KAUTI/GOUT PART 2

HOW DO I KNOW IF I HAVE GOUT?

“Ko e kauti ena!” or “Na’e pehena pe kamata e langa hoku kauti!”  These are normally the diagnostic remarks that we Tongans give when someone starts complaining of pain in the foot, or when we see someone limping!  There’s an inner diagnostician/clinician in everyone but it seems more pronounce in our Tongan community. 

If you grew up in Tonga, or spent some time there as a child, or even have your grandmas or aunts live by you here in the states, then you know exactly what I’m talking about.  “Ko e pala ena ia!”  “Ai o fk-inu ha’a ne vaipala”  “Omai keu mili’I pe tolotolo’I ‘aki ha me’I lolo”.   “Mahalo na’e taa’I ena ha tevolo koe lahi ho’o mou vainga mo halaloto’api he mala’e!” (Yes we are very superstitious too!).

If you have never drink ‘vaipala’ before, consider yourself one lucky SOP (son of privilege)!  That stuff is straight up nasty!  If you don’t know what ‘vaipala’ is, don’t ask your mom, aunt, or grandma…it might give them ideas.  Ok ok…I’ll stay focused and get back to the topic in discussionJ.

Gout is almost always acute…meaning that it comes on suddenly.  We often hear “Ko ‘ene ‘aa hake he pongipongi, ikai lava o tu’u he langa e va’e”.  That’s the most practical Tongan definition of acute.  It often happens without warning at night and it is painful…at least that’s what patients say…don’t accuse me of having gout…and even if I do, I will never admit to it…mhk! 

Within the first 12-24 hours, the pain is intense and most severe.  When a patient is asked to describe the pain, they often use words like “sharp”, “poking”, “stabbing”, and other related adjectives.  As mentioned on the first part, it almost always first appears on the large joint of the big toe.  Medically, this joint is called the first MTPJ (metatarsal phalange) joint.  The pain may last from a few days to a few weeks.  We often hear “Kuo toe kovi aupito hono kauti ona he taimi ni.  Koe kamakamata na’e aho pe fia pea sai.  Taimi ni ia, oku laulau aho ia”.  Recurrent gouty attacks will last longer than before and it happens more often.  This is called CHRONIC gout attack.

The affected area are normally swollen (ki’I fufula), red (kulokula), and tender (mohomoho…I think that’s the right word!).

If you find all of the bold and yellow words and phrases next time your husband, boyfriend (in which case you should turn and run the opposite direction….koe loi pe ia…haha), dad, or brother complains of pain in their foot, you can with confident diagnose them with gouty arthritis/kauti.  Too bad, we can’t prescribe ‘vaipala’ for it!  (At least I am not aware of…lol)

TREATMENTS

Shortly after I posted on facebook that I started a medical information blog for my fellow Tongans, one of my FB friends, Lani Saia Moleni posted “Koe kauti koe folo’I pe fo’I’akau pe a lava ai pe.”  There’s some truth and some dangers to this notion.  There are pills (fo’I’akau) for gout out there.  Here’s a list:

·       Allopurinol (Zyloprim)

·       Anturane (Sulfinpyrazone)

·       ColBenemid (Proben-C)

·       Colchicine

·       Fenofibrate (Tricor)

·       Losartan (Cozaar, Hyzaar)

·       Corticosteroids

·       Probenecid (Benemid)

·       Uloric (Febuxostat)- experimental

This is the point of the reading where you go get your dad’s, brother’s, husband’s, grandpa’s, boyfriend’s, and even yours gout medication to see which one they are using. 

To save you from all the biochemical jargons, I am not gonna discuss each drug individually.  (If you want more info, click on the appropriate link to the right of this).  The general aim behind all of these drugs is to lower the uric acid level in the blood, break up the crystals that are already formed, and/or prevent the formation of the crystals.

Some of you may wonder how come I don’t have IBUPROFEN (ADVIL) and ALEVE (NAPROXEN) listed above.  A lot of our people take these when their kauti is langa and it seems to help.  These are categorized as Nonsteroidal anti-inflammatory drugs (NSAIDs).  They only “treat” the inflammation ~ kulokula, fufula, mohomoho, and langa but they DON’T treat gout. 

