Nursing perspective of Guidelines for Diagnosis and Treatment of Gout with lntegrated Traditional Chinese and Western Medicine

Suqian LI, Chun WANG, Lin LU, Ling TANG, Huaxin WANG

1Department of Rheumatology, Dongfang Hospital of Beijing University of Chinese Medicine, Beijing, China; 2Department of Nursing, Dongfang Hospital of Beijing University of Chinese Medicine, Beijing, China

ABSTRACT Gout is a common rheumatism and its long-term recurrent attacks can cause joint destruction and deformity, even disability, which seriously affects the quality of life of patients. Chinese medicine plays a unique advantage in the treatment and rehabilitation of gout. To further standardize the diagnosis and treatment of gout with integrated traditional Chinese and Western medicine, the Chinese Association of Integrative Medicine issued the Guidelines for Diagnosis and Treatment of Gout with Integrated Traditional Chinese and Western Medicine in August 2021. Expert recommendations were made on the etiology and pathogenesis; diagnosis and classification standards; patient health management; and integrated traditional Chinese and Western medicine treatment, prevention, and nursing of gout. This article interprets the guidelines from the nursing point of view, focusing on the detailed explanation of diet care, functional exercise, and appropriate techniques of traditional Chinese medicine for gout, in order to provide better clinical reference for high-quality nursing services for gout patients.

Keywords: Gout, guideline, integrated traditional Chinese and Western medicine nursing, integrative nursing, interpretation, rheumatism, traditional Chinese medicine

Access this article online Quick Response Code Website:www.journalin.org DOI:10.4103/jin.jin_7_22images/BZ_71_966_2775_1202_3011.png

INTRODUCTION

Gout is an inflammatory joint disease of reduced uric acid excretion due to abnormal purine metabolism.[1]Gout belongs to the category of “Bi syndrome” in traditional Chinese medicine (TCM), presented as redness, swelling, and pain in joints during onset.[2]The global prevalence of gout is 0.1%-10%.[3]The prevalence of gout in China is 0.03%-10.47%, and is increasing year by year with the improvement of people’s living standards.[4]Clinical application of integrated traditional Chinese and Western medicine in the treatment of gout has shown great advantages.[5]

In order to standardize doctors’ diagnosis and treatment behavior, reduce medical costs, and improve medical quality, the Chinese Association of Integrative Medicine formulated theGuidelinesforDiagnosisandTreatmentofGoutwithIntegratedTraditionalChineseandWesternMedicine(hereinafter referred to as “Guidelines”) in August 2021.[6]The Guidelines are designed and formulated based on the World Health Organization Guide Formulation Manual, and adopt the GRADE method to evaluate, formulate, and give a grade to the evidence and recommendations. Grades of evidence are as follows: Grade A (high) indicates very certain that the estimated value is close to the true value; Grade B (medium) has moderate certainty about the estimated value, and the

How to cite this article:Li S, Wang C, Lu L, Tang L, Wang H. Nursing perspective of Guidelines for Diagnosis and Treatment of Gout with Integrated Traditional Chinese and Western Medicine. J Integr Nurs 2022;4:172-6.estimated value may be close to the true value or may vary greatly; Grade C (low) has limited grasp of the estimated value, and the estimated value may be quite different from the true value; and Grade D (extremely low) has little certainty about the estimated value, and the estimated value is very likely to be quite different from the true value. Recommendation levels are as follows: strong recommendations supporting the use of a certain therapy are expressed with the number 1, weak recommendations supporting the use of a certain therapy are expressed with the number 2, weak recommendations against the use of a certain therapy are expressed with the number 2, and strong recommendations against the use of a certain therapy are expressed with the number 1. This article interprets the Guidelines from the nursing perspective, so that patients can have a deeper understanding of gout health management and TCM nursing technology, in order to provide better clinical reference for the high-quality nursing service of gout patients.

ETIOLOGY AND PATHOGENESIS OF GOUT

According to the Guidelines, the initial main causes of gout are improper diet, excessive drinking, or overeating fat and sweet food which damage the spleen and stomach. Another cause of the disease is insufficient congenital endowment, which leads to weak transportation and transformation of spleen and stomach and dysfunction of kidney excretion, thus resulting in endogenous phlegm-dampness. Long-term retention of phlegm-dampness generates heat which in turn intermingles with dampness, consequently forming blockage in joints and leading to redness, swelling, heat, and pain in joints. The nature of this disease is “deficient root and excessive superficial” - spleen and kidney deficiency is root cause involving other organs, with phlegm, damp-heat, blood stasis, and other pathological factors as superficial causes.

