Analysis on the Experience of Mishi Xiaoyu Decoction in Treating Gout of Spleen Deficiency and Phlegm Stasis

: Gout is called arthralgia syndrome in traditional Chinese medicine, and its symptoms are often discomfort such as redness, swelling, heat, pain, acid distension, activity disorder and so on. Doctors have different understanding of its etiology and pathogenesis. In his long-term clinical practice, Dr. Xiao Yang concluded that the etiology and pathogenesis of gout was "spleen deficiency, phlegm and blood stasis". Based on this, Mishi Xiaoyu Jiangzhuo decoction was designed to treat gout, mainly to reduce the symptoms of acute gout and prolong the interval. Reduce the frequency of acute attacks. In clinical practice, the prescription has different emphasis according to different stages of gout, age of patients, deficiency of vital qi, etc., such as pain relief in acute stage, recuperation of spleen, stomach, liver and kidney function during intermission, strengthening spleen and replenishing qi and reducing turbidity in young people, and removing blood stasis and reducing turbidity in middle-aged and elderly people, probably because young people do not decline, phlegm turbidity is heavy, blood stasis is light, fatigue is damaged in middle-aged and elderly people, and long-term illness leads to phlegm and blood stasis. In the treatment, we should also take into account the physiological status of spleen and stomach, liver and kidney deficiency, plus take care of the spleen and stomach, protect Yin fluid drugs, the following from the clinical treatment of medical records to provide ideas for the clinical application of traditional Chinese medicine in the treatment of gout.


Introduction
Gout in western medicine is thought to be due to purine metabolism, disorders and / or reduced uric acid excretion resulting in persistent hyperuricemia (HUA), the formation of monosodium urate crystals and deposition in the body caused by joint inflammation [1]. In recent years, the incidence of gout in the world is high and has an upward trend. Today, gout has become the second largest metabolic disease after diabetes. In clinical treatment, uric acid excretion promoting drugs or uric acid reduction drugs are often used. However, the probability of acute gout caused by uric acid reduction drugs will increase [2]. Therefore, many patients seek comprehensive treatment of traditional Chinese medicine in order to steadily reduce uric acid and alleviate the symptoms of gout attacks.

Pathogenesis
Gout is described as "arthralgia" in ancient books such as Treatise on Febrile Diseases and Miscellaneous Diseases and Synopsis of the Golden Chamber. The term "gout" first appeared in the Jin and Yuan dynasties. Zhu Liangchun [3], a master of traditional Chinese medicine, first proposed the name of "turbid stasis arthralgia". Modern often think that the common cause of gout pathogenesis is damp stasis [4]. Chinese medicine master Li Jiren concluded that gout pathogenesis is ' poison, heat, dampness, phlegm, blood stasis, deficiency ' [5]. Xiao Yang Deputy Chief Physician believes that the pathogenesis of gout is spleen deficiency and phlegm and blood stasis, which can summarize the different stages of gout. There are many pathological factors such as phlegm and blood stasis in the acute stage, and the remission stage is mainly endogenous. Suwen · Jingmai Bielun means 'drinking in the stomach, overflowing essence, transporting in the spleen, dispersing essence in the spleen, and returning to the lung.' It shows that the absorption of nutrients in diet depends on the transmission of the spleen to reach the whole body, that is, 'the spleen is the main transport ', which provides sufficient nutrients for the generation of essence, qi, blood and body fluid, so that the human organs, meridians, limbs, and skin, tendons and muscles are fully nourished to maintain normal physiological functions. The majority of patients due to longterm improper diet, damage to the spleen and stomach, spleen and stomach transport function disorders, water and dampness transport is not as soon as phlegm, accumulated in the bones, meridians, joints, resulting in poor blood circulation, blood stasis, there will be bone swelling pain symptoms. Phlegm and blood stasis obstruction in the joint of bones and tendons, not through the pain, not glorious pain, there is gout attack symptoms, the key to treatment is closely linked to promoting blood circulation and dredging collaterals, spleen and dampness. Xiao Yang ' s self-made Mishi Xiaoyu Jiangzhuo Decoction [6] closely links the pathogenesis of phlegm and blood stasis, and protects the spleen and stomach, so as to take into account the specimens, in order to achieve more in clinical practice.

