Gout is an inflammatory joint condition caused by the build-up of uric acid, a by-product of purine metabolism. 

Purines are found in animal protein, alcohol and from fructose metabolism, therefore reducing or avoiding high-purine foods is an important treatment aim in gout. Insulin resistance and metabolic syndrome reduce uric acid excretion in the kidneys and in turn elevated uric acid is known to potentiate hyperinsulinemia.

Treating the associated metabolic imbalances are equally important for this reason, therefore both uric acid clearance and insulin sensitisation were also primary targets for treatment in the following case.

Initial Consultation

A 34-year old male presented with a 12-year history of gout; affecting his elbows, knees, ankles, fingers and wrists. The right elbow was visibly inflamed appearing significantly larger than the left. He rated the pain as 10/10 and was managing this with diclofenac. The patient reported feeling fatigued, rating his energy as 4/10 and revealed he also had a low libido 2-3/10.

Current medications:

• Diclofenac 12.5 mg. Dose: 5-6 times daily for the last 8 years.
• Diazepam 5mg. Dose: 1-2 times daily.

Additional symptoms:

• Inconsistent bowel movements – either mushy or constipated, malodorous flatulence, abdominal pain if diclofenac was taken on an empty stomach
• High stress 7-8/10
• Cravings for salty foods
• Cramps in hands and legs
• Muscle fatigue when walking up stairs
• A family history of diabetes
• Overweight
• Diet comprised of soft drink, fruit juice and takeaway foods, but also included a fresh green juice in lieu of breakfast.

Initial Treatment Plan

Initial treatment was aimed at providing symptom relief; reducing inflammation and swelling, improving uric acid clearance and replenishing depleted nutrients.

The patient was also referred to his GP for blood work.

Prescription:

• Herbal liquid formula containing: Clivers (Galium aparine), juniper (Juniperus communis), dandelion root (Taraxicum officinale), devil’s claw (Harpagophytum spp.), ginger (Zingiber officinale). Dose: 7.5 mL twice daily
• A herbal tablet containing boswellia (Boswellia serrrata) 1.9 g, turmeric (Curcuma longa) 2.0 g, celery (Apium graveolens) 1.0 g and ginger (Zingiber officinale) 300 mg. Dose: 1 tablet three times daily
• Herbal and nutritional tablet containing grape seed (Vitis vinifera) 4.8 g, ginger (Zingiber officinale) 150 mg, bromelains 100 mg, ascorbic acid 25 mg and quercetin 250 mg. Dose: 2 tablets twice daily
• A nutritional powder containing 310 mg magnesium with B vitamins and cofactors for cardiovascular, muscular and mitochondrial health. Dose: 1 teaspoon twice daily away from meals
• Vitamin C (patient’s own) to be taken once daily until dosage is ascertained

Dietary recommendations included:

• Avoid high purine foods including red meat, oily fish, fruit juice and soft drinks
• Drink more water – aim for 2-3 L daily
• Bring leftovers for lunch to avoid eating takeaway
• 30 minutes of cardio exercise 3 times weekly

2-Week Follow-Up

The patient reported a significant reduction in pain to 3-4/10 thus reducing his diclofenac to once weekly (after a diet-induced flare-up). The swelling in his right hand had reduced, however his elbow remained the same. He had ceased taking diazepam. Energy had improved to 6/10 and his bowel movements had normalised, currently twice daily and formed. He was still experiencing muscle fatigue. Takeaway food and fruit juice had been cut back. Noted no change to water consumption and had not added any exercise to his schedule.

Blood tests revealed:

• Zinc: 10 µmol/L (10-25)
• Copper: 23 µmol/L (10-30)
• Glucose: 4.7 fasting (3.0-6.0), insulin 20 fasting (<25), HbA1c 5.8% (<6.1% excludes diabetes)
• LDL: 3.97 mmol/L (<2.0), HDL 0.88 mmol/L (>0.9)
• Cortisol: 160 nmol/L (190-610) 9:45 AM
• Uric acid: 0.65 mmol/L (0.12-0.45)
• TSH: 6 mU/L (0.4-4.0)
• Testosterone: 9 nmol/L (10-33)
• 25-OH vitamin D: 45 nmol/L (50-300)

Prescription:

His previous prescription was continued. Added support for blood glucose control, thyroid health and to replenish vitamin D levels:

• Herbal and nutritional tablet for balancing blood sugar containing gymnema (Gymnema sylvestre) 3.2 g, chromium 225 mcg, zinc 15 mg, vitamin B3 (as nicotinamide and nicotinic acid) plus cofactors. Dose: 1 tablet 3 three times daily with meals
• A herbal tablet containing bladderwrack (Fucus vesiculosus) 437.5 mg, bacopa (Bacopa monnieri) 1.0 g and withania (Withania somnifera) 600 mg. Dose: 1 tablet twice daily
• Vitamin D3 1000 IU. Dose: 1 capsule twice daily

Dietary recommendations:

• Add a protein and berry smoothie for breakfast
• Take a salad with protein for lunch
• Include almonds, brazil nuts, pepitas and sunflower seeds for mineral replenishment 

4-Week Follow-Up

The patient reported feeling a significant improvement in his energy levels within a week of starting the new supplements. He now reported his energy as 8/10 and to be bouncing out of bed in the morning. His joint pain was ‘amazing’ only using one diclofenac tablet since his last visit; however, swelling had not reduced. He was no longer experiencing any muscle fatigue. 

Prescription:

The previous prescription was continued with the addition of:

• Sarsparilla (Smilax spp) to his herbal formula to support his libido and for its depurative action.
• A herbal and nutritional tablet containing Withania (Withania somnifera), Siberian ginseng (Eleutherococcus senticosus), licorice (Glycyrrhiza glabra), rhodiola (Rhodiola rosea), Korean ginseng (Panax ginseng) and tyrosine. Dose: 1 tablet twice daily with breakfast and lunch, to support adrenal and thyroid health and for stress adaptation. 

Summary

Unfortunately, the patient did not return after his third consultation, so his progress beyond this point is unknown. Nevertheless, this case provided a clear example of the powerful impact herbal and nutritional medicine has on both symptom reduction and on balancing underlying metabolic disturbances in patients with gout. This patient’s health issues spanned multiple organ systems and although complex, he responded incredibly well to a relatively straightforward treatment plan in a short time period – a satisfying result for patient and practitioner alike.