As magical as many of these medications are, we need to remember that they have serious side effects, potential drug interactions (if you are taking medications for other issues), and are also very costly!

This is crucial to understand and remember because you can ‘folo fo’I’akau’ all you want but unless lifestyle and diet changes, then the underlying problem will never be appropriately dealt with.  There’s no ‘magic pill’ for gout.  Each one of these medications will lose its potency and effectiveness if the individual doesn’t invest in fighting gout on a personal level.

I am currently not aware of any natural remedy, at least ones that are scientifically proven, that can relieve gouty attack.  However, I am aware of at least one clinical approach that relieves the pain instantly but is not usually done, let along offered by most clinicians.

A few months back, an expert in Gout spoke to us about doing a Posterior Tibial Injection with local anesthetic to a gout patient.  According to him, this injection does a few crucial thinks.  First, it will numb the patient to the pain. Second, it will increase the temperature in the area, and third, it will increase the pH or decrease the acidity of the local area.  If you remember from the first segment, crystals form due to drop in temperature and drop in pH (high acidity).  This posterior tibial injection reverses both of those and therefore combats the formation of uric acid crystals which therefore alleviate the inflammation and the pain.  So next time you see a clinician for gout, ask about this procedure.  It may set you back a few hundred bucks but it will be worth it.  Plus, you probably would have spent it at your favorite Chinese Buffet anyways…lol…me’a koe kau noa ee…

TAKEHOME MESSAGES

My point here is two-fold.  First, if we are not gonna go to a clinic and attempt to diagnose it at home, then we must know the definite clinical presentations of gout so we can diagnose it correctly.  There are other arthritic conditions that may manifest similar to gout such as pseudogout, arthritis, tendonitis, bursitis, and others.  The danger of wrong diagnosis is that we are helpful people.  We tend to say when someone is ketu-ing, “Mahalo koe kauti ena ia.  Atu e fo’I akau kauti mei api keke folo”. 

Fo’I’akau like allopurinol aka Lopurin, Zyloprim has been known to cause gout.  Can you imagine getting gouty attack/kauti because you took the wrong pills because of a wrong diagnosis?  Scary! Right?  Now, that’s just the minor deal.  We haven’t talked about kidney stones and other kidney related diseases yet!  So, stop taking kauti medication, unless it’s ibuprofen and other NSAIDs, without proper diagnosis.

Second, we need to get rid of the mentality “Kai koe kae toki folo ha fo’I ‘akau”.  I can’t even keep track of many times I’ve heard that at a wedding, family reunion, graduation party, and in buffets.  It always seems encouraging and comforting to the ‘kauti’ person.  This phrase never fails to draw unison laughter.  But this is NOT the only thing this phrase fails to bring.  It always brings pain, discomfort, extra expenses, financial problems, and family problems.  There is no magical pill.  What works now won’t alleviate the pain from gout next month if you continue down the same path.  It has been said that INSANITY is doing the same thing over and over again while expecting the different result.  In that case, “Kai koe kae toki folo ha foi’akau” is an extreme vocalization of insanity!

WE ARE NOT A GENETICALLY DEFECTED PEOPLE!

SURVIVAL OF THE FITTEST

There’s a saying in the circle of Geneticists “Survival of the Fittest” that most, if not all of us have heard before.  I have heard it being used repeatedly on Reality TV shows, sports, in the work place, and even here on facebook.  I‘ve noticed that almost 99.99% of the time, it is being used incorrectly.  It is often used as a declaration of dominance over another.  Normally, I hear it being used when one is flexing his/her physical, mental, and even good look muscles. 