Experience
Mishi Xiaoyu Jiangzhuo Decoction plays the advantages of traditional Chinese medicine in stable lowering uric acid, stable relieving symptoms, less liver and kidney damage, and less inducing acute gout attack. In clinical application, due to different stages of gout, age, underlying diseases, etc., there are different focuses on the cube. Mishi Xiaoyu Jiangzhuo Decoction consists of 30 g Atractylodes macrocephala Koidz, 15g Atractylodes macrocephala Koidz, 15 g Poria cocos, 15 g Semen Plantaginis, 30 g Semen Coicis, 10 g Cortex Phellodendri, etc. . The monarch drugs in the prescription are Atractylodes macrocephala Koidz, Poria cocos, Semen Plantaginis, all of which have the effect of invigorating spleen. Atractylodes macrocephala Koidz can benefit qi and strengthen spleen and dampness, Semen Coicis can strengthen spleen and dampness, remove obstruction and dredge collaterals, mainly treat rheumatism and arthralgia, Poria cocos can strengthen spleen and dampness, and Semen Plantaginis can clear heat and dampness, all of which can improve the root of spleen transportation and transformation function. Danggui and Shengdi are ministerial drugs, in which Danggui Buxue Huoxue; shengdi clearing heat and nourishing yin can prevent excessive dryness of various drugs. Cortex Phellodendri clearing heat and drying dampness, Rhizoma Atractylodis Macrocephalae invigorating spleen and drying dampness, both as adjuvants, Rhizoma Atractylodis Macrocephalae mainly drying dampness in the spleen and soil of middle energizer, and Cortex Phellodendri mainly treating dampness-heat in the liver and kidney of lower energizer. The prescription of traditional Chinese medicine is Ermiao Pill, which is especially good at treating tendon and bone pain and foot and knee swelling caused by dampness-heat pouring. Achyranthes bidentata and radix glycyrrhizae are used to treat rheumatism arthralgia and other syndromes. Long-term illness is easy to cause liver and kidney deficiency. Therefore, Achyranthes bidentata is added to supplement liver and kidney, strengthen tendons and bones, promote blood circulation and dredge collaterals to relieve pain, and cooperate with radix glycyrrhizae to reconcile various drugs. The combination of various drugs has the effect of treating both symptoms and root causes. In clinical application, if it is in the acute attack period of gout, heat-clearing, swelling and pain-relieving drugs can be added, and in the intermittent period, spleen-strengthening and phlegmresolving can be focused to reduce the acute attack.

