Left untreated, gout may lead to a chronic
Its reputation associates gout with overeating (especially meats),
overindulgence in alcohol, and being overweight, but it can strike at any time
and for no apparent reason. The mechanism is excessive uric acid production,
decreased uric acid excretion, or both. Primary disease is an inborn error of
metabolism attributed to several biochemical defects. Secondary disease is a
complication of acquired disorders such as leukemia or the use of certain
- Family history of gout
- Stress resulting from a fracture or surgical procedure
- Thiazide diuretics
- Drinking alcohol
- Polynesian heritage
- Renal failure
|Signs and Symptoms|
- Pain in a single joint, often at the base of the great toe, but can
be in other joints of the feet, fingers, wrists, elbows, knees, and
- "Exquisite" pain and tenderness
- Swelling, heat, and stiffness of joint
- Shiny red or purple coloration of joint
- Fever up to 39°C (102.2°F) with or without chills
- Begins in hours and may subside over a few days or up to three
- In later attacks, may see tophi (accumulations of urate just beneath
the skin) in hands, feet, olecranon, prepatellar bursa, and in external parts of
- Untreated, attacks will be more frequent and more
- Rheumatoid arthritis
- Infectious (acute pyogenic) arthritis
- Multiple myeloma
- Chronic lead intoxication
- Lead toxicity
Metatarsophalangeal joint is most commonly affected and appears red, swollen,
hot, and exquisitely painful to touch. History may reveal recent food and
alcohol excess, surgery, infection, physical or emotional stress, use of
diuretics, certain chemicals, or uricosuric drugs. Fever is common, along with
tachycardia, local desquamation, and sometimes pruritus. Tophi may be found in
later attacks, as can progressive functional loss and disability and possibly
gross deformities. Hyperuricemia with typical history of monarticular acute
arthritis is usually sufficient for diagnosis.
- Serum uric acid level—Hyperuricemia greater
than 7.5 mg/dL (unless uricosuric drugs are being taken) may be present but is
not in itself diagnostic.
- Erythrocyte sedimentation rate (ESR) is elevated during
- White blood cell count (WBC) is mildly elevated during
- Urate crystals in synovial membrane
- Tophi present in some
Plain radiograph to rule out other disorders; no typical findings in early
disease, but late disease may show punched-out lesions (tophi) and joint
Synovial aspirate is cloudy and markedly inflammatory, with urate crystals
(needle-shaped and birefringent under polarized light).
Microscopic gout crystals seen in synovial
Gout is often completely controlled by proper treatment.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain and
- Abstinence from alcohol
- Dietary restrictions (avoid fat, alcohol, sardines, anchovies,
scallops, organ meats, sweetbreads, cocoa, spinach, asparagus, eggs, oatmeal,
- Medication to reduce the amount of uric acid produced or to promote
- NSAIDs—such as ibuprofen and indomethacin;
IM 50 mg every 8 hours until symptoms resolve (5 to 10 days); avoid if allergic
or have active peptic ulcer disease or impaired renal function.
- Colchicine—0.5 to 0.6 mg orally every hour
until pain is relieved or nausea or diarrhea appears, then stop drug; usual
total dose, 4 to 8 mg; generally only effective for 24 to 48 hours; many side
effects, but GI symptoms relieved by IV administration of initial dose of 1 to 2
mg in 10 to 20 ml saline solution; severe toxicity limits usefulness of IV
colchicine. Can also be used to prevent future attacks.
- Corticosteroids—dramatic symptom relief in
acute attack; best for patients who cannot take NSAIDs. For monarticular
disease, give intra-articularly (e.g., triamcinolone, 10 to 40 mg depending on
size of joint). For polyarticular disease, give IV (e.g., methylprednisolone, 40
mg daily tapered over seven days) or orally (e.g., prednisone 40 to 60 mg daily
tapered over seven days). Do joint aspiration and Gram stain of synovial fluid
before giving steroids.
- Analgesics—such as codeine or meperidine for
severe pain. Avoid aspirin as salicylates may exacerbate the
- Uricosuric agents—to reduce serum uric acid
levels; probenecid (250 mg bid for one week, increased to 500 mg bid) or
sulfinpyrazone (100 mg daily initially, gradually increased to 200 to 400 mg
daily). Hypersensitivity is indicated by fever and rash (5% of cases) or GI
complaints (10%). Maintain daily urine output of at least 2,000 ml and urine pH
of at least 6.0; salicylates must be avoided.
