V.

SURESHBABU
2009-
GOUT
JSS INSTITUTE OF NATUROPATHY AND YOGIC SCIENCE

2010
2/22/2009

YOGIC MANAGEMENT OF GOUT

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 ACKNOWELDGEMENT

We would like to convey our sincere gratitude to our respectable and beloved guide

Dr.RENJISH Professor & Head Department of Yoga Therapy who constantly guided

and aided to create this project. His constant dedication, support, guidance and his

enthusiasm for the subject kept on motivating us towards the completion of the

project. We are blessed to be working under him for our project.

We are honored to be a part of an institution like JSS, which provided all the facilities

needed to complete our project work. We sincerely thank our dear and dear Principal

Dr.R.C.VERMA for providing the necessary motivation and infrastructure facilities to

undergraduate students like us.

Lastly, we would like to thank GOD Almighty for constantly giving the vision to do

their right thing.

Dr.Renjish

Dr.R.C.Verma
 GOUT

History:

The first written description of gout dates from 2,600 BC, when Egyptians

noted gouty arthritis of the big toe. Around 400 BC, the Greek physician Hippocrates

also commented on gout. Writing ca. 30 AD, Aulus Cornelius Celsus appeared to

recognize many of the features of gout, including its link with a urinary solute, late

onset in women, linkage with alcohol, and perhaps even prevention by dairy products:

"Again thick urine, the sediment from which is white, indicates that pain and disease

are to be apprehended in the region of joints or viscera. … Joint troubles in the hands

and feet are very frequent and persistent, such as occur in cases of podagra and

cheiragra. These seldom attack eunuchs or boys before coition with a woman, or

women except those in whom the menses have become suppressed. Upon the

commencement of pain blood should be let; for when this is carried out at once in the

first stages it ensures health, often for a year, sometimes for always. Some also, when

they have washed themselves out by drinking asses' milk, evade this disease in

perpetuity; some have obtained lifelong security by refraining from wine, mead and

venery for a whole year; indeed this course should be adopted especially after the

primary attack, even although it has subsided.

Colchicum was described for treatment of rheumatism and swelling in the

Ebers Papyrus, ca. 1500 B.C. The use of Colchicum corm for gout probably traces

back to ca. 550 A.D., as the "hermodactyl" recommended by Alexander of Tralles.

Colchicum corm was used by ibn Sina and other Islamic physicians, was

recommended by Ambroise Pare in the sixteenth century, and appeared in the London

Pharmacopoeia of 1618.[49] In 1833 P.L. Geiger purified an active ingredient, which he

named colchicine.[50] Colchicum was brought to America by Benjamin Franklin;

Franklin suffered from gout himself and had written humorous doggerel about the

disease during his stint as Envoy to France. As a drug predating the FDA, colchicine

was sold as a generic in the United States for many years. In 2009 the FDA approved

colchicine for gout flares, awarding Colcrys a three year term of market exclusivity,

prohibiting generic sales, and increasing the price of the drug from $9 to $485 per

bottle.

Around 200 AD, the Roman gladiatorial surgeon Galen described gout as a

discharge of the four humors of the body in unbalanced amounts into the joints. The

word "gout" was initially used by Randolphus of Bocking, around 1200 AD. It is

derived from the Latin word "gutta", meaning "a drop" (of liquid).

The Dutch scientist Antonie van Leeuwenhoek described the microscopic

appearance of urate crystals in 1679. In 1848 English physician Alfred Baring Garrod

realised that excess uric acid in the blood was the cause of gout.

The Tyrannosaurus rex specimen known as "Sue" appears to have suffered

from gout.

Historical treatments for gout include gin and numerous medications that have

since been found to be not effective. Sodium bicarbonate (baking soda) is a traditional
remedy,[56] thought to work by raising blood pH (lowering blood acidity). However,

the added sodium may be inappropriate for some people

Definition:

Gout is a disease that involves the build-up of uric acid in the body. About 95

percent of gout patients are men. Most men are over 50 when gout first appears.

Women generally don't develop gout until after menopause. But some people develop

gout at a young age.

Gout is a form of acute arthritis that causes severe pain and swelling in the

joints. It most commonly affects the big toe, but may also affect the heel, ankle, hand,

wrist, or elbow. It affects the spine often enough to be a factor in lower back pain.

Gout is often a recurring condition. An attack usually comes on suddenly and goes

away after 5–10 days. Gout occurs when there are high levels of uric acid circulating

in the blood, and the acid crystallizes and settles in the body. According to the

National Institutes of Health (NIH), gout accounts for about 5% of all cases of

Arthritis reported in the United States.

Gout appears to be on the increase in the American population. According to a

study published in November 2002, there was a twofold increase in the incidence of

gout over the 20 years between 1977 and 1997. It is not yet known whether this

increase is the result of improved diagnosis or whether it is associated with risk

factors that have not yet been identified.

Anatomy:

Gout was the first disease in which researchers recognized that crystals in the

synovial fluid could be the cause of joint pain. Synovial fluid is the fluid that the body

produces to lubricate the joints. In gout, excess uric acid causes needle-shaped

crystals to form in the synovial fluid. Uric acid is a normal chemical in the blood that

comes from the breakdown of other chemicals in the body tissues.

Everyone has some uric acid in his blood. As your immune system tries to get

rid of the crystals, inflammation develops. For the person with too much uric acid, this

inflammation can cause painful arthritis.

The first attack of gouty arthritis usually happens in just one joint. Half of the

time, gout affects the metatarsophalanll (MTP) joint. This is the joint at the base of

the big toe. Eventually, 90 percent of people with gout will have pain in the MTP

joint. Other joints that are commonly affected include the mid-foot, ankle, heel, and

knee joints. Less commonly gout affects the fingers, wrists, and elbows.

Over time, patients with gout can develop tophi, or lumps that grow around

crystal deposits in joints or near pressure points. Tophi most often occur in the

fingers, wrists, ears, knees, elbows, forearms, and heels. Tophi can also grow in the

kidneys, heart, and eyes.

Hyperuricemia:

The underlying condition that causes gout is called hyperuricemia. It means

that you have high levels of uric acid in your blood. This can happen for two reasons:

(1) your body creates too much uric acid, or (2) your kidneys don't excrete the uric

acid effectively. Whether or not you will develop gout is related to how bad your

hyperuricemia is over time.

 For people who create too much uric acid, the cause is usually genetic. Some

rare genetic and metabolic disorders can cause overproduction of uric acid, which can

eventually lead to gout. The breakdown of purines in the body also releases uric acid.

Purines are ingested through certain types of food such as sweetmeats (e.g., liver,

kidney, brain) and seafood. The increased intake of fructose-sweetened soft drinks has

also been linked with an increased risk of gout. Usually the excess uric acid is then

passed out of the body through the urine.

More than 90 percent of people with gout have kidneys that don't effectively

get rid of uric acid. Sometimes this is caused by certain kinds of drugs, such as

diuretics, cyclosporine, and low-dose aspirin. Other medical conditions, such as

obesity, hypertension, and diabetes, can also make some people more likely to

develop gout.