Cases
Liu, a 23-year-old male, visited Xiao Yang's deputy director's clinic on October 05, 2020 for 'finding elevated uric acid in June'. The patients had frequent plain drinking, thick taste of cream and fat, and severe obesity. Before 6 months, excessive drinking induced pain in the toes of both feet, which was diagnosed as gout in local hospitals. After treatment with uric acid lowering drugs and analgesic and anti-inflammatory drugs (specific unknown), the symptoms of the patients were relieved. Recently, they again showed symptoms due to irregular diet, and came to Xiao 's office for medical treatment. The symptoms were as follows: pain in the toes of both feet, redness and swelling, elevated skin temperature, aggravated pain after activity, fatigue, poor stool, light tongue, yellowish greasy coating, and smooth pulse string. Serum uric acid: 609mmol / L. According to the four diagnostic syndromes, spleen deficiency and phlegm and blood stasis syndrome was treated with activating blood and dredging collaterals, invigorating spleen and eliminating dampness, and modified Mishi Xiaoyu Jiangzhuo decoction. Prescription: bran fried Atractylodis Rhizoma 15g, Jiuchuanniuxi 15g, Huangbai 12g, bran fried coix seed 30g, Danggui 12g, Shengdihuang 15g, Chuanxiong 15g, Baizhu 30g, Tufuling 30g, Yancheqianzi 30g bag frying, Zhigancao 6g, Danshen 15g, Shengdahuang 9g, lotus leaf 15g, duckweed 15g, Xuanshen 15g, Maidong 15g, Tianhuafen 15g, areca nut 12g, fried bitter almond 9g. 7 pay, 1 pay / day, 2 times / day, 200 ml each time. Combined with oral administration of etoricoxib tablets 60 mg, once a day. And told patients during medication low purine diet, prohibition of alcohol, drinking water.
Second diagnosis, first metatarsophalangeal joint pain relief, joint Third diagnosis, the patient suffered from joint pain of the left foot and toe after excessive activity. The patient was asked to pay attention to the low-purine diet, and the left foot was braked. On the basis of the prescription, lotus leaf, duckweed, Scrophulariae Radix, Ophiopogon japonicus, trichosanthin powder, areca nut and fried bitter almond were removed. The wax gourd kernel and Dioscorea zingiberensis were added to relieve swelling, and no joint pain was observed. No obvious discomfort was complained. The blood uric acid was 400 μmol / L. Will pay attention to diet, exercise regulation, follow-up six months no recurrence.
Note: Young male patients, like to eat fat, sweet and thick taste, long-term improper diet, damage the spleen and stomach, transport disorders, blood and body fluid obstruction can not reach the end of the four, so the performance of double toe pain; the body fluid cannot moisten the intestine, so the stool is not smooth ; qi and blood cannot be inherited from the joints and muscles of the limbs, and there is a lack of body, light and dark tongue, yellowish and greasy coating, and smooth pulse string. Atractylodes, Atractylodes, Poria, Coix lacryma-jobi all play the role of invigorating the spleen in a prescription, helping healthy qi. Plantago, Achyranthes bidentata, Radix Achyranthes bidentata, Radix Angelicae Sinensis, Radix Rehmanniae, and Cortex Phellodendri promote the operation of Qi and blood by removing dampness, lowering turbidity, promoting blood circulation and removing blood stasis. Zengye Decoction in the prescription can increase water and rowing, and betel, and betelnut is used to improve defecation, relieve thirst, and improve dry mouth. Yinye can be protected to prevent water drugs from damaging yin. Lotus leaf can reduce turbidity and lipid, enhance lipid metabolism, and reduce weight. Increase renal excretion of uric acid while reducing blood uric acid, play a renal protective role [7]. Second diagnosis effective follow-up. Three diagnostic stool unobstructed, dry mouth symptoms improved significantly, so to Shengjin Zhike, Shengjin Runchang Tongbian drugs, plus Dongguaren, Mianbixie dampness turbidity, expelling wind and removing Bi. Prescriptions closely linked to the pathogenesis, both symptoms and root treatment, the main benefit qi spleen phlegm, patients medication 21 toe joint pain symptoms can be improved, all symptoms have eased, followed up for half a year without acute attack.

Realize
Most of the current guidelines for gout treatment, including those in China, believe that uric acid-lowering therapy should begin at least two weeks after the onset of acute gout [1][2], on the grounds that the use of uric acid-lowering therapy during acute gout episodes may cause blood uric acid fluctuations, thereby aggravating the symptoms of gout. Xiao Yang Deputy Chief Physician has been engaged in clinical practice of endocrine and metabolic diseases for many years. In the acute phase of gout, Mishi Xiaoyu Jiangzhuo Decoction combined with analgesic and antiinflammatory drugs can more smoothly control the onset of gout, improve the symptoms of acute phase, reduce the frequency of acute attacks, have less toxic and side effects, and have good curative effect. It can improve the quality of life of patients, and each treatment has good effect. It is worthy of clinical doctors to learn and apply. Gout treatment is a comprehensive long-term treatment. More importantly, it is more important to strengthen patient education, improve their understanding of the disease, and promote patients to change bad lifestyles, control weight, limit smoking and alcohol consumption, and develop good habits such as appropriate exercise, sleep, and adequate drinking [2].