CLINICAL STAGING AND TREATMENT PRINCIPLES OF GOUT

Staging of gout from the perspective of Western medicine

The Guidelines suggest that the gout classification follows the gout classification standard jointly launched by the American College of Rheumatology and the European League Against Rheumatism in 2015 (1A).[7]Gout is divided into hyperuricemia period, acute attack period, intermittent period, and chronic arthritis period.

Staging of gout from the perspective of traditional Chinese medicine

The TCM staging standard refers the TCM Syndrome Score Scale recommended by the Guidelines, which is used to calculate an integral from joint pain, swelling, mobility, to systemic symptoms. Therefore, the disease is divided into stable period (TCM syndrome score ＜6 points) and active period (TCM syndrome score ≥ 6 points) (1B). In clinical practice, there are corresponding TCM syndrome types for each stage.[8]

General treatment principles and goal of gout

According to the Guidelines, the overall treatment principle and goal of this disease is to keep the patient’s blood uric acid level stable, reduce gout attack, and reduce the occurrence of complications. When choosing the treatment plan, the patient’s acceptance should be considered, and the patient’s right to choose treatment should be maintained maximally.

NURSING CARE OF GOUT WITH INTEGRATED TRADITIONAL CHINESE AND WESTERN MEDICINE

Diet care

The Guidelines propose health management for gout patients, so that patients can understand the relationship between purine and hyperuricemia, and the relationship between uric acid and gout. Reasonable dietary structure and eating habits are effective means to relieve gout symptoms. Gout patients should strictly control their diet; adjust their diet structure according to the scientific diet plan; and adhere to the dietary principles of low purine or no purine, low calorie, low salt, low fat, and high water.[9]

Purine

The Guidelines propose that patients should follow the principle of low purine, low calorie, low salt, low fat, and drinking more water and avoid high purine food, which can effectively increase the number of patients with low purine diet and help patients control blood uric acid level (1C).[10]The Guidelines also point out that the daily intake of purine in the diet of the general population is 600-1000 mg, but the daily intake of purine in gout patients should be controlled within 150 mg during acute attack period.[11]

Different kinds of food have different purine content. Qu[12]found that the total purine content in fish, shrimp, and shellfish is the highest, which is higher than the total purine content in livestock and poultry meat, and is several times higher than that in vegetable food materials. Purine content in vegetables, fruits, and their related products and dairy products is generally low; the purine content in plant food is much lower than that in animal food. Panetal.’s study proved that eating animal viscera can significantly increase the uric acid level of human body.[13]

Therefore, it is recommended for gout patients not to eat foods with high purine content such as pork, animal viscera, crab, broth, sardine, clams, beef and mutton, aquatic products, and chicken soup. It is recommended to eat foods with low purine or no purine content such as edible fungi, spinach, milk, peanuts, cabbage, and cucumber. It is necessary to avoid spicy and irritating foods and condiments, such as pepper, curry, pepper, pepper, and mustard ginger.

Fructose

The Guidelines propose to limit fructose intake (1A). Meta-analysis shows that the intake of sugary drinks is positively correlated with blood uric acid level,[14]and the intake of fructose in daily diet mainly comes from sugary drinks, sweets, and fruits. Therefore, it is very important to limit the intake of those foods to strictly control blood sugar, blood pressure, and hypercholesterolemia, and thus reduce the occurrence of gout by changing dietary habits.[15]

Drinking water

The Guidelines propose to drink 2000-3000 mL (1A) of water every day. Patients are advised to drink plenty of boiled water, mineral water, etc., at ordinary times. It is best to drink a small amount for many times, 1 cup (250 mL) every hour. In order to prevent the concentration of nocturia, gout patients are informed to appropriately replenish water before going to bed.[16]

Alcohol

In the Guidelines, it is proposed to limit alcohol intake (1A), and alcohol intake is positively correlated with gout risk.[17]Drinking alcohol is an important risk factor for gout attack, and daily alcohol intake exceeding 15 g can obviously increase the risk of gout attack.[18]

Calorie

To control the total calorie intake daily, the blood uric acid level of gout patients should be reduced to 357 μmol/L, and that of patients with gouty tophus should be controlled below 297.5 μ mol/L.[19]According to the Guidelines, patients should pay attention to weight control (1A) whether they start drug treatment or not. A cohort study shows that weight gain is an independent risk factor for gout.[20]A meta-analysis also shows that weight loss can significantly improve the compliance rate of uric acid level and reduce the frequency of acute gout attack.[21]With the change of people’s lifestyle, the prevalence of obesity and gout is increasing year by year. Obesity not only increases the risk of gout but also advances the onset age of gout with the increase of body mass index. Hence, obese gout patients should pay attention to regular exercise while paying attention to blood uric acid.[22]Gout patients should maintain or reach their ideal weight, and it is best to make their weight lower than 10%-15% of the standard weight. The key point is to control the total calories eaten every day. Patients can eat potassium-containing foods, such as bananas, broccoli, and celery, and eat more alkaline foods, such as cabbage, rape, carrots, potatoes, wax gourd, and other yellow-green vegetables. Protein-energy supply is 10%-15% of total energy, and milk, cheese, skim milk powder, and eggs are mostly selected.