Many gout patients have a combination of overproduction and under-excretion

of uric acid. Their bodies create too much uric acid and have problems getting rid of

it. This combination of problems happens with drinking alcohol, especially beer. The

more alcohol the patient drinks, the worse the problem is. Alcohol both raises uric

acid levels in the body and impairs the kidneys' ability to excrete the buildup.

PATHOLOGY:

Uric acid is formed in the bloodstream when the body breaks down waste

products, mainly those containing purines. Purines can be produced naturally by the
body, and they can be ingested from such high-purine foods as meat. Normally, the

kidneys filter uric acid particles out of the blood and excrete it into the urine. If the

body produces too much uric acid or the kidneys aren't able to filter enough of it out,

there is a buildup of uric acid in the bloodstream. This condition is known as

hyperuricemia.

Uric acid does not tend to remain dissolved in the bloodstream. Over the

course of years, or even decades, hyperuricemia may cause deposits of crystallized

uric acid throughout the body. Joints, tendons, ear tips, and kidneys are favored sites.

When the immune system becomes alerted to the urate crystals, it mounts an

inflammatory response that includes the pain, redness, swelling, and damage to joint

tissue that are the hallmarks of an acute gout attack.

The body's uric acid production tends to increase in males during puberty.

Therefore, it should come as no surprise that nine out of ten of those suffering from

gout are men. Since it can take up to 20 years of hyperuricemia to have gout

symptoms, men don't commonly develop gout until reaching their late 30s or early

40s. If a woman does develop gout, typically, it will be later in her life. According to

some medical experts, this is because estrogen protects against hyperuricemia. It is

not until estrogen levels begin to fall during menopause that urate crystals can begin

to accumulate.

Hyperuricemia does not necessarily lead to gout. The tendency to accumulate

urate crystals may be due to genetic factors, excess weight, or overindulgence in the

wrong kinds of food. In addition, regular use of alcohol to excess, the use of diuretics,
and the existence of high levels of cholesterol and triglycerides in the blood can

increase the risk of developing the disease. In some cases, an underlying disease such

as lymphoma, leukimia, or hemolytic anemia may also lead to gout.

Intensive care unit (ICUs) may have an acute flare-up of gout. In addition, it is

now known that chronic occupational exposure to lead leads to decreased excretion of

urates and an increased risk of developing gout.

In many cases, the gout attack begins in the middle of the night. There is

intense pain, which usually involves only one joint. Often it is the first joint of the big

toe. The inflamed skin over the joint is warm, shiny, and red or purplish, and the pain

is often so excruciating that the sufferer cannot tolerate the pressure of bedcovers. The

inflammation may be accompanied by a fever.

Acute symptoms of gout usually resolve in about a week, and then disappear

altogether for months or years at a time. Eventually, however, the attacks may occur

more frequently, last longer, and do more damage. The urate crystals may eventually

settle into hard lumps under the skin around the joints, leading to joint deformity and

decreased range of motion. These hard lumps, called to phi, may also develop in the

kidneys and other internal organs, under the skin of the ears, or at the elbow. People

with gout also face a heightened risk of kidney disorders and almost 20% of people

with gout develop kidney stones. As of 2002, however, the relationship between gout

and kidney stone formation is still not completely understood.

Diagnosis:
 Doctors can diagnose gout based on a physical examination and the patient's

description of symptoms. In order to detect hyperuricemia, doctors can administer a

blood test to measure serum urate levels. However, high urate levels merely point to

the possibility of gout. Many people with hyperuricemia don't have urate crystal

deposits. Also, it has been shown that up to 30% of gout.

Inspection of Gout:

Hand:

Leg
 Elbow

Sufferers have normal serum urate levels, even at the time of an acute gout

attack. The most definitive way to diagnose gout is to take a sample of fluid from an

affected joint and test it for the presence of the urate crystals.
 The serum sample collection

Diagnosis is important because crystals within the joint can lead to joint

damage. This can happen without you knowing it. Patients with arthritic episodes that

come and go may not seek medical help. Some patients are medically evaluated but

complete testing is not done. They are misdiagnosed with rheumatoid arthritis. Either

of these situations will delay treatment and increase the risk of erosive damage to the

joint.
 The diagnosis begins with a history of your symptoms and a physical exam.

Your doctor will need to look at synovial fluid from the affected joint to identify the

needle-like crystals. This is the most important part of the diagnosis. To get a sample

of the synovial fluid, the physician performs an arthrocentesis. A long, thin needle is

inserted into the affected joint and a small amount of synovial fluid is aspirated or

removed. The fluid is sent to a laboratory where it is viewed under a special polarized

light microscope to determine if uric acid crystals are present.

If there are uric acid crystals, then you have gout. But only 80 per cent of the

tests are positive when the person really has gout, so this test is not completely

accurate. In some cases (such as the midfoot), it isn't easy to aspirate fluid. Without

the use of fluoroscopy (a special X-ray imaging) or ultrasound to guide the needle,

aspiration isn't done. In these situations, the diagnosis is made without joint aspiration

when the patient responds favorably to therapy.

 Examination of the uric acid collection from the affected region:

Ultrasonography may be helpful in the diagnosis because the crystals form

into the shape of rosary beads inside the hyaline cartilage and this can be seen in the

ultrasound pictures. Hyaline cartilage coats the ends of the bones to protect them.

Ultrasonography can also show the double contour sign. This sign looks like a top

covering or extra coating of the joint surface when crystals are deposited in the

hyaline cartilage. Ultrasound studies do not replace fluid removal and examination

under a microscope because ultrasound does not confirm infection.

The diagnosis must rule out the presence of infection, which can be a hidden

problem. Your doctor may also get a blood test to look at the levels of uric acid.
However, uric acid levels rise and fall depending on many complex factors in your

body. It is possible to have a normal uric acid level while you are having severe gout

pain. Gout can occur with other forms of arthritis, such as septic arthritis and

rheumatoid arthritis. There are also other diseases that cause different kinds of crystals

to form in the synovial fluid.

X-rays don't show doctors much in the early stages of gout. X-rays can help

monitor your disease, and they may be needed to rule out other problems.
Treatment:

The symptoms of gout will stop completely a week or so after an acute attack

without any intervention. It is important, however, to be diagnosed and treated by a

health care practitioner in order to avoid attacks of increasing severity in the future

and to prevent permanent damage to the joints, kidneys, and other organs. During an

acute attack, treatment should focus on relieving pain and inflammation. On an

ongoing basis, the focus is on maintaining normal uric acid levels, repairing tissue

damage, and promoting tissue healing.

YOGIC MANAGEMENT OF GOUT

The Yogic Exercise for Gout

Suryanamaskara: 13 times with mantras.

Yogasana

1. Tadasana

2. Sarvangasana

3. Shirshasana

4. Gomukhasana

5. ArdhaMatsyendrasana

6. Matsyasana

7.Naukasana

8.Trikonasana
 9.Dhanurasana

10. Paschimothanasana

Pranayama:

1. Anuloma-Viloma pranayama :

2. Surya bheda pranayama

Yogasanas :

Tadasana

"Tala" means "palm tree" in Sanskrit. In this posture, the body is held upright

like the trunk of a palm tree. Hence the name.

 Sequence:

1. Stand erect.

2. Keep your feet slightly turned out and sufficiently apart according to your height and

build. Look straight ahead.

