Integrative Approaches to the Treatment of Gout: A Comprehensive Review

Gout, a painful and often debilitating condition, is currently affecting a significant proportion of the global population, with a staggering 4% prevalence rate in the United States alone. Characterized by episodes of severe joint pain and swelling, gout has been recognized as one of the most painful forms of arthritis, potentially diminishing the quality of life if left unaddressed. This article will provide you with a comprehensive understanding of gout, its symptoms, causes, and integrative approaches for managing it.

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What is Gout?

Gout is a form of arthritis that is characterized by sudden attacks of pain, irritation, and joint tenderness, often at the base of the big toe. It occurs when urate crystals accumulate in the joint and leads to inflammation and intense pain called a gout attack. These urate crystals can form when high levels of uric acid in the blood accumulate, often resulting from a diet high in purines found in certain foods and drinks (4).

Gout Symptoms

Gout is notorious for its abrupt and often nocturnal onset of symptoms. In the majority of cases, gout targets the big toe, although it doesn't discriminate against other joints and can also affect the ankles, knees, elbows, wrists, and fingers. The initial wave of intense joint pain typically reaches its peak within the first four to twelve hours, often disturbing individuals from their sleep with an agonizing throbbing sensation (5).

This discomfort doesn't vanish quickly. Once the acute pain subsides, a lingering discomfort persists in the joint for several days to weeks. The frequency of these discomforting episodes is likely to increase with time, and the attacks may last longer and involve more joints. One of the distinctive signs of gout is inflammation and redness in the affected joint. The area becomes swollen, tender, and warm, and presents as an outward manifestation of the inflammation caused by urate crystals deposited in the joint. This inflammation triggers severe pain and may also be accompanied by systemic symptoms like fever (3,5).

The deposition of urate crystals can also lead to the formation of tophi, small nodules that emerge under the skin in soft tissues such as the fingers, toes, elbow, kneecap, and even the ear. These tophi trigger further inflammation and, although rare, can appear in the eyes, potentially leading to vision changes (3,5).

As gout progresses, the range of motion in the affected joints may become limited. If not managed, gout can result in joint damage over time, underscoring the importance of early detection and management. The symptoms of gout, particularly the sudden onset of severe pain, are often precipitated by certain triggers like alcohol consumption, trauma, or ingestion of purine-rich foods such as meats and oily seafood (3,5).

What Causes Gout?

Gout is caused by hyperuricemia, a condition characterized by high levels of uric acid found in the blood. Purines are found in certain foods and drinks, including organ meats, seafood, and alcohol and are broken down into uric acid. Factors like a diet high in purines, obesity, certain medications (aspirins, some diuretics for high blood pressure, and drugs used in organ transplants), and genetics may contribute to gout development (6).

Ruling Out Differential Diagnosis for Gout

Diagnosing gout involves ruling out other conditions that mimic its symptoms, such as pseudogout, rheumatoid arthritis, and infections. It's critical to differentiate gout from these conditions because they present similar symptoms but require different management approaches (7,8).

One common condition that can be confused with gout is pseudogout, also known as calcic gout or calcium pyrophosphate dihydrate deposition disease. Deposits of calcium pyrophosphate dihydrate cause this inflammatory arthritis in older adults (CPPD) crystals in and around the joints, quite different from the uric acid crystals associated with gout. Symptoms of pseudogout can resemble those of gout, although there are significant differences, such as the attack usually affecting the knee first and symptoms appearing more slowly, taking days to develop. Pseudogout also tends to first develop in older people, particularly those with osteoarthritis (7).

Another condition that may resemble gout, particularly in its chronic form, is rheumatoid arthritis. This autoimmune disorder can cause deformaties of the joints and cause inflammation and pain similar to gout. In older people, distinguishing between chronic gout and rheumatoid arthritis can be challenging, necessitating a detailed medical history, laboratory tests, and identification of monosodium urate crystals (7).

