Gouty tophi are usually noticed under the skin, and are not usually painful until they burst through the skin, or become infected.

We tend to ignore them in the early stages, and concentrate more on relieving the pain from acute gout flares.

But is this wise?

Probably not now that technology allows us to see tophi growing into cartilage, tendons and bones, leading to bone erosion and severe, painful, joint damage.

Gouty Tophi & Bone Erosion Revealed

It has been a few years since improvements in scanning techniques allowed us to view what is happening inside joints. Over 3 years ago, I quoted from Dalbeth [1]:

There is a strong relationship between bone erosion and the presence of intraosseous tophus. These results strongly implicate tophus infiltration into bone as the dominant mechanism for development of bone erosion and joint damage in gout.

Gouty Tophi & Bone Erosion Reviewed

A significant part of Dalbeth’s, and related research, is the observation that DECT reveals urate deposits much more effectively than any other technique, to the point that joints often show uric acid deposits prior to any physical or inflammatory indication of gout.

There is a commonly held belief that asymptomatic hyperuricemia (high uric acid with no gouty arthritis symptoms) does not need to be treated. This DECT research prompts me to believe that this policy needs to be reconsidered. As I said in my DECT review earlier this year [2]:

Lowering uric acid is more important than generally recognized. The policy of waiting for
several acute gout attacks before commencing urate lowering therapy is outdated, especially
given these clear indications that tendon damage takes place prior to acute gout flares.

Fortunately, this view is beginning to change amongst the more enlightened members of the rheumatology profession. Black and colleagues [3] note:

Utilization of imaging studies in order to accurately diagnose, monitor progression or treatment response, and assess clinical outcomes is increasing rapidly

Black’s review includes additional investigation showing benefits in over 50 cases. Note that this study has the diagnostic software to show urate deposits in green, rather than the red selected by most investigators. Many of their cases show clear diagnosis through DECT where traditional techniques have failed.

However, they do add a cautionary note:

Limited initial availability will likely continue the role of DECT to those individuals with diagnostic uncertainty or access to larger imaging centers.

Gouty Tophi & Bone Erosion Restrained

Perhaps the cautionary note is contagious.

It is disappointing to see that whilst recent professional advice recognizes the value of DECT it fails to acknowledge it’s importance as a diagnostic technique, and fails to recognize the implications on asymptomatic hyperuricemia.

Schumacher & Weaver [4] give with the one hand…

Recent studies show that DECT scans reveal signifcantly more areas of urate deposition than a physical examination. [...] But if these newer imaging techniques can identify MSU crystal deposition prior to bone erosion or joint destruction, they offer promise as a noninvasive alternative for diagnosing gout in the earliest stages of the disease. In addition, they may be used in the future to monitor the progression of gout and the effectiveness of ULT.

… but take with the other:

The consensus standard of care today is that asymptomatic hyperuricemia should not be treated.

Perhaps there will come a day when DECT, and other imaging techniques are common enough to dispel the myth that high uric acid is only dangerous when accompanied by acute gout flares. Until then, I recommend you do all you can to maintain your uric acid at a safe concentration below 6.5mg/dL (0.4 mmol/L).

Gouty Tophi & Bone Erosion References

1. Title: Mechanisms of bone erosion in gout: a quantitative analysis using plain radiography and computed tomography. Authors: Dalbeth N, Clark B, Gregory K, Gamble G, Sheehan T, Doyle A, McQueen FM. Published: Ann Rheum Dis. 2009 Aug;68(8):1290-5.
2. Title: DECT For Gout Diagnosis Author: Keith Taylor (GoutPal.com)
3. Title: Dual-Energy Computed Tomography for the Evaluation of Gout and Calcium Crystal Deposits. Authors: Black DF , Glazebrook K , Bongartz T , Matteson EL , Manek NJ , Leng S , Fletcher JG, McCollough C. File: Gouty Tophi Revealed With DECT
4. Title: Core Principles in the Diagnosis and Management of Gout and Hyperuricemia. Authors: Schumacher HR, Weaver AL. File: Gout And Hyperuricemia
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I’ve long been a proponent of seeking foods that are good for gout, rather than worrying about foods to avoid.

Finding something you enjoy eating or drinking, then finding it also helps your gout brings a smile to any gout sufferer.