3. Inhaling, slowly raise your arms overhead with the palms facing each other.

4. Raise your heels slowly, keeping your balance.

5. Lift yourself on your toes slowly until you stand on tiptoe.

6. Exhale slowly and keep balance.

7. Inhale slowly again.

8. Balancing the body on tiptoe, pull up and stretch your arms upwards from the

shoulder-blades with the fingers outstretched.

9. Raise your heels also simultaneously as high as possible and stretch your body to the

maximum.

10. Stretch your neck and head backwards and look up.

11. Hold your breath and keep your balance. Keep yourself firmly in this position as long

as you can hold your breath comfortably.

12. Exhaling, relax the body and return to the starting position by slowly lowering the

arms and heels simultaneously, bending the neck and head forward.

Benefits:

• Talasana fully stretches the upper portion of the body.

• It stretches the spine vertically in particular and straightens out unnatural curves if

any.

• By practicing this asana, the body becomes well-built, well-proportioned, nimble and

agile.

• It expands the ribcage and increases the capacity of the lungs.

•
 Sarvangasana:

"Sarva" means "all" and "Anga" means "part" in Sanskrit. Almost all parts of

the body are involved and derive benefit from this asana and hence the name.

Sequence:

1. Lie on your back with arms on the sides and palms turned down.

2. Keep the legs together, the heels and big toes together.

3. Breathe normally and relax the whole body.

4. Pressing the palms and elbows down and keeping the knees straight.
5. Inhale and while inhaling, raise the legs together till they are perpendicular to the

floor.

6. Exhale and while exhaling, increase the pressure of your palms and elbows against the

floor and raise your hips and lower back off the floor and move your legs towards

your head.

7. Place the palms beneath the hips and prop up the trunk and legs.

8. Sliding the palms higher on the trunk, keep on pushing the hips and the small of the

back higher and raise the whole trunk off the floor till it is vertical. While doing this,

bring the legs also back to the vertical position.

9. Place the palms at the back of the ribs and support the raised trunk and legs with the

palms, forearms and elbows.

10. Sliding the palms higher and higher again, raise the hips and legs further till the trunk

and legs are in a straight line.

11. Push the chest forward towards the chin and form a chin-lock.

12. Fix your gaze on the big toes and keep the balance.

13. Breathe deeply and rhythmically and maintain this posture for about three minutes.

14. Return slowly to the starting position in the reverse order.

15. Take a few deep breaths and then breathe normally.

16. Relax the body completely in Savasana.

 Benefits:

• The principal physical benefit of Sarvangasana lies in keeping the thyroid and

parathyroid glands healthy, which regulate the functioning of many vital organs of the

body and stabilize the metabolic processes. A healthy thyroid will reduce nervous

tension. Signs of old age, due to the faulty functioning of the thyroid, are counteracted

by performing this asana regularly.

• It also activates the pituitary and thyrnus glands and keeps the prostate gland healthy.

• It prevents the untimely wrinkling of the face and premature ageing.

• The inverted position of the body in Sarvangasana, in which the feet and legs are kept

higher than the heart, promotes an increased flow of blood to the thorax, neck and

head on account of the reversal of the gravitational pull on the blood flow. A rich flow

of blood to the brain, the scalp, face, the organs of the chest, the roots of the cranial

and spinal nerves, and other vital organs and glands is ensured. Most circulatory

congestions are relieved besides promoting the free flow of hormones into the blood.

The reverse flow of blood also relieves the work of the heart.

• A regular practice of this asana will keep the vertebral column supple. A stiff spine

can be made pliable and minor defects in its curvature are corrected. The spinal nerves

are also toned up.

• The muscles of the upper arms, shoulders, neck and thighs get strengthened.

• The inversion of the body relieves any congestion of the organs in the lower part of

the abdomen and the pelvis.

• The liver and kidneys get massaged and function better.

• It improves digestion and pancreatic secretion.

• It prevents the accumulation of fat around the abdomen, waist and hips.

• This asana prevents sagging of breasts in women.

• It improves the functioning of the throat vessels and the vocal cords. The voice is

enriched on account of the pressure exerted on the neck and the massaging of the

larynx and pharynx and all the organs of the throat.

• It enables the practitioner to have good eyesight.

• Persons engaged in sedentary occupations or whose work demands long hours of

standing will find this posture ideal for easing the legs.

A regular practice of this asana will help to regulate and normalize the weight of the

body because of its effect on the thyroid gland.

• The practice of this asana gives relief to those suffering from palpitation, bronchitis,

tonsillitis, headache, insomnia and epilepsy.

• Doing this asana regularly will prevent goiter.

• It relieves pain in the back of the neck.

• It prevents hernia and gives relief in cases of bleeding piles and urinary disorders.

• This asana has often been found helpful in the treatment of leprosy.

• Sarvangasana counteracts nervous fatigue and exhaustion.

• The continued practice of Sarvangasana prevents cold and other nasal disturbances by

clearing congestion in the sinus cavities.

Sirshasana :

"Sirsha" means "head" in Sanskrit. It is required to "stand on his head" in this

asana and hence the name.

Sequence:
1. Spread a cloth or blanket folded several times on the carpet to serve as a cushion or

pad for your head.

2. Kneel down in front of the pad with only the toes and knees touching the ground.

3. Sit back between your heels.

4. Stoop forward, raising the haunches from the heels.

5. While doing so, bend your arms and place your elbows, forearms and hands on the

pad on either side of your head.

6. Form a firm finger-lock to fit round the back of your head, palms facing inwards.

7. Bring the elbows in towards each other and make a convenient angle in front of you

with the forearms and elbows.

8. Bend the head down perpendicularly and place the hind part of the crown of your

head on the pad with the interlocked fingers pressing the back of your head.

9. Raise your knees, hips and the lower part of your trunk and straighten out your legs.

10. Bring the feet together.

11. Drag your feet slowly towards your face and balance your feet on tiptoe.

12. Knees should be close to the chest.

13. Pressing the toes, elbows, forearms and head against the floor, give a gentle kick and

lift your feet together off the floor.

14. The thighs should be upright, the legs horizontal and the trunk perpendicular to the

ground.
15. Keep the feet together and maintain balance.

16. Fold the legs back on the thighs.

17. Raise the folded legs and thighs till the thighs come parallel to the floor.

18. Straighten the back maintaining balance.

19. Straighten out the thighs fully in line with the trunk, with the legs still folded back on

the thighs.

20. Open out your legs and stretch them up vertically.

21. Bring the legs together and maintain balance.

22. This is the final position.

23. Return to the starting position slowly in the reverse order.

24. Lie down in Savasana and allow your muscles to relax.

Benefits:

• This asana directly stimulates the pineal and the pituitary glands in the brain whose

healthy functioning is essential proper metabolism.

• A regular practice of Sirshasana benefits the nervous, circulatory, respiratory,

digestive, excretory and endocrine systems.

• It also sharpens the sensitivity of the sense organs.

 Gomukasana :

"Go" means "cow" and "Mukha" means "face" in Sanskrit. When this asana is

performed, the final position of the legs resembles the face of a cow.

