VATARAKTA : GOUT

WHAT IS GOUT?

Gout is a true crystal deposition disease. It can be defined as the pathological reaction of the joint or peri articular tissues to the presence of mono sodium urate monohydrate (MSUM) crystals. MSUM crystals preferentially deposit in peripheral connective tissues in and around synovial joints, initially favoring lower rather than upper limbs and especially targeting the first metatarsophalangeal and small joints of feet and hands. As the crystal deposits slowly increase and enlarge there is progressive involvement of more proximal sites and the potential for cartilage and bone damage, and development of secondary OA. MSUM crystals takes months or years to grow to a detectable size, implying a long asymptomatic phase. Prolonged hyperuricaemia is necessary, but not sufficient for development of gout. This is one of most common rheumatic disease of adulthood. A metabolic disease characterized by recurrent attack of acute inflammatory arthritis caused by elevated levels of uric acid in the blood (hyperuricemia). Swelling of I^st Metatarsophalengeal joint initially followed by other joints with an abnormal elevation of urate level in the body either due to over production or under excretion. Gout usually affects one joint in the beginning (monoarticular), usually the big toe. Epidemiology

The prevalence of gout varies between populations but is around 1% with a strong male predominance (>10:1). Prevalence increases with age and increasing serum uric acid concentration. “Primary” gout is almost exclusively a male disease and the most common cause of arthritis in men over the age of 40. ‘Secondary gout’, due to renal impairment or drug therapy, mainly affects people over the age of 65 and is the form usually seen in women.

Aetiology

Primary Gout

About one-third of the body uric acid pool is derived from dietary sources and two-thirds from endogeneous purine metabolism. The concentration of uric acid depends on the balance between its synthesis and its elimination via the kidneys (two-thirds) and gut (one-third). Purine nucleotide synthesis and degradation are regulated by a network of enzyme pathways; xanthine oxidase catalyses the end conversion of hypoxanthine to xanthine and then xanthine to uric acid.

The normal range of uric acid in blood:

• 4 to 7 mg/dL for men and
• 4 to 6 mg/dL for women

Predisposing factors for high uric acid and gout

• High Purine Diet
• Genetics
• Obesity
• Stress
• Certain metabolic disorders
• Trauma to the joint
• Surgery
• Exposure to cold
• Injection of Foreign Protein
• Excessive use of Alcohol Ø Drugs
• Acute Infection
• Sometimes it is associated with changes in the atomospheric pressure. Ø
• Chemicals like Urografin, Allopurinol, Urocosuric drugs etc. Ø
• Diuretics
• High Protein Diet
• Renal insufficiency
• Underactive thyroid
• Endocrine or metabolic conditions like diabetes or acidosis
• Certain cancers, chemotherapy agents, and cancer medications
• Excessive exercising
• Fasting and crash dieting may elevate uric acid levels temporarily

 

AYURVEDIC CONCEPT OF GOUT: VATARAKTA

According to Ayurveda, gout can be correlated to Vatarakta. Vatarakta also called as vata shonita is one of the important disease adequately described in the Ayurvedic classical literature. It is a disease having sandhi sula (joint pain) as one of the important symptom. The disease is caused by excessively aggravated Vata and rakta (blood). Hence this disease is called Vatarakta. Vatarakta is also known as- Khuda roga, Vata–balasa, Vatasruk and Adhyavata. To be more specific, the obstruction of raktamarga or raktavaha srotas is the leading pathology. In the literature it is emphasized that the etiological factors leads to the predominant morbidity of vata dosa and rakta dhatu and hence the name Vatarakta. Vatarakta comes under the domain of Vatavyadi and mostly affecting the extremities. The umbrella of Vatarakta in parlance with conventional medicine includes many conditions related to extremities and to mention a few are connective tissue disorders as well as peripheral vascular disorders.