Today, I’ll revisit milk to bring us all up to date with the latest research, before I delve into my investigation of the myths and mysteries surrounding high protein foods.

Milk Diet For Gout: Contents

Milk Diet For Gout: Introduction

The 1991 investigation claiming milk is beneficial for gout appears to be somewhat ignored by the medical profession. Now, almost 10 years later, a similar investigation reports similar findings. I have not done a full comparison of the two milk and uric acid studies. For one thing, I do not have full access to the latest study. However, you should find plenty of useful information in this summary taken from the American College of Rheumatology (ACR) press release.

Please note that I’ve paraphrased the original press release to make it more readable and relevant to us non-medical people. The full gout and milk report has subsequently been published in the British Medical Journal [1].

Milk Diet For Gout: Overview

The ACR’s press release, ‘Got Gout? Get Milk’, promotes the research presented at their Annual Scientific Meeting in Philadelphia, Pa.

It describes gout as a painful and potentially disabling form of arthritis with symptoms usually consisting of intense episodes of painful swelling in single joints, most often in the feet (especially the big toe).

They note that treatments are already available to prevent or control the arthritis associated with gout, but managing this disorder can be difficult, and treatment plans often have to be tailored for each person. I believe it is vital that treatment is planned individually, which is a key point in the Gout Freedom campaign.

They note that previous studies indicate that individuals who drink a lot of milk have a lower risk of developing gout. Though not specifically referenced, this is almost certainly Choi’s statistical analysis linking high dairy consumption with lower gout incidence.

Milk Diet For Gout: Research Report

The presentation is titled: “The Acute Effect of Skim Milk On Serum Urate Concentrations: A Randomized Controlled Cross-Over Trial” and it’s authors are listed as:

• Nicola Dalbeth, FRACP , Department of Medicine, University of Auckland, Auckland, New Zealand
• Sumwai Wong, Department of Medicine, University of Auckland, Auckland, New Zealand
• Greg Gamble, Department of Medicine, University of Auckland, Auckland, New Zealand
• Anne Horne, Department of Medicine, University of Auckland, Auckland, New Zealand
• Barbara Mason, Department of Medicine, University of Auckland, Auckland, New Zealand
• Lynette Fairbanks, Guy’s Hospital, London, United Kingdom
• Fiona M. McQueen, Department of Medicine, University of Auckland, Auckland, New Zealand
• Jillian Cornish, Department of Medicine, University of Auckland, Auckland, New Zealand
• Ian R. Reid, University of Auckland, Auckland, New Zealand
• Kate Palmano, Fonterra Research Centre, Palmerston North, New Zealand

Uric Acid Research Purpose

Recent observational studies have highlighted the beneficial role of skim milk in prevention of gout. The aims of this study were to determine the acute effects of intact skim milk on serum urate concentrations, and to examine the mechanisms of the urate-lowering effects of skim milk.

Uric Acid Research Method

This was a short-term randomized controlled cross-over trial of skim milk in 16 healthy male volunteers. The following products were tested (each 80g protein):

1. soy control
2. early season skim milk
3. late season skim milk (containing high concentrations of orotic acid, a naturally occurring uricosuric agent)
4. MPC 85 skim milk (an ultra-filtrated skim milk containing very low concentrations of orotic acid, purines and lactose)

Each participant received a single dose of each product (each containing 80 grams of protein) in random order. Researchers collected samples of blood and urine immediately before each participant drank one of the beverages and then hourly over a three-hour period. They completed this with each participant for each of the four beverages with a week in between each session.

Uric Acid Research Results

After drinking the soy milk, uric acid in the blood increased by about 10 percent. In contrast, all skim milks led to a decrease in serum uric acid by approximately 10 percent. All products (including the soy milk) rapidly increased the ability of the kidneys to remove uric acid from the body.

Additionally, researchers found that late season skim milk led to a greater increase in the removal of uric acid by the kidneys when compared to the other skim milks. Late season skim milk is primarily available from countries where milking is seasonal and cows are grass-fed, such as New Zealand and Australia, and is known to contain higher levels of orotic acid, a substance that promotes uric acid removal by the kidneys.

There were no significant differences over time or between groups in changes in serum oxypurines (xanthine and hypoxanthine) or purines (guanosine and inosine). However, all products led to an increased excretion of xanthine.