Sequence:

1. Sit erect in Sukhasana.

2. Stretch out the legs straight in front of you.

3. Fold back the left leg a little. Raising the right knee, draw in the left foot beneath the

right thigh and set the heel on the side of the right buttock, just touching

4. it.

5. The toes and the lower edge of the left foot must lie flat on the floor with the sole

turned upwards and the toes pointing away from the body.

6.
7. Keep the thigh of the folded left leg straight in front of you.

8. Drawing in the right foot and crossing it over the left thigh, set the heel on the side of

the left buttock, just touching it.

9. Bring the knees exactly one above the other and both of them should be directly in

front of you.

10. Sit erect.

11. Twist the left arm from the elbow and bring the forearm upwards behind the back,

moving up the back of the hand along the spine. Push the forearm up as far as it will

go.

12. Raise the right arm straight up, the upper arm touching the ear.

13. Folding it back at the elbow, slide down the forearm behind the back over the right

shoulder, palm and fingers facing inward, till the right hand meets the left hand.

14. Lock the forefingers of both hands together.

15. Keep the head, neck and spine erect.

16. Look straight ahead.

17. Return to the starting position in the reverse order.

18. Repeat the entire procedure by reversing the positions of the legs and arms.

Benefits:
• The practice of Gomukhasana strengthens the muscles of the upper back, upper arms,

shoulders, chest, hips and thighs.

Ardhamatsyendrasana :

"Ardha" means "half" in Sanskrit. Since the full posture is difficult to be

practiced, the half-posture, which is easier, is followed widely. This posture was first

promoted by the great Yogi Matsyendranath, one of the founders of Hatha Yoga, and

hence the name.

Sequence:

1. Sit erect.

2. Stretch out your legs.

3. Place the right heel in the perineum. Keep the right thigh straight.

4. Place the left foot flat on the floor, crossing the right knee.
5. The left heel should rest close to the right side of the right knee.

6. Pass the right arm over the left side of the left knee and line it up with the left calf.

7. Grasp the left big toe with the index finger, middle finger and thumb of the right hand.

8. Slide the left hand across the small of the back and grasp the root of the right thigh.

9. Turn round your head, neck, shoulders and the whole trunk to the left and bring the

chin in line with the left shoulder.

10. Look as far behind you as you can. Keep the head and spine erect.

11. Maintain this position until strain is felt.

12. Release in the reverse order.

13. Repeat on the other side.

Benefits:

• Ardha Matsyendrasana is considered to be the best of the twisting postures as it

rotates the spine around its own axis besides giving two side-twists to the spine

throughout its length with the greatest efficacy, using one's own arm and knee as a

lever.

• As the spine is twisted spirally, each movable vertebra rotates in its socket, as a result

of which the spinal column, particularly the lumbar vertebrae, becomes more flexible.
 Matsyasana :

"Matsya" means "fish" in Sanskrit. If a person lies steadily on water in this

posture, he can keep floating on it easily like a fish without the help of the hands and

legs, as the name of the asana suggests.

Sequence:

1. Form a footlock in Padmasana with the knees touching the ground.

2. Lean hack gradually on your elbows and lie flat on your back with the support of the

hands and elbows.

3. Bring the hands backward towards the head and place your palms flat on the floor

under the corresponding shoulders in the reverse direction.

4. Pressing down the knees and palms and pushing your chest and abdomen forward,

raise the shoulders, back and hips from the floor, supporting the body with your

hands. While raising them, make an arch of the spine and, simultaneously, bend your

head and neck backward as far as you can to place the crown of your head

perpendicularly on the floor.

5. Bring your hands forward and grasp the back of your thighs with your palms.
6. Using your elbows for leverage, raise your chest and abdomen and, accentuating the

arch of the spine, place the crown of your head in position on the floor.

7. Make hooks of the index finger, the middle finger and thumb of each hand and catch

in each of them the opposite big toes and pull them gently.

8. Maintain this position comfortably, breathing deeply and rhythmically.

9. Return slowly in the reverse order to the starting position of Padmasana.

Benefits:

• Matsyasana tones up the spinal column.

• The cervical and dorsal regions are fully extended and become more flexible. If the

spine has become habitually curved by sitting incorrectly, it will again become

straight by the regular practice of this asana.

• The chest expands and the capacity of the lungs increases by the abundant supply of

fresh air.

Nauakasana :

"Nauka" means "boat" in Sanskrit. The final position of this asana resembles a boat.

Hence the name.

 Sequence:

1. Lie straight on your abdomen and chest with your forehead resting on the floor.

2. Keep the feet together and the arms on the sides.

3. Stretch out the arms on both sides of the head and keep them parallel.

4. Turn down the palms on the floor with fingers close together.

5. Keep your forehead on the floor between the upper arms.

6. Inhaling, raise the arms, head, neck, shoulders, trunk and legs all together slowly and

simultaneously as high as possible without bending the knees and elbows and without

any jerk.

7. While doing this, keep the upper arms touching the ears and the feet together.

8. Bring the head up as high as possible and keep it between the raised upper arms.

9. Bend the extremities as far back as possible, and the back should be well arched.

10. The whole body should be curved from the fingertips to the toes, both of which

should be on the same level.

11. Balance the entire weight of the body on the lower part of the abdomen which alone

should touch the ground.

12. Maintain the posture motionlessly, as long as you can comfortably hold your breath.

13. Exhaling return slowly to the starting position.

14. Relax completely in Savasana.

Benefits:

• Naukasana bends the middle of the spine and makes it flexible.

• Deformities of the spinal column are corrected.

• It strengthens the hips, arms, thighs, knees, calves, feet and the pelvic region.

• It expands the chest and strengthens the lungs.

• It strengthens the muscles of the back, abdomen, the lower limbs,

Trikonasana :

"Tri" means 'three', 'Kona' means 'angle', and 'Trikona' means 'triangle' in Sanskrit The

straight legs with the floor between the feet resemble the three sides of a triangle in

this asana. Hence the name.

 Sequence:

1. Stand erect. Keep the feet sufficiently apart.

2. Inhaling, raise and stretch out your arms sideways to shoulder level and parallel to the

floor with palms facing downward.

3. Exhale slowly and breathe normally a few times.

4. Take a deep breath.

5. Exhaling slowly, rotate the trunk and head together from the waistline all the way

around to the left without moving the feet or changing the position of the arms, and

complete the exhalation. Hold this position for a few seconds while holding out your

breath.
6. Hold this position for a few seconds while holding out your breath.

7. Take a deep breath again.

8. Exhaling slowly, extend your right arm downward towards the left big toe without

bending the knees. While the right arm is moving downward, bend down your head

and trunk slowly to the left from the waist.

9. Rest the fingertips of the right hand on the left big toe.

10. Raise and stretch your left arm straight up and bring it in line with your lowered right

arm, keeping the left palm turned inwards.

11. Holding out your breath, turn your head to the left and look up quickly at the

fingertips of your left hand.

12. Still holding out the breath, again turn your head downwards and look down quickly

on the left big toe and look up at the fingertips of the raised hand a second time.

13. Maintain this position as long as you can comfortably hold out your breath.

14. Inhaling, release the right hand, twist the trunk and head back and rise up slowly to

the erect standing position, lowering the left arm to the shoulder level and rotating the

right arm sideways up to shoulder level in a wide circle.