- Allopurinol—to reduce serum uric acid
levels; 100 mg daily for one week, increased as needed; normal levels often
obtained with 200 to 300 mg daily. Use cautiously in renal insufficiency; do not
use in asymptomatic hyperuricemia (may precipitate attack). May develop signs
ranging from pruritic rash to toxic epidermal necrolysis (rare, yet potentially
|Complementary and Alternative
A combination of therapies can be very effective at decreasing both the
length and frequency of attacks. Alternative therapies are often most useful in
decreasing the frequency and severity of attacks, but may not necessarily offer
the best pain relief. Alternative therapies avoid the sometimes toxic effects of
some pharmaceutical agents used for gout. Some nutrients may actually exacerbate
- Avoid obesity. However, it is important to avoid crash dieting and
rapid weight loss.
- Avoid alcohol, especially beer, which has a higher purine content
than wine or spirits.
- Hydration—Drink plenty of water; dehydration
may exacerbate gout.
- Restrict purines in diet—Purines increase
lactate production which competes with uric acid for excretion. Foods with a
high purine content are beef, goose, organ meats, sweetbreads, mussels,
anchovies, herring, mackerel, and yeast. Foods with a moderate amount of purines
include meats, poultry, fish, and shellfish not listed above. Spinach,
asparagus, beans, lentils, mushrooms, and dried peas also contain moderate
amounts of purines.
- Cherries—One half pound of cherries/day
(fresh or frozen) for two weeks lowers uric acid and prevents attacks. Cherries
and other dark red berries (hawthorn berries and blueberries) contain
anthocyanidins that increase collagen integrity and decrease inflammation. 8 to
16 oz. of unadulterated cherry juice per day is also helpful. A lower
maintenance dose can be continued for prevention.
- Vitamin C—8 g/day can lead to decreased
serum uric acid levels. Note that there is a small subset of patients with gout
who will actually get worse with this level of vitamin C.
- Folic acid—10 to 75 mg/day inhibits xanthine
oxidase which is required for uric acid production. B12 levels need to be
monitored to avoid masking a B12 deficiency.
- EPA (eicosapentaenoic acid) inhibits pro-inflammatory leukotrienes.
Dose is 1,500 mg/day.
- Niacin—Avoid niacin in doses greater than 50
mg/day. Nicotinic acid may precipitate an attack of gout by competing with uric
acid for excretion.
- Vitamin A—There is some concern that
elevated retinol levels may play a role in some attacks of gouty
Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as
- Devil's claw (Harpagophytum
procumbens)—analgesic and anti-inflammatory. Dose
is 1 to 2 g tid of dried powdered root, 4 to 5 ml tid of tincture, or 400 mg tid
of dry solid extract during acute attacks.
- Bromelain (Ananas
comosus)—proteolytic enzyme (anti-inflammatory)
when taken apart from food. Dose is 125 to 250 mg tid during acute
An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency. For acute
prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours
until acute symptoms resolve.
- Aconite for sudden onset of burning pain, anxiety,
restlessness, and attacks that come after a shock or injury
- Belladonna for intense pain that may be throbbing; pain is made
worse by any motion and better by pressure; joint is very hot.
- Bryonia for pain made much worse by any kind of motion; pain
is better with pressure and with heat.
- Colchicum for pains made worse by motion and changes of
weather, especially if there is any nausea associated with the
- Ledum when joints become mottled, purple and swollen; pain is
much better with cold applications and is worse from getting
- Hot and cold compresses—three minutes hot
alternated with 30 seconds of cold compresses provide pain relief and increase
circulation to the affected joint.
- Bed rest for 24 hours after acute attack. However, prolonged bed rest
may exacerbate the condition.
If joint destruction is present, refer patient for orthopedic consultation.
Surgical intervention is occasionally needed. There is increased incidence of
urolithiasis, with 80% of calculi being uric acid stones, and of hypertension,
renal disease, diabetes mellitus, hypertriglyceridemia, and
Dietary measures and nutritional supplementation may help prevent attacks and
decrease their frequency, thereby decreasing the risk for joint
- Renal disease or kidney stones are most common, but these develop
slowly with no effect on life expectancy.
- Chronic tophaceous arthritis may occur after repeated attacks of
acute gout, but only with inadequate treatment.
- Possible nerve or spinal cord
Asymptomatic periods grow shorter as the disease progresses. Marked
deformities are possible, but few patients become bedridden. The younger the
client at onset, the greater the chance of progressive disease. Destructive
arthropathy is rare in those whose first attack is after age 50. Appropriate
treatment will suppress attacks and keep uric acid to normal
Because the disease affects mainly men and postmenopausal women, pregnancy is
not usually impacted.
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Ferri FF. Ferri's Clinical Advisor: Instant Diagnosis and Treatment.
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William Morrow and Company; 1996.
Murray MT, Pizzorno JE. Encyclopedia of Natural Medicine. 2nd ed.
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Copyright © 2000 Integrative Medicine
CommunicationsThis publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
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