Content on this page:
Content on this page:
Clinical Presentation
Clinical Phases of Gout
Acute Gout
Gout_Initial Assesment 1
Acute gout usually manifests as an acute, self-limiting, monoarticular inflammatory arthritis in majority of patients. The symptoms of a gout flare include severe pain, redness, swelling, warmth and disability. Lower extremity joints are affected more often than upper extremity joints. The joints that are affected most include the first metatarsophalangeal joint (podagra), forefoot, ankle, and knee. Extra-articular sites (eg olecranon bursa and Achilles tendon) may also be involved.
The attacks may occur and last from a few days to 2-3 weeks, with the resolution of all inflammatory signs.
- Early attack: <12 hours after onset of attack
- Well-established attack: 12-36 hours after onset of attack
- Late attack: >36 hours after attack onset
Intercritical Gout
Intercritical gout are periods in-between attacks when the patient is free of symptoms. Asymptomatic joints may still have crystals detected in the synovial fluid.
Chronic Gout
If hyperuricemia is not treated properly, intermittent acute gouty attacks can develop into chronic gouty arthritis. There is persistent inflammation in the joints and connective tissues associated with bony erosions and deformities. Chronic tophaceous gout is marked by polyarticular arthritis and the formation of tophi which are chalky deposits of monosodium urate. The tophi are usually painless, appearing as firm, nodular or fusiform masses located subcutaneously. In this phase, the tophi—which are firm, mass-like collections of monosodium urate crystals—form in various parts of the body, including the ears, joints, tendons, finger pads, and olecranon bursae. The risk factors for chronic tophaceous gout include polyarticular presentation, and a serum urate level 9 mg/dL (>0.54 mmol/L). The presence of urate nephropathy or urate renal calculi may also be seen in chronic gout.
Gout_Initial Assesment 2Diagnosis or Diagnostic Criteria
Gout Classification Criteria1
The gout classification criteria were developed by the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) in 2015. This is based on the presence of monosodium urate crystals, imaging modalities, and clinical parameters. This method provides a scoring system for a patient’s symptomatic episode, regardless of the clinical phase. A total score of ≥8 confirms the diagnosis of gout. The entry criterion is defined as at least one episode of swelling, pain, or tenderness in a peripheral joint or bursa. Sufficient criterion should be considered with the presence of urate crystals in a symptomatic joint or bursa, or a positively-identified tophus. The classification criteria should be used if sufficient criterion is not met.
| Criteria | Categories | Score |
| Clinical Parameters (Per Symptomatic Episode) |
||
| Pattern of joint or bursa involvement | Ankle or midfoot First metatarsophalangeal joint |
1 2 |
| Characteristics: Erythema overlying affected joint Unable to tolerate touch or pressure on the affected joint Difficulty with walking or unable to use affected joint |
One characteristic Two characteristics Three characteristics |
1 2 3 |
| Time course: Presence of ≥2 of the following regardless of anti-inflammatory treatment: Time to maximal pain <24 hours Resolution of symptoms happen in ≤14 days Complete resolution between symptomatic episodes |
One typical episode Recurrent typical episodes |
1 2 |
| Clinical evidence of tophus2 | Present | 4 |
| Laboratory Parameters |
||
| Serum urate3,4 | <4 mg/dL (<0.24 mmol/L) 6-<8 mg/dL (0.36-<0.48 mmol/L) 8-<10 mg/dL (0.48-<0.60 mmol/L) ≥10 mg/dL (≥0.60 mmol/L) |
-4 2 3 4 |
| Synovial fluid analysis per symptomatic episode | MSU negative | -2 |
| Radiologic Parameters5 | ||
| Evidence of urate deposition: Double-contour sign seen with ultrasound or urate deposition seen by dual-energy computed tomography (DECT) | Present | 4 |
| Evidence of gout-related joint damage: At least one erosion seen using conventional radiography of the hands and/or feet | Present | 4 |
| 1Reference: Neogi T, Jansen TL, Dalbeth N, et al. 2015 Gout classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheumatol. 2015 Oct;67(10):2557-2568. 2Tophus characterized as a draining or chalk-like subcutaneous nodule under transparent skin, often with overlying vascularity, usually located in joints, ears, olecranon bursae, finger pads, and/or tendons. 3Obtained using the uricase method; scoring should be done while the patient is not taking urate-lowering drugs and >4 weeks have passed since the occurrence of symptoms. 4For serum urate results of >4-<6 mg/dL (>0.24-<0.36 mmol/L), score to be given is 0. 5A score of 0 is given if imaging modalities are unavailable. |
||
European League Against Rheumatism (EULAR) Recommendations for the Diagnosis of Gout
The presence of hyperuricemia alone is not diagnostic of gout. Look for crystals in the synovial fluid or tophus aspirates in suspected gout patients, as the presence of monosodium citrate is a definitive diagnosis of gout. In patients with undiagnosed inflammatory arthritis, it is recommended to have synovial fluid aspiration and crystal examination. In any acute arthritis in an adult, gout should be considered in the diagnosis. In patients with an uncertain clinical diagnosis of gout and when identification of crystals is not possible, patients should be investigated by imaging to search for monosodium urate crystal deposition and features of any alternative diagnosis. Search for imaging evidence of monosodium urate by the use of plain radiographs. Ultrasound scanning is used to establish a gout diagnosis in patients with suspected gout flare or chronic gouty arthritis. The risk factors for chronic hyperuricemia should be investigated in patients with gout. It is recommended to have a systematic assessment of associated comorbidities in patients with gout.
Diagnostic Rule for Gout in the Primary Care Setting
The likelihood of gout can be estimated in the primary care setting without joint fluid analysis using the following variables: Symptom onset within 24 hours (0.5 points), joint redness (1 point), hypertension or at least one cardiovascular disease (CVD) (1.5 points), male gender (2 points), prior patient-reported arthritis (2 points), involvement of the first metatarsophalangeal joint (2.5 points), and serum urate level >5.88 mg/dL (>350 micromol/L) (3.5 points). The probability of gout is low at ≤4 points, intermediate at 5-7 points, or high at ≥8 points and joint fluid analysis may be done in patients in the intermediate group.