15. Exhale slowly and take a few normal breaths.

16. Repeat the whole exercise, twisting the trunk and head to the right.
 Caution:

• The movements must be very slow and rhythmical.

• Keep the knees and elbows straight throughout this asana.

• Bend only to the sides. While bending, the trunk must not sway forward. Your hips

should not move so that the pull comes from your waist. Do not twist the trunk or

hips.

• While bending, your feet should not slip.

• Bend the trunk little by little by sliding the palm lower and lower towards the foot,

going a little further each time you practice. The movement must be continuous

without interruption at any stage.

• Shift the weight of the body to the left when your left arm slides down on the left leg,

and vice versa.

• If you cannot touch the ankle-joint, hold on to any portion of the leg as near to it as

you can manage.

Benefits:

• It removes tension from the neck and the side muscles and opens up the chest and

expands it.

• It exercises the hips and the buttocks.

• This asana reduces excess fat in the abdomen, waist and hips and massages that area

of the flank where fat accumulates. It thus gives the body a graceful form with

minimum effort.

• It increases the flexibility of the waist and the hip joints.

• It benefits women by slimming the waistline and giving shape and grace to the hipline

besides exercising the pectoral muscles which hold the breasts in position.

• This is an excellent exercise for correcting a faulty posture and for making the body

well-proportioned.

• Persons who have to sit for long periods at the workplace will find this posture

invigorating, if it is practiced during the period of work.

• Practicing Trikonasana regularly improves the appetite. It also helps digestion and the

assimilation of food.

• It relieves constipation by invigorating the peristaltic action of the bowels.

• It will help a person to attain full stature.

Dhanurasana :

"Dhanus" means "bow" in Sanskrit. In the final position of this asana, the body

takes the shape of a bow, drawn tight to shoot an arrow. The stretched arms and lower

legs resemble the taut bowstring, while the trunk and thighs resemble the wooden part

of the bow.
 Sequence:

1. Lie with your abdomen, chest and chin resting on the ground.

2. Stretch the arms on the sides. Keep the feet a little apart.

3. Bend the legs backwards and grasp the corresponding ankles firmly.

4. Hold the arms stiff and straight. Keep the knees sufficiently apart.

5. Raise your chin and bend your head and neck backward without raising the chest.

6. Inhaling, pull the legs slowly upward towards the ceiling (not the head).

7. While pulling hard against the ankles, raise the knees, thighs, hips, the lower region of

the navel, chest, shoulders, chin, neck and head upward all together until the body is

balanced on the navel region which alone should touch the floor.
8. Arch the back as much as possible with the arms and legs tugging at each other.

9. Slowly bring the big toes, the inner edges of the feet and the knees closer and join

them together.

10. Keep your head up and backward as far as you can and look up.

11. Hold your breath and maintain the posture until you feel the strain.

12. Exhaling, return slowly to the starting position in the reverse order.

Caution:

• Persons who suffer from high blood pressure, heart ailments, stomach ulcer, colitis,

hernia or slipped disc must not attempt this posture.

• Those who have undergone any abdominal operation must give it up until they have

recovered fully.

• Women should not practice this asana during pregnancy.

Benefits:

• Dhanurasana helps to cure rheumatism of the legs, knee-joints, hands.

• It relieves pain in the neck and back, and also certain types of lumbar pain.

• It also alleviates sciatica.

• It helps to set right slipped disc.

• It also helps to cure flatulence after meals.

• It will eradicate dyspepsia, sluggishness of the liver and urinary troubles.

• It relieves constipation by improving the peristaltic action of the intestines. It prevents

or gives relief in piles.

• It can be specially prescribed for those suffering from diabetes as it stimulates

pancreatic action.

• It prevents sterility.

• Dhanurasana strengthens the muscles of the thighs and buttocks. It makes the

abdominal, lumbar and pelvic muscles supple and strong.

• This asana has a beneficial effect on the heart, liver, spleen, bladder, the genital

organs and the solar plexus.

• Dhanurasana promotes digestion by stimulating gastric secretions and relieves

congestion of blood in the abdominal viscera.

• It reduces excess fat around the abdomen, waist, hips and thighs and is specially

beneficial to women.

• It improves the posture. It also rectifies slouching.

Paschimotanasana :
 "Paschima" means 'behind', 'back' or 'posterior' and 'Uttana' means to stretch

out in Sanskrit. "Paschimotana" means stretching the posterior regions of the body.

Sequence:

1. Sit upright in Sukhasana, keeping the head, neck and spine erect.

2. Stretch your legs straight out in front of you and keep them together.

3. Keep the knees straight.

4. Place the palms on the respective knees.

5. Bend your trunk and head slowly forward and downward from the waist. While doing

this, slide forward the hands along the shins and grasp the corresponding big toes with

the index finger, middle finger and thumb of each hand without bending the knees.

6. Keep the head between the upper arms and pull the big toes steadily. While doing so,

bend further forward, curve the spine and aim your forehead towards the knees.

7. Take a deep breath and exhale slowly.

8. Lower the head down as far as you can towards the knees, drawing in your abdominal

muscles gently, still grasping and pulling the big toes and keeping the knees straight.

9. Bend the arms and rest the elbows gradually on the floor.

10. Using the elbows as levers, rest your forehead on the knees which should not be

raised or bent.

11. Exhale completely.

12. Holding out your breath, stay in this posture for a few seconds or as long as you are

comfortable.

13. Return slowly and smoothly in the reverse order to the starting position.

14. Freely exhale and inhale until your breathing returns to normal.

Caution:

• Perform Paschimotanasana on an empty stomach.

• Persons who have back trouble or have undergone any abdominal operation should

practice this asana only on the advice of a doctor who is knowledgeable about yoga.

• Persons who have slipped disc or hernia and women who are pregnant must not

practice this asana.

• Do not release the posture suddenly and get back to the starting position quickly.

Unbend the spine slowly and gently while returning.

• Be relaxed and comfortable in the final position and do not allow the body to become

tense.

Benefits:

• Paschimotanasana is a fine stretching exercise for the back of the whole body, from

the heels to the top of the spine. In one continuous movement, almost all the posterior

muscles of the body, particularly the hamstring muscles at the back of the thighs and

the muscles of the small of the back, are fully stretched and relaxed. The muscles of

the neck, chest, shoulders, the spinal column, hips and the recti are also brought into

play.

• This asana stretches the spine to its maximum length, which makes it supple and

flexible.

• The asana stretches the ribcage and its regular practice will expand the lungs more.

• The practice of this asana improves digestion and the peristaltic action of the bowels.

• The joints of the arms, elbows, shoulders, legs, knees, ankles and hips become more

elastic.

• This asana is good for reducing fatty deposits in the abdomen, hips, backside and

thighs. Obese persons may repeat it as many times as possible to reduce their waist

and protruding belly.

• The loins and the waist get into good shape. The legs also become firm and develop

evenly.

• This asana rectifies minor postural defects and deformities in the curvature of the

spine, and helps a person to attain his full stature.

• Paschimotanasana gives relief in cases of sciatica, muscular rheumatism of the back,

backache, lumbago, slipped disc and asthmatic attacks.

