Uric Acid and Gout – Now Undertreated
Update on Gout
Gout, the most common inflammatory arthritis worldwide, is treatable but vastly undertreated, according to epidemiologic studies that now encompass three continents. The under treatment problems previously reported in the United Kingdom and the United States also characterize gout in Taiwan, according to a nationwide population study.
Chang-Fu Kuo, MD, from the Division of Rheumatology, Orthopaedics and Dermatology, School of Medicine, University of Nottingham, United Kingdom, and the Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan, and colleagues report the study results in an article published online in Arthritis Research & Therapy. Dr Kuo was also the lead author on the UK study.
Jasvinder A. Singh, MD, MPH, who led the US study told Medscape Medical News, “The rates of undertreatment of gout in the US are also quite high. . . Undertreatment includes not only lower rate of use of urate-lowering drugs but also infrequent monitoring of the serum urate and a low proportion reaching the target serum urate of less than 6 mg/dL due to use of suboptimal dose of urate-lowering drugs.” Dr Singh is professor of medicine at the University of Alabama, Birmingham.
Majid Ali, M.D.
Acthar Gel is a drug used to control gout arthritis at the cost of $28,000 for a 5-milliter vial. Its efficacy for that disease has not been validated. The other drugs used for the disease (allopurinol, probenecid, and colchicine) cost less than one-thousandth of the cost of the Acthar. I designate this knowledge as belonging to the domains of disease-literacy and drug-literacy. There is another path to understanding, controlling, and preventing gout which I call healing-literacy.
Uric Acid and Gout
Recently, a colleague told me that her mother in India saw an orthopedic surgeon for chronic arthritis pain in her knees and hips. The doctor noted an elevated blood uric acid value and promptly prescribed five drugs, including a high-dose steroid level. When my colleague protested that her mother did not have gout but osteoarthritis, the orthopedist shrugged her off by saying, “This is our standard treatment for treating high uric acid levels.”
I asked fifteen practitioners (five physicians, one nurse, one physician assistant, two nutrition advisors, four laboratory technologists, and two administrative staff members) to answer the following two questions:
► What is your general sense about vitamin C, is it a good player or a bad player?
► What is your general sense about uric acid, is it a good player or a bad player?
Thirteen called vitamin C a good player and considered uric acid to be a bad player. The remaining two said uric acid could go either way. That did not surprise me since uric acid is embedded deep in drug medicine thinking as a villain. A raised blood uric acid level is used to diagnose gout arthritis, as well as to detect an increased risk of heart attacks and strokes. This is what medical textbooks teach medical students and doctors. Next, I wondered what the oxygen prism and Darwin might have to say about uric acid.
Killing the Messenger
Uric acid is a marker of tissue injury. Rising blood levels herald pathologic inflammation that causes cell death. When I see elevated blood uric acid level in my patients’ lab reports, I see it as injured cells’ call for relief. To me this the lab abnormality requires diligent efforts to detect and eliminate all relevant insults to the body. I do not see uric acid as an evil player that must be snuffed with drugs.
Uric Acid Is a Potent Antioxidant
Over half the antioxidant capacity of human blood plasma is derived from uric acid. It is a fifty-fold stronger antioxidant than vitamin C. So, if we consider vitamin C to be a good player, we must consider uric acid as fifty times as good. Why is this fact not generally known? The answer: no drug company or medical journal profits from disseminating this information.
Uric acid has been successfully employed in the prevention and treatment of an animal model of multiple sclerosis. A 2006 study found that oral use of inosine raised serum uric acid values in patients with this disease, without causing any adverse effects. It does not surprise me that this nutritional possibility for multiple sclerosis was not explored further since no one can make obscene profits from it.
Uric Acid Is An Immune Booster
This is likely to surprise nearly all readers. I myself never considered uric acid biology in a broader context during the first twenty-five years of my work as a surgeon and pathologist. This is a gift of understanding from my patients. They forced me to think differently when I recognized how they responded to overhydration and nondrug therapies (listed below) that normalize the inflammatory response by focusing on ecologic disruptions of the bowel, blood, and liver ecosystems.
Uric Acid Facilitates Cross-talk Between Dead and Living cells
Uric acid is a principal endogenous danger signal released from dead and dying cells. This basic but generally unrecognized fact of uric acid biology calls for a major shift in the way we look at it. Uric acid stimulates a type of immune cell (dendritic cell) to its maturation. When such cells are injected along with certain substances in experimental animals, another type of immune cell (CD8+ T cell) becomes stronger in its responses to microbes and noxious chemicals. In other experiments, removal of uric acid weakens certain types of immune responses, indicating immune- boosting effects of uric acid.
Why do blood uric acid levels rise?
What might be the basis of observed association between raised uric acid levels and increased risks of insulin resistance, diabetes, heart attacks, and strokes?
Uric acid is produced by the enzyme, xanthine oxidase, from xanthine and hypoxanthine, which in turn are produced from purine. Evolutionary design for the redox systems in living organisms is simple: if you increase oxidative stress, the antioxidant systems are upregulated. When the body is insulted by the trio of toxicities of foods, environments, and thoughts—the trio that sets the stage for insulin toxicity, the so-called metabolic syndrome, heart attacks, strokes, and gouty arthritis—the body gears up its antioxidant defenses. Uric acid, a potent weapon in the body’s antioxidant armamentarium, is produced in excess to cope with incremental oxidative stress. So, the blood uric acid levels go up. It is not the body’s cries for drugs, only for relief from the trio of toxicities.
Prevention and Treatment of Gout
Inflammation in acute gout arthritis is caused by the trio of toxicities of foods, environments, and thoughts. The rational and scientific approach to the prevention and treatment of gout is to systematically identify and address all relevant elements of toxicity. In decades of clinical work, I have not found any natural remedy that by itself gives good long-term results.
My preferred therapies are:
(2) hydrogen peroxide foot soaks;
(3) optimal hydration;
(4) control of gut fermentation and leaky gut state;
(5) and liver detox.
Some dietary measures are very helpful. Uric acid is derived from compounds called purines, which are found in large amounts in animal food products, such as liver, kidneys, and sardines. Lesser amounts are in pork, beef, poultry, seafood, and certain vegetables (asparagus, cauliflower, spinach, mushrooms, and green peas), and certain grains (oatmeal, wheat bran and wheat germ). So, it is advisable to eliminate these items during acute attacks, and reduce their intake in general.
In drug medicine, symptoms are managed with nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, and colchicine. These approaches can be justified only in unusual circumstances for short periods of time to relieve acute symptoms that cannot be rapidly controlled with nondrug therapies.
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