Uric Acid Research Conclusion

The press release concludes that the study showed that skim milk has a specific acute uric acid-lowering effect. The authors suggest long term studies for further proof that it might be a good dietary way to assist in the prevention and treatment of gout.

“This study has shown that skim milk can significantly reduce the serum uric acid concentration in the short term,” explains Nicola Dalbeth, MD, FRACP; senior lecturer, clinical medicine, University of Auckland, Auckland, New Zealand, and lead investigator in the study. “The results suggest that increasing the amount of skim milk in the diet may help with preventing the development of gout, and also assist with treatment for those with the disease. We are now continuing this work by studying the longer term effects of milk in people with gout.”

Milk Diet For Gout: Next Steps

Now is a good time to seriously consider improving your diet with skim milk. Do not forget that even the lowest fat skim milk still has some energy, so if you are counting the calories make sure you plan this diet change properly.

More importantly, you must realize that the uric acid lowering effects of skim milk, though significant, may not be enough to reduce you uric acid to a safe level. You must continue to check uric acid levels regularly to ensure that you remain safe.

If you are used to drinking full-fat whole milk, I found that by gradually reducing the fat content, I was soon happy with the taste of skim milk. In fact, I now find full fat milk far too creamy for my palate.

There are more natural gout cures to lower uric acid in the Gout Treatment Section.

Milk Diet For Gout: References

1. Dalbeth N, Wong S, Gamble GD, et al. Acute effect of milk on serum urate concentrations: a randomised controlled crossover trial. Ann. Rheum. Dis. 2010;69(9):1677-1682.

Leave this Milk & Gout page to browse other Gout Cures…

Devil Claw, also called Devil’s Claw, is often sold as a treatment for various forms of arthritis, including gout.

The herbal gout treatment is extracted from the secondary roots of the Devil’s Claw plant (Harpagophytum procumbens).

As far as I can see, there have been no studies of Devil Claw & gout. However, a number of studies have looked at the anti-inflammatory properties. I have summarized 3 studies below.

When studying the effect of Devil’s Claw on inflammation in rats, McCleod et al[1] could find little positive evidence that it could help with arthritis problems:

in humans, Devil’s Claw when used at the recommended dose would not be expected to show anti-arthritic activity.

They did allow that investigation of much higher doses might show some benefit, but, as far as I can tell, no safety and efficacy studies have been carried out on very large doses.

Grahame & Robinson [2] looked at humans with arthritic conditions taking a dose of 3 410mg tablets each day for 6 weeks. This is a very small study of 13 patients, with one of those dropping out after 4 days due to side effects. Again, they could find little evidence of anti-inflammatory benefits, concluding:

The purpose of these studies was to determine whether a prima facie case could be made for undertaking further studies in patients, including controlled studies. The results described provide little justification for such action, and the usefulness of devil’s claw as an anti-rheumatic agent remains unproved.

Finally, Whitehouse et al[3] also studied Devil’s Claw in rats, confirming earlier studies showing lack of anti-inflammatory properties. Furthermore, they compared Devil’s Claw with aspirin and indomethacin showing that these classic anti-inflammatory drugs both showed beneficial properties. They conclude:

These results indicate that Devil’s Claw lacks the anti-inflammatory properties possessed by all antiarthritic drugs of the nonsteroidal, anti-inflammatory analgesic type.

Next Devil Claw Gout Steps

You can see there is very little scientific support for Devil’s Claw as a treatment for gout. Questions remain as to whether there is a safe effective dose, but on the evidence to date, this appears unlikely. Better to focus on lowering uric acid with medical or natural treatments that have been proved to work.

Devil Claw Gout References

1. McLeod DW, Revell P, Robinson BV. Investigations of Harpagophytum procumbens (Devil’s Claw) in the treatment of experimental inflammation and arthritis in the rat [proceedings]. Br. J. Pharmacol. 1979;66(1):140P-141P.
2. Grahame R, Robinson BV. Devils’s claw (Harpagophytum procumbens): pharmacological and clinical studies. Ann. Rheum. Dis. 1981;40(6):632.
3. Whitehouse LW, Znamirowska M, Paul CJ. Devil’s Claw (Harpagophytum procumbens): no evidence for anti-inflammatory activity in the treatment of arthritic disease. Can Med Assoc J. 1983;129(3):249-251.
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