• It is a good remedy for constipation, dyspepsia, flatulence, belching, hiccoughs and

digestive disturbances.

• It can be recommended for the enlargement or sluggishness of the liver and spleen.

• It will check the development of piles and prevent several functional disorders of the

intestines.

• Diabetic patients may practice this asana with advantage as it activates the pancreas.

• It helps overcome many menstrual disorders.

• Daily practice of this asana helps to cure impotency and seminal weakness, increases

vitality, and enhances the power of sex control.

Pranayamas :
 1. Anuloma viloma pranayama :

This pranayama manipulates the flow of energy through the nadis (channels)

in your body and ultimately brings about a balance of both stimulation and relaxation.

Sequence:

1. Using your right hand close your nostrils:

i. Tuck your index and middle fingers into the palm of your hand.

ii. Use your thumb to close your right nostril.

iii. Use your ring and little fingers together to close your left nostril.

2. Breathe in through the left nostril closing the right.

3. Hold breath, closing both nostrils.

4. Breathe out through the right nostril keeping the left nostril closed.

5. Breathe in through the right nostril keeping the left nostril closed.

6. Hold the breath, closing both nostrils.

7. Breathe out through the left nostril keeping the right closed.
8. Count to two when inhaling, hold for the count of eight then exhale to the count of

four.

9. Start with eight rounds build up to sixteen rounds.

Caution:

• Try to make the inhalation and exhalation of equal length.

• Take care not to strain.

• Try to make every breath soft and gentle.

• Count to two when inhaling, hold for the count of eight then exhale to the count of

four.

Benefits:

• Anuloma Viloma restores the natural balance in your breathing.

• It will remove tension, fear, and worry and will make the mind calm, poised and

serene.

• Through the practice of this Pranayama, happiness, health, vigour and melodious

voice can be attained.

1. Suryabedha pranayama :
 "Surya Bheda Pranayama" - a breathing technique in which

inhalation is done through the right nostril.

Sequence:

1. Sit in a comfortable posture, keeping the head, neck and spine in a straight line.

2. Place the right thumb on the right nostril, the right index finger between the eyebrows

and rest the middle finger against the left nostril.

3. Close the left nostril and slowly inhale through the right nostril, filling the lungs

completely.

4. Close both nostrils and apply Jalandhara Bandha.

5. Lift the chin, keep the right nostril closed and exhale through the left nostril.

6. Try to gradually increase your period of breath retention.

7. Build up to ten repetitions of Surya Bheda in the beginning; eventually you may do

forty repetitions.

Caution:
• It enhances heat, so it should not be practice it to pacify these conditions, but those

laden with bile should practice this exercise in moderation.

Benefits:

• When you inhale solely through the right nostril you generate heat energy which is

sent out through your body.

• Impurities are dispelled.

• It helps your immune system in general.

• It helps in gastric fire, cold and asthma.

• It reduces wind and mucus and increases bile and digestive power.

Diet & Nutritional supplements :

Generally, gout is unheard of in vegetarians. It is a condition that responds

favorably to improvements in diet and nutrition. Recurrent attacks can be avoided by

maintaining a healthy weight and limiting the intake of purine rich foods. A diet high

in fiber and low in fat is also recommended. Processed foods should be replaced by

complex carbohydrates, such as whole grains. Protein intake should be limited to

under 0.8g/kg of body weight per day.

Vitamin E and selenium are recommended to decrease the inflammation and tissue

damage caused by the accumulation of urates.

 Folic acid has been shown to inhibit xanthine oxidase, the main enzyme in

uric acid production. The drug allopurinol is used for this same purpose in the

treatment of gout. The therapeutic use of folic acid for this condition should be

prescribed and monitored under the supervision of a heath care practitioner. The

recommended dosage range is 400–800 micrograms per day.

The amino acids alanine, aspartic acid, glutamic acid, and glycine taken daily

improve the kidneys' ability to excrete uric acid. Bromelain, an enzyme found in

pineapples, is an effective anti-inflammatory. It can be used as an alternative to

NSAIDs and other prescription anti-inflammatory drugs. It should be taken between

meals at a dosage of 200–300 mg, three times per day.

The bioflavonoid quercetin helps the body absorb bromelain. It also helps

decrease uric acid production and prevents the inflammation that leads to the acute

symptoms of gout and the resulting tissue destruction. Quercetin should be taken at

the same time and dosage as bromelain: 200–400 mg, between meals at a three times

per day.

Herbs:

Dark reddish-blue berries such as cherries, blackberries, hawthorn berries,

and elderberries are very good a source of flavonoid compounds that have been found

to help lower uric acid levels in the body. Flavonoids are effective in decreasing
inflammation and preventing and repairing the destruction of joint tissue. An amount

of the fresh, frozen, dried, juiced, or otherwise extracted berries equal to half a pound

(about 1 cup) fresh should be consumed daily.

Devil's claw, Gout represents a serious strain on the kidneys. The dried

leaves of nettles, Urtica dioica, can be made into a pleasant tea and consumed

throughout the day to increase fluid intake and to support kidney functions. However,

some people are allergic to nettles.

• Cherries and an herb called devil's claw are folk medicine remedies that have

been used as anti-inflammatories to treat gout. Research is needed to evaluate

the usefulness of these and other complementary medicines to treat gout.

• Eicosapentaenoic acid (EPA) is known to reduce chronic inflammation. It has

not yet been studied to see whether it can help reduce inflammation from gout.

• Although still just a theory, some studies indicate that folic acid may be

helpful in inhibiting the enzyme needed to produce uric acid.

HOMEOPATHIC THERAPY:

Colchicum is a general homeopathic remedy that can be used for pain relief

during a gout attack. It is formulated from the same plant, Autumn crocus, as the drug
colchicine, used in the conventional treatment of gout. Gout may be improved by

having a constitutional remedy prescribed that is based on the tendency to develop the

disease and its symptoms.

HERBOLOGY:

HYDROTHERAPY:

Hydrotherapy is essential. It should be begun immediately and used long

term. Alcohol and coffee should be avoided, but if they are not, note the instruction

"For every 6 ounces of alcoholic beverage or coffee, an additional 10 ounces of water

must be drunk due to the dehydrating effects of these." Using this one simple, cheap

method may completely solve the problem in a few days, but for fast relief,

supplements and other measures should be used.

Gout is cause by uric acid crystals and usually occurs in the hands or feet.

Besides the painful effects of the glass-like crystals irritating the tissues, sometimes

massive inflammation occurs. Uric acid crystals form from undigested protein so

whatever amount of enzymes that is required should be taken to prevent further

deposition for a quick resolution.

