The following is a reader submission from Doc Martyn, head of Pattaya Medical Club, formerly Buriram Medical Club, who regularly gives opinions and updates on medical situations he has seen in Thailand. He is a retired doctor. His opinions and statements are entirely his own.
1.      Chris, a 69-year-old retired Welshman has been domiciled in Thailand for 16 years. He married his Thai wife 13 years ago. She is 28 years his junior. They have a 12-year-old son.
2.      I did not know Chris. I received the following message on March 7, 2023: ‘Suffering with bunions…obviously an operation required but no idea of cost. Your advice would be greatly appreciated’. He sent photos of his feet; See photos below.
3.      See photo 3; a typical bunion. Chris did not have bunions, he had bilateral hallux, big toe, tophus gout.
Gout is caused by an excess of uric acid in the blood, termed hyperuricaemia. The illness is caused by several different factors, including; a genetic predisposition, a purine rich diet, and intercurrent illness. The excess uric acid forms needle-like crystals, monosodium urate crystals, in joints. It is an acute, very painful, arthritic condition.
Tophus (Latin; stone) Gout occurs when hyperuricaemia persists over many years, usually >10 years.
4.      Chris had suffered intermittent gout for years. Following a recent flare-up, in addition to his regular Allopurinol 100mg 1 tablet 2x/day, a treatment which reduces hyperuricaemia, his local hospital prescribed the following: Paracetamol 1 tablet 4x/day for pain (a typically low dose suitable for Thais but not for Farangs), Prednisolone 5mg, 2 tablets 3x/day, an anti-inflammatory, Omeprazole 20mg daily, to protect his stomach against the side effects of the Prednisolone, and Colchicine 0.6mg I tablet twice/day.
5.      I discussed this management with Chris, highlighting the following problems:
-The Paracetamol dose was manifestly inadequate both in quantity and analgesic efficiency. By extrapolation; this treatment was ordered by a physician who did not have gout. If the doctor had experienced the acute intensity of pain that results from the crystal formation, he/she would not have prescribed such an inadequate analgesic agent.
-Prednisolone is a steroid, it is an effective anti-inflammatory, but replete with side effects, including adrenal suppression. Chris had been taking prednisolone 30mg/day for the previous 10 days. If continued, adrenal suppression would ensue. I asked him to cease the steroid, replacing it with a NSAID (Non-Steroidal Anti-Inflammatory Drug) or the newer, more effective, and safer, NSAID called a COX-2 Inhibitor. This type of medication specifically targets the Cyclooxygenase-2 (COX-2) enzyme which causes inflammation and pain. I recommended Celecoxib 200mg, 1 capsule daily.
-Omeprazole 20mg daily; having ceased the steroid medication, this treatment was no longer necessary.
-Colchicine is an anti-inflammatory effective in the treatment of acute gout, but it must be given cautiously. Colchicine has a narrow therapeutic window and overdose is a problem. The recommended dose for acute gout is; 2 tablets stat, followed by 1 tablet 1 hour later and then as required, with a maximum dose of 6 tablets in any 24-hour period. Chris’s dose; 1 tablet twice a day, was inadequate. But after 10 days his pain had settled and continued therapy was not required.
6.      The objective of both Gout and Tophus Gout treatment is to maintain the patient’s uric acid in the low normal range. Chris’s Uric acid was 10 mg/dl (3.5-7.2). He required an increase in his Allopurinol medication to 3 tablets/day, the normal dose for a Farang, overweight or otherwise.Â
Chris was satisfied with my advice. He wrote: ‘Thank you for your very professional help and advice’. I asked him to attend my next Club Medical meeting on 14th March. Despite the long drive, he was from the Surin Province, Chris was looking forward to our meeting.
7.      When he arrived, Chris was deflated and reserved. I asked him if he was OK.
In typical generous Farang style, Chris had renovated his wife’s family home, see photo 4 as the cover. Once finished, he started building a property for himself, his wife, and their son. For convenience, Chris rented a bedsit, about 25Km from the village, his wife moved into an annex in her village, which had no running water, toilet facilities or WiFi. Their son lived with his maternal grandmother.
In December last year his wife employed a new builder, ostensibly, her cousin, he was a member of her father’s extended family. The build was about 50% complete. Despite the payments Chris made to the builder there was little or no progression over the next 5 months.
Chris became suspicious. The day before our meeting he discovered that the new builder was not a family member, that he was not a registered builder, and that he was living with his wife.
We discussed his situation, the infidelity, and his emotional vulnerability. His sadness and disappointment aside, Chris remained positive, pragmatic, and resolute. His wife had another man to care for her. The THB 16,000 monthly support that he paid her would stop and she could keep the unfinished house. Being only half built, it would constitute her half share of their property settlement. Chris sent me a cartoon, see photo 5, which made his intention very clear. (Original cartoon credit Mike Baird)
Despite his positive attitude, the emotional pain associated with his wife’s deception and betrayal will endure. And emotional pain is often greater than physical pain.“Life can be so painful.â€