Osteoarthritis, a degenerative joint disease, can also coincide and be confused with gout in older individuals, especially when it occurs in arthritic finger joints in women. If the joints in the fingertips are abnormally enlarged, gout should be ruled out (7).

Joint infections can also mimic gout, as they may exhibit features similar to it. Distinguishing between these conditions is crucial for appropriate management. Indicators such as high fever and high white blood cell count can help diagnose infection, while the presence of urate crystals found in the joint usually indicates gout (7).

Functional Medicine Labs That Can Help Individualize Management for Gout Patients

Functional medicine labs offer a variety of tests that can help tailor gout management to patients, allowing providers to optimize strategies.

Uric Acid Testing for Gout Patients

The Uric Acid test by Access Medical Laboratories provides the level of uric acid in the blood. High levels can indicate that your body is producing too much uric acid or that your kidneys are not excreting enough. This accumulation can lead to the formation of uric acid crystals, which can cause the painful symptoms of gout. Therefore, managing uric acid levels can help manage and reduce gout symptoms (12).

Stool Testing for Gout Patients

Studies have demonstrated the gut microbiome's role in purine and uric acid metabolism, and changes in the abundance and composition of gut microbiota can increase serum uric acid levels through the dysfunction of uric acid degradation and increased uric acid production. A gut barrier panel also assesses gut inflammation and intestinal permeability. Elevated gut inflammation may require interventions like dietary changes, prebiotics, or probiotics. If the gut barrier function is compromised (leaky gut), therapies to support its integrity, such as L-glutamine supplementation, may help patients.

hs-CRP Testing for Gout Patients

The BostonHeart High-Sensitivity C-Reactive Protein (hs-CRP) test measures the level of C-reactive protein, a protein produced in the liver that signals inflammation in the body. Since gout is an inflammatory condition, inflammatory markers like those offered in the test above can provide insight into the root cause of patient's symptoms. Therefore, regular monitoring of hs-CRP offers insights into the severity of inflammation in the body, which could potentially be due to a gout flare. This in turn can help providers track the effectiveness of management and to adjust your therapeutic regimen accordingly. In addition, gout has been associated with an increased risk of cardiovascular diseases. The hs-CRP test, a recognized marker of cardiovascular risk, can provide valuable information about your overall health status. If hs-CRP levels are elevated, interventions such as dietary modifications or weight management may be considered.  

Joint Fluid Test

In addition to the above tests, the joint fluid test may also be indicated to confirm a diagnosis. This test (also referred to as Synovial Fluid Analysis) involves drawing fluid from the affected joint to look for urate crystals, providing a definitive diagnosis of gout.

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Conventional Management for Gout

Conventional management for gout primarily involves medications to address acute attacks and support future prevention. These include nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and medications that lower uric acid levels. Lifestyle modifications, like dietary changes and increased physical activity, are also considered.

Functional Medicine Management Protocol for Gout

Functional medicine integrates conventional treatments with holistic approaches that address the root cause rather than just manage symptoms. For gout, this involves dietary modifications, supplementation, and lifestyle changes.

Therapeutic Diet and Nutrition Considerations for Gout

The complex task of managing gout requires careful attention to diet and nutrition, as these factors significantly influence uric acid levels within the body. While no single diet plan can eliminate the risk of gout flare-ups entirely, integrating certain dietary changes can help manage symptoms and reduce the likelihood of attacks (24,25).

One of the pivotal strategies in gout prevention is weight management. Excess weight not only stimulates the production of uric acid but also exerts additional stress on the joints. Therefore, reducing calorie intake and achieving weight loss can contribute to decreased uric acid levels and a less frequent occurrence of gout attacks, even in the absence of a strictly enforced purine-restricted diet. A gradual shift towards a diet abundant in complex carbohydrates is beneficial. This can be accomplished through increased consumption of fruits, vegetables, and whole grains. Simultaneously, it is advisable to reduce the intake of high-fructose corn syrup and naturally sweet fruit juices. Adequate hydration plays an important role in the elimination of uric acid from the body (24,25).