The next step is using a bromelain supplement such as NSI Bromelain or other

good non-acidic high potency enzyme product in sufficient amounts. Enzymes which

contain acidic components such as ox bile or HCL should not be used. The reason is

that this type of product cannot be taken in high enough amounts without causing

stomach upset, not because the acidic components would add to the problem (see
below for further information). Use triple or more recommended dosage with meals to

digest protein and between meals to relieve pain and inflammation. Using enzymes

in sufficient amounts along with plenty of water will solve a gout problem

quickly. The most common error is using too little. 6 to 10 bromelain capsules of

2000 GDU potency at one time is not an unreasonable serving size when fighting an

acute attack of gout

Allopathic treatment:

Standard medical treatment of acute attacks of gout includes nonsteroidal anti-

inflammatory drugs (NSAIDs) such as naproxen sodium (Aleve), ibuprofen (Advil),

or indomethacin (Indocin). Daily doses until the symptoms have subsided are

recommended. Colchicine (Colbenemid), is also used. Corticosteroids such as

prednisone (Deltasone, prednisolone, and corticotropin [ACTH]) may be given orally

or may be injected directly into the joint for a more concentrated effect. Because these

drugs can cause undesirable side effects, they are used for only about 48 hours so as

not to cause major problems. Aspirin and other salicylates should be avoided, because

they can impair uric acid excretion and may interfere with the actions of other gout

medications.

Once an acute attack has been successfully treated, doctors try to prevent

future attacks of gout and long-term joint damage by lowering uric acid levels in the
blood. Colchicine is the drug of choice to deter recurrence. This medication can be

very hard on the vascular system and the kidneys, however, and it is incompatible

with a number of antidepressants, tranquilizers, and antihistamines. It should be

avoided by pregnant women and the elderly.

There are two types of drugs used for lowering uric acid levels. Sometimes

these drugs resolve the problem completely. However, the use of low-level amounts

may be required for a lifetime. Uricosuric drugs, such as probenecid (Benemid) and

sulfinpyrazone (Anturane), decrease urates in the blood by increasing their excretion.

These drugs may also promote the formation of kidney stones, and they are

contraindicated for patients with kidney disease. Xanthine oxidase inhibitors block the

production of urates in the body. They can dissolve kidney stones as well as treat

gout. Allopurinol is the drug most used in this respect. Its adverse effects include

reactions with other medications, and the aggravation of existing skin, vascular,

kidney and liver dysfunction.

Literature Review

Doherty et al studied the new dimension to the epidemiology of gout. He

reported that the gout is due to the crystal deposition of monosodium urate in

joints and other tissues, gout results from the interaction of genetic,

constitutional and environmental risk factors. The diagnosis of gout is primarily

through the degree of elevation of uric acid. 16

1. New insights into the epidemiology of gout.

Doherty M.

Academic Rheumatology, Clinical Sciences Building, City Hospital, Nottingham

NG5 1PB, UK. michael.doherty@nottingham.ac.uk

Gout is a true crystal deposition disease caused by formation of monosodium urate

crystals in joints and other tissues. It is a common inflammatory arthritis that has

increased in prevalence in recent decades. Gout normally results from the interaction

of genetic, constitutional and environmental risk factors. It is more common in men

and strongly age related. A major determinant is the degree of elevation of uric acid

levels above the saturation point for urate crystal formation, principally caused by

inefficient renal urate excretion. Local joint tissue factors may influence the

topography and extent of crystal deposition. Recent studies have provided information
on dietary risk factors for gout: higher intakes of red meat, fructose and beer are

independently associated with increased risk, whereas higher intakes of coffee, low-

fat dairy products and vitamin C are associated with lower risk. Several renal urate

transporters have been identified including URAT1 and SLC2A9 (GLUT9) and

polymorphisms in these genes are associated with an increased risk of hyperuricaemia

and gout. Many drugs influence serum uric acid levels through an effect on renal urate

transport. Comorbidities, including the metabolic syndrome and impaired renal

function are common in gout patients. The usual initial presentation of gout is with

rapidly developing acute inflammatory monoarthritis, typically affecting the first

MTP joint. If left untreated it may progress with recurrent acute attacks and eventual

development of chronic symptoms and joint damage. New knowledge of the

modifiable risk factors for gout can be integrated into the management strategy to

optimize long-term patient outcomes.

2. Observation on therapeutic effect of electroacupuncture plus blood-letting

puncture and cupping combined with diet intervention for treatment of acute

gouty arthritis

[Article in Chinese]

Zhao QW, Liu J, Qu XD, Li W, Wang S, Gao Y, Zhu LW.

Department of Nutrition, Longnan Hospital, Daqing Oilfield General Hospital Group

in Daqing City of Heilongjiang Province, Daqing 163453, China. zqw420@tom.com

OBJECTIVE: To explore a more effective therapy for acute gouty arthritis.

METHODS: Sixty cases were randomly divided into an observation group and a

control group, 30 cases in eachgroup. On the basis of diet intervention, the

observation group was treated with electroacupuncture at local points combined with

blood-letting puncture and cupping, and the control group with oral administration of

Probenecid. Their therapeutic effects were ob served. RESULTS: The effective rate

was 96.7% in the observation group which was better than 86.7% in the control group

(P < 0.01). After treatment, blood uric acid decreased significantly in the two groups

(both P < 0.01), the observed group being lower than the control group (P < 0.01).

CONCLUSION: On the basis of diet intervention, electroacupuncture plus blood-

letting puncture and cupping is a better therapy for acute gouty arthritis.

3. Gout in the elderly--a population health study.

Hanly JG, Skedgel C, Sketris I, Cooke C, Linehan T, Thompson K, van Zanten SV.

Division of Rheumatology, Department of Medicine, Queen Elizabeth II Health

Sciences Centre, College of Pharmacy, Dalhousie University, Halifax, Nova Scotia

B3H 4K4, Canada. john.hanly@cdha.nshealth.ca

OBJECTIVE: To determine the incidence, healthcare utilization, and costs in older

adults with gout. METHODS: A 5-year retrospective case-control study of patients

with incident gout and matched controls was performed. Study variables were derived

from health administrative data and included patient demographics, International

Classification of Diseases diagnostic codes, and healthcare cost information.

RESULTS: There were 4,071 cases and 16,281 controls, providing a 5-year incidence

of gout of 4.4%. The mean (+/-SD) age (77+/-7.3 and 76+/-7.1 yrs) and the

male:female ratio (1.0:1.04) were similar in both groups. Gout was diagnosed by

family physicians (77%), nonrheumatology subspecialists (18%), general internists

(4%), and rheumatologists (0.02%). Hospitalizations were significantly higher in

cases (p<0.001) in the year of diagnosis. Patients with gout had an average of 28.1

physician visits per year compared to 20.6 for controls (p<0.0001). Drug utilization

for the treatment (nonsteroidal antiinflammatory drugs, colchicine, corticosteroids)

and prevention (allopurinol, probenecid, sulfinpyrazone) of gout was significantly

higher (p<0.0001). The average healthcare cost differential was +$134 (Cdn) per

month (p<0.001) and +$8,020 per case over 5 years. These costs were due to hospital

utilization (64.4%), medications (23.1%), and physician visits (12.5%).

CONCLUSION: Gout is associated with a high disease burden in older men and

women. The cost is primarily attributable to hospitalization, probably due to the

comorbidities associated with gout. As the majority of cases are managed by

nonrheumatologists, it is important that guidelines for the diagnosis and treatment of

gout are disseminated to and met by all physician groups.

4.The practical management of gout.

Schumacher HR Jr, Chen LX.