However, such implication is a little misconstrued.  “Survival of the Fittest” refers to those that are MOST able to pass on their genetic information via offsprings.  In which case, it’s not always the most physical dominant, the best looking, or the brightest that are most able to pass on their genetic information.  Sometimes, it is the opposite, or most times it is a combination of these and little bit of luck. If you have looked at a couple and mentally wondered “Masi’I, na’e anga fefe e to ‘a e ki’I fefine he masi’I ko eni? Then you have witnessed what I am talking about.  Our Tongan ancestors understood this clearly and that’s why we have such sayings “Kapau ‘oku kovi e mata, pea ‘ai a e anga ke sia’a” or “Ai e setesi ke koula” or “Fena pe ka ko Nua”.  You guys know what I’m talking about…I won't mention names...MHK!

Most times, it is those that have experienced some sort of genetic mutations that allow them to function without hindrance under stressful conditions that are able to be the SURVIVOR OF THE FITTEST!

“API FA’A TOE TU’U AI E TEVE”

My purpose for opening with such discussion above is to dispel any misconceptions (I’m not saying that there’s any) that my last post may have suggested that we, Polynesians, are genetically DEFECTED since studies have shown that we have some sort of genetic mutation(s) that lead to high level of uric acid in our blood (pheww…such a long sentence….forgive my FOBiness).

We can suspect that such mutation(s) was beneficial and perhaps necessary to our ancestors considering their living conditions and circumstances.  It allowed our ancestors to squeeze every little ounce out of whatever meats they consumed or allowed for less secretion and higher chance of metabolizing molecules for energy.  There’s no actual scientific data to back my presumption.  However, a similar presumption has been documented for why the Native Americans tend to have high sugar level in their blood.  That led to the coining of the term “Hunter/Gatherer Genes”.

There’s a Tongan proverbs that says “Api fa’a, toe tu’u ai e Teve”.  Api means home, estate, or in this case, a farm.  Fa’a refers to being abundant...most likely with food, normally referring the place of a fruitful farmer.  Teve, was a type of food that was only eaten when there were absolutely nothing else to eat.  Perhaps it was unpleasant and hard to ‘stomach’.  (Sorry, I have never tried it, let along seen it).  So, the proverb basically means to be prepared. 

With that in mind, perhaps we can say that such mutation(s) left us with some ‘Api fa’a toe tu’u ai e Teve’ GENES.  I guess we can LITERALLY say that being prepared is IN OUR GENES!!  I believe these genetic mutations played a great role in the survival of our ancestors and our being here today.  Those without where weeded out!

ONCE OUR ALLIES, NOW OUR ENEMY?

Change is the only thing that’s constant.  Time has change and the stresses and challenges that we face today are definitely different from those that our ancestors dealt with.  This ‘Api fa’a toe tu’u ai e Teve’ gene that perhaps once protected our ancestors may have become our demise.  Its role seems to change.  Since we can’t easily re-mutate these genes back or easily weed out those with it (unless your name is Adolf Hitler), we need to do everything we can to protect ourselves from…..ourselves!  Embracing who we are as a people also means having the ‘SURVIVE and PROSPER’ mentality as our ancestors did.  
Time, nature, and our forefathers did whatever they could to pass down their genetic information and now it is our turn to follow suit!  TONGA MA'A TONGA!

GOUT aka KAUTI - "The Rich Man's Disease" Part I

"Tokanga na'a langa ho kauti he fo'i kai ko ena!"  (Watchout with that meal, it might set off your gout!)  "Oku 'ikai ke lava mai he oku langa hono kauti.  Fk'ofa 'auptio!"  (He can't make it because he's having a gout attack.  Feel bad for him!)  How often have you heard these exclamations?  Gout has got to be one of the most (if not the most) debilitating disease out there.  Whether the man is 6'5" or 5'2", Gout, without a doubt, will always put him on his back for days.
MUCH have or is being SAID about KAUTI among our community.   "Fu'u lahi e kai puaka" or "Fu'u lahi e fakapikopiko moe fa'a kai".  But very little (in my humble opinion) has been or is being DONE.  It is ALMOST accepted that GOUT/KAUTI is a part of who we are.  I guess in a way, such notion has some truth to it.  It has been found that if you are a Pacific Islander, you are pre-dispose to HYPERURICEMIA (abnormal high level of uric acid in the blood-more on this later) which eventually can cause GOUTY attack (Simmonds et al., 1994; Zimmet et al., 1978)..  In a sense, we can blame our ancestors for not weeding out those that had the genetic mutations that leads to this deal.  I guess that's enough warming up and complaining.  It's time to sink our teeth into the subject matter and really try to get a working definition and understanding.  To overcome our enemies, we must understand everything about them.