Eat a Low-Purine Diet

When considering fat intake, it's essential to opt for healthier sources. A reduction in saturated fats from red meat, fatty poultry, and high-fat dairy products is recommended. Lean meats, low-fat dairy, and lentils can serve as healthier alternative protein sources. It's advisable to moderate the intake of certain purine-rich foods, such as organ meats and specific types of seafood, as well as red meat. Moderate portions of fish and high-purine vegetables, like spinach and asparagus, can be incorporated into a balanced diet, as they do not significantly elevate the risk of gout (24,25).

Beverage choices can also impact uric acid levels. Drinks high in purines, such as beer and grain liquors, as well as sugary beverages like soda and certain fruit juices, should be avoided. Conversely, moderate consumption of wine and caffeinated coffee may be acceptable, although it's always best to consult with a healthcare provider to ensure these choices align with individual health needs (24,25).

Focus on Low Inflammatory Food

Lastly, along with following a diet low in purines, it is important to reduce inflammation in the body. The Mediterranean diet emphasizes primarily plant-based foods like fruits, vegetables, whole grains, legumes, and nuts. It prioritizes replacing butter with healthier fats like olive oil and using herbs and spices for flavor instead of salt, while limiting red meat to a minimum. This diet is a great choice for individuals with gout as it aids in reducing inflammation levels, which is the main cause of intense pain and swelling associated with gout. High levels of inflammation can lead to acute gout attacks and chronic inflammation may result in long-term joint damage. Managing inflammation through this diet can help control gout symptoms and prevent complications. The diet includes several anti-inflammatory foods such as olive oil, fatty fish like salmon, fruits, especially berries, and leafy green vegetables. Additionally, if you or your patients find abnormalities in gut testing either through dysbiosis or leaky gut, it is especially important to follow strategies such as supplementation with probiotics or L-glutamine (along with the diet suggestions above) to help support gut health in addition to reducing inflammation.

Supplements Protocol for Gout

For patients interested in supplements, vitamin C and cherries (especially tart cherry juice) may help support symptom management in patients with gout.

Vitamin C for Gout Symptoms

Vitamin C, a potent antioxidant, has been investigated for its potential role in managing the symptoms of gout. Intriguingly, findings from several studies suggest that supplementation with vitamin C can lead to reductions in serum uric acid (SUA), the excess of which can precipitate gout attacks. In a comprehensive meta-analysis of sixteen randomized controlled trials involving 1,013 participants, vitamin C supplementation was associated with significant decreases in SUA levels. The analysis incorporated a broad range of study designs, durations, and participant profiles, lending credibility to the conclusion.

Dosing: 500 mg per day (most common dose; range of 200-2,000 mg/d)

Duration: Range of 2 weeks to 6 months with best results seen in supplementation that lasted less than 1 month.

Cherry Intake for Gout Management

Cherries, particularly tart cherries, have been implicated for their potential benefits in managing gout symptoms. Evidence from a randomized, placebo-controlled crossover study showed that consuming 240 mL (8 oz) of tart cherry juice daily for four weeks significantly decreased serum uric acid (sUA) concentrations by 20%. This is particularly important as the accumulation of sUA is the primary cause of gout.

Additionally, a systematic review of six studies further supported the role of cherries in gout management. Regular ingestion of cherry extract or juice was linked with a reduction in the incidence and severity of gout attacks.

Dosing: 240 mL (8 oz) of tart cherry juice per day

Duration: four weeks

When to Retest Labs

Retesting is usually done 3-6 months after the initiation of management to assess the effectiveness of the interventions and make necessary adjustments.

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Summary

Gout, a common form of arthritis, is characterized by severe and sudden attacks of pain, redness, and tenderness in joints, often triggered by high levels of uric acid in the blood. Its symptoms can be highly debilitating, significantly impacting quality of life. Functional medicine offers a comprehensive approach to managing gout, incorporating dietary changes, supplementation, and lifestyle modifications alongside conventional treatments. This allows patients a greater chance to manage symptoms and improve disease burden.