Gout

Also known as Gouty arthritis · Podagra · Monosodium urate crystal disease

GP-fellowship guide to gout: the crystal-confirmed diagnosis and 2015 ACR/EULAR criteria, acute flare management with low-dose colchicine (CLEAR trials), oral and intra-articular steroids, urate-lowering therapy indications and target-driven allopurinol titration, the ACR 2020 positions, febuxostat cardiovascular caution after CARES, prophylaxis duration during ULT initiation, lifestyle modification with real effect sizes, and the comorbid clustering that makes gout a metabolic disease marker.

high20 referencesUpdated 22 Aug 20269 min readVerification in progress

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Key points

Gout is the clinical expression of monosodium urate crystal deposition; crystal confirmation from synovial fluid or tophus remains the gold standard, but the 2015 ACR/EULAR criteria (92% sensitivity, 89% specificity) formalise clinical diagnosis.^[20]
Acute flares: low-dose colchicine (1 mg then 500 µg) matches high-dose efficacy with a placebo-like safety profile; oral prednisolone equals indomethacin; intra-articular steroid suits monoarticular flares.^[3]^[5]^[4]
Urate-lowering therapy is indicated for frequent flares, tophi, radiographic damage and urate stones; allopurinol is first-line, started at 50–100 mg and titrated monthly to serum urate below 0.36 mmol/L (below 0.30 with tophi).^[1]
Prophylactic anti-inflammatory cover for 3–6 months accompanies every ULT start — flare rates fall from 40% at 8 weeks to 3–5% at 6 months of prophylaxis.^[6]

Overview

Gout is the most common inflammatory arthritis in men and its burden is rising: 55.8 million people had gout globally in 2020, age-standardised prevalence rose 22.5% since 1990, and prevalence is projected to grow more than 70% by 2050 on population growth and ageing alone.^[13] High body mass index accounts for 34.3% of the disability gout causes and kidney dysfunction for 11.8% — gout is a metabolic disease marker as much as a joint disease.^[13]

The consulting-room stakes are high because the treatment gap is enormous: most patients with recurrent gout are never offered urate-lowering therapy, and most who are offered it abandon it. Recent reviews frame this as the central failure of gout care — effective drugs, poorly deployed.^[19] Every gout consultation is a chance to close that gap.

References20Show

[1]FitzGerald JD, Dalbeth N, Mikuls T, Brignardello-Petersen R, Guyatt G, et al. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Rheumatol, 2020.PMID 32390306
[2]McKenzie BJ, Wechalekar MD, Johnston RV, Schlesinger N, Buchbinder R Colchicine for acute gout. Cochrane Database Syst Rev, 2021.PMID 34438469
[3]Terkeltaub RA, Furst DE, Bennett K, Kook KA, Crockett RS, Davis MW High versus low dosing of oral colchicine for early acute gout flare: Twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study. Arthritis Rheum, 2010.PMID 20131255
[4]White WB, Saag KG, Becker MA, Borer JS, Gorelick PB, et al. Cardiovascular Safety of Febuxostat or Allopurinol in Patients with Gout. N Engl J Med, 2018.PMID 29527974
[5]Rainer TH, Cheng CH, Janssens HJ, Man CY, Tam LS, et al. Oral Prednisolone in the Treatment of Acute Gout: A Pragmatic, Multicenter, Double-Blind, Randomized Trial. Ann Intern Med, 2016.PMID 26903390
[6]Wortmann RL, Macdonald PA, Hunt B, Jackson RL Effect of prophylaxis on gout flares after the initiation of urate-lowering therapy: analysis of data from three phase III trials. Clin Ther, 2010.PMID 21353107
[7]Jennings CG, Mackenzie IS, Flynn R, Ford I, Nuki G, et al. Up-titration of allopurinol in patients with gout. Semin Arthritis Rheum, 2014.PMID 24560169
[8]Zhang Q, Gao F, Sun W, Ma J, Cheng L, Li Z The diagnostic performance of musculoskeletal ultrasound in gout: A systematic review and meta-analysis. PLoS One, 2018.PMID 29979706
[9]Gamala M, Jacobs JWG, van Laar JM The diagnostic performance of dual energy CT for diagnosing gout: a systematic literature review and meta-analysis. Rheumatology (Oxford), 2019.PMID 31089688
[10]Choi HK, Atkinson K, Karlson EW, Willett W, Curhan G Purine-rich foods, dairy and protein intake, and the risk of gout in men. N Engl J Med, 2004.PMID 15014182
[11]Choi HK, Curhan G Soft drinks, fructose consumption, and the risk of gout in men: prospective cohort study. BMJ, 2008.PMID 18244959
[12]Lyu JQ, Miao MY, Wang JM, Qian YW, Han WW, et al. Consumption of Total and Specific Alcoholic Beverages and Long-Term Risk of Gout Among Men and Women. JAMA Netw Open, 2024.PMID 39196557
[13]GBD 2021 Gout Collaborators Global, regional, and national burden of gout, 1990-2020, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol, 2024.PMID 38996590
[14]Kannangara DRW, Graham GG, Wright DFB, Stocker SL, Portek I, et al. Individualising the dose of allopurinol in patients with gout. Br J Clin Pharmacol, 2017.PMID 28417592
[15]Miravitlles M, Dirksen A, Ferrarotti I, Koblizek V, Lange P, et al. European Respiratory Society statement: diagnosis and treatment of pulmonary disease in α(1)-antitrypsin deficiency. Eur Respir J, 2017.PMID 29191952
[16]van Durme CM, Wechalekar MD, Landewé RB, Pardo Pardo J, Cyril S, et al. Non-steroidal anti-inflammatory drugs for acute gout. Cochrane Database Syst Rev, 2021.PMID 34882311
[17]Wechalekar MD, Vinik O, Schlesinger N, Buchbinder R Intra-articular glucocorticoids for acute gout. Cochrane Database Syst Rev, 2013.PMID 23633379
[18]Park DJ, Kang JH, Lee JW, Lee KE, Wen L, et al. Cost-effectiveness analysis of HLA-B5801 genotyping in the treatment of gout patients with chronic renal insufficiency in Korea. Arthritis Care Res (Hoboken), 2015.PMID 25047754
[19]Afinogenova Y, Danve A, Neogi T Update on gout management: what is old and what is new. Curr Opin Rheumatol, 2022.PMID 34907116
[20]Neogi T, Jansen TL, Dalbeth N, Fransen J, Schumacher HR, et al. 2015 Gout classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Ann Rheum Dis, 2015.PMID 26359487