University of Pennsylvania, Philadelphia, PA, USA. schumacr@mail.med.upenn.edu

Gout management requires a comprehensive strategy that considers both acute and

chronic aspects of the disease. Acute gout flares should be treated with anti-

inflammatory agents as rapidly as possible. The underlying hyperuricemia may be

treated with urate-lowering agents initiated at a time appropriate for the individual

patient. Successful urate lowering ultimately prevents flares and disease progression

and should be started immediately in patients with advanced or tophaceous disease.

When urate-lowering therapy is initiated, anti-inflammatory prophylaxis should be

used to reduce the risk of flares induced by abrupt changes in urate levels. Regular

monitoring of serum urate can ensure therapeutic dosing of urate-lowering agents to

achieve levels below 6 mg/dL, which are associated with a reduction in flares and

tophi.

5.Pain management in gout.

Kirby BS, McTigue JC, Edwards NL.

Edwards@medicine.ufl.edu

Gout is currently the most common form of inflammatory arthritis in men. The overall

incidence of gout has increased rapidly in the past 20 years. Clinicians in all fields are

likely to experience a patient with acute gout in their career. Uncontrolled gout and

hyperuricemia can lead to joint destruction and significant morbidity. Fortunately,

these diseases can be readily treated and long-term sequelae can be prevented. Recent

advances in understanding the role of the innate immune system in acute gout have

provided new treatment options. This article addresses the epidemiology,

inflammatory pathophysiology, pain management techniques (including recent

advances), and treatment of the underlying disease itself.

6.Gout--current diagnosis and treatment.

Tausche AK, Jansen TL, Schröder HE, Bornstein SR, Aringer M, Müller-Ladner U.

Bereich Rheumatologie, Medizinische Klinik und Poliklinik III, Universitätsklinikum,

Carl Gustav Carus an der TU Dresden, Dresden, Germany. anne-

kathrin.tausche@uniklinikum-dresden.de

BACKGROUND: Because of the changing dietary habits of an aging population,

hyperuricemia is frequently found in combination with other metabolic disorders.

Longstanding elevation of the serum uric acid level can lead to the deposition of

monosodium urate crystals, causing gout (arthritis, urate nephropathy, tophi). In

Germany, the prevalence of gouty arthritis is estimated at 1.4%, higher than that of

rheumatoid arthritis. There are no German guidelines to date for the treatment of gout.

Its current treatment is based largely on expert opinion. METHODS: Selective

literature review on the diagnosis and treatment of gout. RESULTS AND

CONCLUSIONS: Asymptomatic hyperuricemia is generally not an indication for

pharmacological intervention to lower the uric acid level. When gout is clinically

manifest, however, acute treatment of gouty arthritis should be followed by

determination of the cause of hyperuricemia, and long-term treatment to lower the

uric acid level is usually necessary. The goal of treatment is to diminish the body's

stores of uric acid crystal deposits (the intrinsic uric acid pool) and thereby to prevent
the inflammatory processes that they cause, which lead to structural alterations. In the

long term, serum uric acid levels should be kept below 360 micromol/L (6 mg/dL).

The available medications for this purpose are allopurinol and various uricosuric

agents, e.g., benzbromarone. There is good evidence to support the treatment of gouty

attacks by the timely, short-term use of non-steroidal anti-inflammatory drugs

(NSAID), colchicine, and glucocorticosteroids.

7.We can make gout management more successful now.

Becker MA, Chohan S.

Rheumatology Section, Department of Medicine, University of Chicago Pritzker

School of Medicine, 5841 South Maryland Avenue, Chicago, IL 60637, USA.

mbecker@medicine.bsd.uchicago.edu

PURPOSE OF REVIEW: The purpose of this editorial review is to identify and

comment on factors contributing to the current less-than-optimal state of gout

management and to emphasize immediate opportunities to improve management

practices affecting many patients with gout. RECENT FINDINGS: Numerous

publications document deficits in the current management and clinical outcomes of

gout despite detailed understanding of the pathogenesis and pathophysiology of the

disorder, the ability to establish the diagnosis with certainty, and the likely
effectiveness, for most patients, of available lifestyle and pharmacological

interventions. Among impediments to successful gout management are diagnostic

inaccuracy; a paucity of validated management recommendations to guide care

providers; incomplete patient education about gout and the aims and modalities of

management; suboptimal patient adherence, even to demonstrably effective

therapeutic recommendations; comorbidities and drug interferences that complicate

treatment of gout; patient groups at special risk for progression to chronic tophaceous

gout; and limited urate-lowering alternatives. SUMMARY: Recent publication of

evidence-based recommendations for the diagnosis and management of gout and the

impending availability of new urate-lowering agents suggest that this is an opportune

time to initiate professional and patient education efforts toward improved

management of this increasingly common disorder.

8.Lifestyle and gout.

Hak AE, Choi HK.

Departments of Internal Medicine and Rheumatology, Erasmus MC University

Medical Center, Rotterdam, The Netherlands.

PURPOSE OF REVIEW: This review summarizes recent epidemiologic research

findings on gout, and attempts to put them into the context of clinical and public

health decision-making aimed at prevention and improved management of gout.

RECENT FINDINGS: A large prospective study found that coffee consumption was

inversely associated with risk of gout and that consumption of sugar-sweetened soft
drinks or fructose was strongly associated with an increased gout risk. Studies based

on the Third National Health and Nutrition Examination Survey (NHANES III)

suggest that these consumptions affect serum uric acid levels parallel to the direction

of gout risk. Furthermore, data from NHANES III show a remarkably high prevalence

of the metabolic syndrome among individuals with gout. Prospective studies found an

increased risk of myocardial infarction and cardiovascular mortality in gout patients.

SUMMARY: Lifestyle and dietary recommendations for gout patients should

consider other health benefits, since gout is often associated with major chronic

disorders such as the metabolic syndrome and an increased risk for cardiovascular

disease and mortality. In addition to recent dietary recommendations, gout patients

should be advised to limit fructose intake. The inverse link between coffee and the

risk of gout suggests that coffee could be allowed among gout patients.

9. Overview of the management of acute gout and the role of adrenocorticotropic

hormone.

Schlesinger N.

Department of Medicine, UMDNJ-Robert Wood Johnson Medical School, New

Brunswick, New Jersey 08903-0019, USA. schlesna@umdnj.edu

It is important to distinguish between therapy used to reduce acute inflammation in

gout and therapy used to manage hyperuricaemia in patients with chronic gouty

arthritis. This article discusses treatments for acute gout, emphasizing the use of

corticotrophin (adrenocorticotropic hormone; ACTH) and the evidence on which we

base our treatment of acute gout. There are no formal guidelines for the treatment of

acute gout and only a few randomized controlled trials have been conducted to

evaluate the efficacy of the various treatments for acute gout. The options available

for the treatment of acute attacks of gout are NSAIDs, colchicine, corticosteroids,

corticotropin and intra-articular corticosteroids. Most rheumatologists practicing in

the US use combination therapy to treat acute gout, a practice that merits study. In a

patient without complications, NSAIDs are the preferred therapy. The most important

determinant of therapeutic success is not which NSAID is chosen, but rather how

soon NSAID therapy is initiated. Exciting new research shows that corticotropin acts

peripherally by activation of the melanocortin type 3 receptor, and this could be

responsible, at least in part, for its efficacy in acute gout. Hopefully, this will lead to

renewed interest in corticotropin as a treatment for acute gout.