Functional exercise

The Guidelines point out that patients should maintain the proper intensity of exercise (1B). According to the Guidelines, moderate- and low-intensity exercise with a heart rate of 64%-76% HRmax and 3-5 times a week can effectively reduce the blood uric acid level of patients (1B).[23]Meanwhile, patients are advised to master the amount of functional exercise and training rhythm, take exercises gradually, and avoid excessive fatigue as each appropriate muscle exercise will cause certain muscle fatigue, but excessive exercise can cause muscle strain and excessive sweating. In addition to that, excessive sweating will lead to decreased renal blood volume and reduced uric acid excretion, thus resulting in transient hyperuricemia.[24]

Appropriate traditional Chinese medicine techniques

The treatment of gout patients in acute stage with TCM characteristic external therapies can obviously relieve their symptoms and improve their quality of life. The Guidelines recommend TCM characteristic therapies for gout patients, and point out that the external therapies with TCM characteristics such as TCM fumigation and washing embody unique advantages in the treatment of this disease (1C). This article focuses on interpretation of the TCM technical operation in the Guidelines suitable for the implementation of nursing staff.

External application with Chinese medicine

External application with Chinese medicine is mainly used in treating pain and relieving swelling of gout patients, so as to achieve the effects of clearing heat and promoting diuresis, reducing swelling, and relieving pain. The Guidelines recommend that heat-clearing and dampness-eliminating drugs are common for external use, such as Dahuang (RadixetRhizomaRhei), Cangzhu (RhizomaAtractylodis), Huangbai (CortexPhellodendri), Niuxi (RadixAchyranthisBidentatae), Rendongteng (CaulisLonicerae), Huzhang (RhizomaPolygoniCuspidati), and Weilingxian (RadixClematidis) (1C). Chuanwu (RadixAconiti) and Caowu (RadixAconitiKusnezoffii) are selected for the external application for patients with cold-dampness obstruction in chronic arthritis stage; Ruxiang (Olibanum), Moyao (Myrrha), Taoren (SemenPersicae), Honghua (FlosCarthami), and insect drugs are chosen for the external application for patients with phlegm and blood stasis obstruction; patients with spleen deficiency and damp-heat syndrome can be treated with drugs for clearing heat and promoting diuresis, similar to those in acute stage, and spleen-strengthening drugs can be added as appropriate (1C).[25]The usage of the above drugs is as follows: the drugs are crushed into powder and sifted and then mixed with Vaseline into paste at the ratio of 1:4, which is smeared to the affected part of the patient and wrapped with plastic wraps.[26]

Traditional Chinese medicine fumigation and washing

The TCM liquid of heat-clearing and dampness-eliminating drugs is used for fumigation and washing. The fumigation and washing prescription mainly consists of Cangzhu (RhizomaAtractylodis), Huangbai (CortexPhellodendri), Xixinye (FoliumHerbaAsari), Sumu (LignumSappan), Haifengteng (CaulisPiperisKadsurae), Lulutong (FructusLiquidambaris), and Chuanwu (RadixAconiti). Those drugs are decocted to 2000 mL liquid and used for soaking feet for 30 min when the liquid temperature reaches 39°C-42°C, which can effectively reduce inflammatory indexes and relieve pain.[27]

CONCLUSION

The release of the Guidelines can provide more clear guidance for clinical work for medical and nursing staff. The gout Guidelines emphasize the importance of health management. The implementation of health education can urge patients to better cooperate with treatment and nursing, especially individualized health education on admission and in hospital and continuity of care after discharge. It can urge patients to pay attention to their daily life, change their bad eating habits, relieve bad emotions, and do appropriate functional exercises, so as to improve their self-care ability and nursing compliance and improve their quality of life.

According to the TCM pathogenesis of gout, it is mainly caused by congenital endowment deficiency and dysfunction of spleen and kidney, and its superficial causes are damp-heat, turbid phlegm, and blood stasis. Proper early reasonable treatment can control the development of the disease to the maximum extent and alleviate the pain of gout patients as much as possible. TCM nursing technology is an important means for nursing staff in TCM hospitals to provide high-quality and characteristic services for patients,[28]and plays an vital role in the treatment and nursing of gout because TCM nursing technology is easy to operate and has few side effects, which can make drugs better absorbed and avoid some people’s gastrointestinal reactions or other discomfort symptoms due to oral drugs. With the improvement of TCM nursing techniques, they are more recognized and valued.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.