WHAT IS GOUT or KAUTI?
GOUT has been known as the "Rich man's Disease" because it was only common in wealthy and privileged people who had more access to meats in their diets.  It is simply an inflammation of the joint due to crystallized uric acid that aggregate at the joints.  You can envision it as 'momo'i nge'esi hina sio'ata oku lingi'i ki he hokotanga hui!"  It is most often first manifested (~50%) in the big toe joint of the foot.  The reason being is because it is farther away from the core and therefore the temperature is lower.  The lower temperature is necessary for the crystallization process.  This is why most GOUTY attack happens during cold season.  However, it is important to note that it can happen anytime.
If you couldn't envision it, check out the pictorial depiction below:

(image retrieved from http://www.graphicshunt.com/health/images/gout-35.htm)










WHAT IS THE CAUSE/PATHOPHYSIOLOGY OF GOUT?
As mentioned above, it is due to aggregation of uric acid crystals in the joint and the associated tissues and tendons.  Abnormally high level of uric acid (hyperuricemia) will lead to accumulation in the joints and turning into crystals.  High level of uric acid can be due to three reasons: (1) either your body is making too much uric acid or (2) your body is not being able to get rid of the uric acid and (3) mixed of the first two.  It is important to note that having hyperuricemia doesn't mean that you have gout.  It is only when the uric acid crystallizes that one will have a gout attack.
The crystallization of uric acid is initiated when the (1) temperature at the joint is low enough and (2) the acidity (pH level) is at the threshold level.
How does 'kai puaka' and diet contributes to kauti then?  Studies have shown that diet contributes to 12% of gouty attacks (Chen LX, Schumacher HR (October 2008). "Gout: an evidence-based review". J Clin Rheumatol 14 (5 Suppl): S55–62.). Foods that are high in purines and proteins have been associated with hyperuricemia and gout.  Alot of these food not only contribute to high level of uric acid but they also lowers the pH level (increasing acidity) and therefore allowing for the formation of the crystals!  Here's a list of the acid forming foods  and substances:
Artificial sweeteners, Carbonated soft drinks & fizzy drinks , Cigarettes , Flour (white wheat), Goat, Lamb, Pastries & cakes from white flour, Pork, Sugar, Beer, Brown sugar, Deer, Chocolate, Coffee , Custard with white sugar, Jams, Jellies, Liquor , Pasta,  Table salt refined & iodized, Tea black, Turkey, Breads White / Wheat, White rice, commercial vinegar.


To wrap it up, we see that as Pacific Islanders, we are genetically predisposed to HYPERURICEMIA (high level of uric acid in the blood) and with the abundance of the foods and substances listed above and cold weather, gout will continue to plaque us UNLESS we do something about it.  In the next portion of the GOUT/KAUTI blog, we will explore how to combat this disease and address how dangerous the "Kai koe kae toki folo ha fo'i akau" attitude is.  TONGA MA'A TONGA!

MALO E LELEI!

Welcome to my blog!  As the name indicates "Pikipiki Hama Kae Vaevae Manava", I hope that this may serve as a resource and help to our people in regards to some of the health conditions that wreck havoc among us.  I will post twice a week on separate medical conditions such as DIABETES (SUKA), GOUT (KAUTI), HYPERTENSION (MAFU), HIGH BLOOD PRESSURE (TOTO MA'OLUNGA), and so forth.  I will discuss the CAUSES/PATHOPHYSIOLOGY, SYMPTOMS, RISK FACTORS, DIFFERENTIAL DIAGNOSIS (DDX), DIAGNOSTIC TESTS, TREATMENTS, and  PROGNOSIS.

I hope you find this informative, enlightening, and empowering!