Nidana / Causes

The causative factors said by various Acharya’s may be divided into three categories as (A) The factors aggravating the Vatarakta (B) The factors vitiating the Rakta (C) The factors aggravating the Vata

The factors which aggravate the Vatarakta

• Excessive intake of sweet food
• Sedentary habits and Leisurely eating
• Unwholesome diets and activities
• Deteriorated diseases
• Long walking
• Excessive sexual activities, physical exercise
• Obesity
• Day time sleep and remaining awake at night
• Intake of food before the previous meal is digested
• Excessive intake of radish, Horsegram, urad dal, leafy vegetables, meat and sugarcane
• Excessive intake of sesamun indicum cake preparation
• Intake of mutually contradictory- incompatible foods

The Factors Vitiates the Rakta

• Trauma
• Omission of the purification of the body. i.e. omission of the use of elimination therapies which are supposed to be done in routine during different seasons
• Partaking of foods which cause burning sensation during digestion which are incompatible

The Factors Aggravates the Vata

• Excessive intake of astringent, pungent, bitter and unctuous ingredients
• Intake of less food

SAMPRAPTI/ ETIOPATHOGENESIS

Due to the aforesaid causative factors, both vata and rakta gets aggravated and both these doshas start circulating in the body through the medium of blood vessels and after sometime the localization takes place in the big toe of the feet or the thumb of the hands. Vata Rakta usually starts from the big toe and gradually involves other joints or tissues

TYPES

It has been divided into two major types

Uttana Vatarakta (superficial type)

Gambhira Vatarakta (deep seated type)

 

Similarly according to the predominance of Dosha

• Rakta predominant
• Kapha predominant
• Pitta predominant
• Vata predominant

Progression of Vatarakta

Vatarakta disease process initiates from feet ie. padamuli (root of feet) and sometimes from karamula (root of hand) and like mushika visha ie rat poison it gradually spreads throughout the body.

Purvarupa(prodromal symptoms)

• Excess or loss of perspiration
• Hyper pigmentation of skin
• Anaesthesia
• Exaggerated pain on injury
• Loosening of joints
• Lethargy
• Boils and carbuncles
• Hyperesthesia
• Joint pain
• Discoloration of skin and blisters

SIGNS & SYMPTOMS

Uttana Vatarakta

• Itching
• Burning sensation
• Ache
• Extension
• Pricking pain
• Throbbing sensation and contraction
• Skin becomes brownish black, red or coppery in colour
• Burning penetrating sensation like mustard oil

 

Gambhira Vatarakta

• Hard inflammation with stiffness
• Severe pain with swelling
• Black or copper colour skin
• Piercing pain and suppuration inside the edema
• Burning and pulsation in the affected parts
• More prominent in the bones, nerves, muscles and bone marrows produces cutting pain, make the joints curved inwards & when this aggravated Vayu moves to all over the body, results the person lame & paraplegic.

Edema and bone changes in Vatarakta

COMPLICATIONS OF VATARAKTA

• Anidra
• Arochaka
• Swasa
• Mamsakotha
• Shirograha
• Murcha
• Mada-vedna-trishna-jwara-moha
• Hikka-pangulya-vishrpa-bhrama-klama
• Daha-marmagrha-Arbuda

GOUT : COMPLICATIONS

• Joint deformity
• Osteoarthritis
• Tophi may produce draining sinuses that may become infected
• Renal stones, pyelonephritis, obstructive renal disease

TREATMENT

• In Uttana Vatarakta (superficial), alepa (topical application), abhyanga (massage), parisheka and upanaha (poultice)
• In Gambhira Vatarakta (deep seated) virechana (medicated purgation), niruha basti (decoction enema) and snehapana (intake of unctuous substances)
• Vata dominant type : ghee, oils, vasa (animal fat) and majja (bone marrow) should be used for paniya (oral drinks), abhyanga (massage), anuvasana basti (medicated enema) and lukewarm poultice
• Rakta and Pitta type: virechana (medicated purgation), ghrutapana, ksheerapana (medicated ghees and milk), parisheka (pouring of medicated liquid) and anuvasana basti (medicated enema), sheetala and daha shamaka pralepa (cold and pacifying topical pastes)
• Kapha type : mrudu vamana (mild emesis), sneha, parisheka (pouring of medicated liquid) and langhana (emaciating therapy)

 

Bahiparimarjana : External therapy

Lepa : external application of medicated pastes. Eg. fried sesame powder combined with cow’s milk as a lepa(topical application), Shatadoutha ghrita (clarified ghee)

Seka: steam pouring of medicated liquids like decoction, oils, milk over afflicted areas

Sneha: internally medicated ghee. Eg– Guduchi ghruta, externally abhyanga (herbal oil massage)eg. Jivaneeya ghruta, Pinda taila, Guduchyadi taila, Mahapadmaka taila

Upanaha: medicated poultice

Anataparimarjana: Internal therapy

Sodhana : purificatory procedures

Raktamokshana – since the spread of disease takes place through vitiated blood, blood letting is a must. Depending upon the type of disease and strength of the patient, blood letting should be carried out by

• Venesection (siravyadha) : if the disease is spreading rapidly
• Leech application (jaluka): if there is burning sensation

 Vasti – kashaya vasti (decoction enema) with Dashamula kashaya or with Padmadigana kashaya are indicated when there is pain. Ksheera vasti with ghee gives good results. It is always advisable to administer kashaya vasti and sneha vastis alternately.

 

Shamana: Shamana drugs (pacifying therapy)

• Mahamanjishtadi kwatha : 20 to 30 ml twice daily
• Kaishordi guggulu: 500 mg twice a day
• Patoladi kwatha: 20 to 30 ml twice daily
• Hareethaki kwatha : 20 to 30 ml twice daily
• Amruthadi guggulu: 500 mg twice a day
• Nimbadi churna : 1 teaspoon thrice a day
• Haritaki churna 3g and jiggery 3g should be mixed and taken internally twice a day
• Suddha silajatu 500 g twice a day with Guduchi kwatha
• Guduchi swarsa
• Guduchi kalka
• Guduchi kwatha

SINGLE HERBS

Herbomineral preparations

Rasamanikya

Sarveshvara rasa

Rasabhra guggulu

Araogyavardhini vati

 

Dietics (pathya &apathya)

PATHYA Dos

• Old rice, barley, wheat, green gram, masur dal (lentils), bitter gourd, bottle gourd, Indian gooseberry, dry grapes, butter, ghee, milk of cow, goat.
• Whole grains legumes, Fruits that are low in fructose .ex- Apricot, muskmelon, Raspberry, strawberries, blackberry, blueberry, grapefruit, pineapple, orange, plum, peach, as well as cherries.
• Dairy products, Eggs, Beverages:Coffee, tea, and green tea.
• Herbs and spices:All herbs and spices.
• Plant-based oils:Including canola, coconut, olive, and flax oils
• Excess stress increases uric acid levels in the blood. Practicing mindful techniques, yoga, breathing exercise helps keep you calm.

APATHYA – Donts

• Urad dal, horsegram, sesame, curd, sour, salt, pungent, alkaline and hot potency foods and those causing burning sensation, alcohol, smoking
• Most fishes like Herring, trout, mackerel, tuna, sardines, as well as anchovies and haddock.
• Seafood:Scallops, crab, shrimp, and roe
• Cereals: Maida / refined flour and its products like cakes, bread, pastries, biscuits, and cookies.
• High fructose fruits like kiwi, raisin, banana, grapes, mango, watermelon, apple, prunes, pear, dried dates, and dried figs.
• Vegetables– Asparagus, Spinach, Mushrooms, broccoli, etc. They need not be completely eliminated, but use in restriction.
• Sugary beverages:Avoid fruit juices as fructose can increase the risk of developing gout.
• Natural Sweetners :Honey, agave nectar, and corn syrup
• Yeasts: Nutritional yeast, brewer’s yeast, and other yeast supplements.

Editor: Dr. Anu PK

Email: editor@ayurvedam4you.webc.in