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Gout

Definition
Gout is a type of inflammatory arthritis characterized by the deposition of monosodium urate monohydrate crystals in synovial fluid and other tissues.
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Pathophysiology
Gout is due to persistently elevated blood levels of uric acid (hyperuricemia), which is often multifactorial (increased intake of purine-rich foods, defects in purine metabolism, older age, male sex, obesity, renal failure, diuretics).
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Epidemiology
In the US, the prevalence of gout is estimated at 3,900 persons per 100,000 population. The incidence of gout is estimated at 400 per 100,000 person-years in men, and 140 per 100,000 person-years in women.
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Disease course
In patients with acute gout, deposition of urate monohydrate crystals inside joint cavities initiate an inflammatory response that results in the clinical manifestations of arthritis. Chronic synovitis, bony erosions, cartilage damage, and tophi formation may occur in patients with chronic gout.
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Prognosis and risk of recurrence
The 1-year recurrence rate for acute gout attack in patients who have experienced an attack in the past year is estimated at 69%.
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Key sources
The following summarized guidelines for the evaluation and management of gout are prepared by our editorial team based on guidelines from the American College of Rheumatology (ACR 2023; 2020; 2012), the European League Against Rheumatism (EULAR 2022; 2020; 2017), the American College of Radiology (ACR 2017), the Treat-to-target (T2T 2017), the British Society for Rheumatology (BSR 2017), the American College of Physicians (ACP 2017), and the Clinical Pharmacogenetics Implementation Consortium (CPIC 2013).
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Guidelines

1.Screening and diagnosis

Diagnosis: include gout in the differential diagnosis of any adult patient with acute arthritis.
B
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2.Diagnostic investigations

Clinical evaluation: as per EULAR 2020 guidelines, assess for risk factors for chronic hyperuricemia in all patients with gout, specifically CKD, overweight, medications (including diuretics, low-dose aspirin, cyclosporine, tacrolimus), consumption of excess alcohol (particularly beer and spirits), non-diet sodas, meat and shellfish.
A

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  • Diagnostic imaging

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3.Diagnostic procedures

Synovial fluid analysis
As per EULAR 2020 guidelines:
Perform synovial fluid aspiration and examination for crystals in any patient with undiagnosed inflammatory arthritis.
B
Assess for the presence of crystals in synovial fluid or tophus aspirates in all patients with suspected gout, because demonstration of monosodium urate monohydrate crystals allows a definitive diagnosis of gout.
B

4.Medical management

Management of acute flares: as per ACR 2020 guidelines, initiate concomitant anti-inflammatory prophylaxis therapy (such as colchicine, NSAIDs, prednisone/prednisolone) in patients with gout. Select the specific agent of anti-inflammatory prophylaxis based on patient factors.
B
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  • Indications for urate-lowering therapy

  • Treatment targets

  • Allopurinol

  • Xanthine oxidase inhibitors

  • Uricosuric therapy

  • Pegloticase

  • Anti-inflammatory therapy

5.Nonpharmacologic interventions

Discontinuation of contributing medications: discontinue non-essential medications that are associated with elevation in serum urate levels (such as thiazide diuretics, loop diuretics, niacin, and calcineurin inhibitors).
B

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  • Rest and ice packs

  • Dietary modifications

  • Weight loss

  • Exercise

  • Alcohol intake

  • Alkohol intake

  • Vitamin C

6.Specific circumstances

Carriers of HLA-B5801: avoid prescribing allopurinol in carriers of the HLA-B5801 allele.
D

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  • Patients taking antihypertensive medications

  • Patients taking aspirin

  • Patients taking fenofibrate

7.Patient education

Patient education: as per BSR 2017 guidelines, educate patients on the importance of initiating treatment for attacks as soon as an attack occurs. Ensure that patients are aware of the importance of continuing any established urate-lowering therapy during an attack.
B
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8.Preventative measures

Routine immunizations: consider offering high-dose or adjuvanted influenza vaccination, rather than regular-dose influenza vaccination, in ≥ 65 years old patients with rheumatic or musculoskeletal diseases and in 18-65 years old patients with rheumatic or musculoskeletal diseases on immunosuppressive medications.
C
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9.Follow-up and surveillance

Indications for specialist referral: refer patients for specialist consultation in the following situations:
unclear etiology of hyperuricemia
refractory signs or symptoms of gout
difficulty in reaching the target serum urate level, particularly with renal impairment and a trial of xanthine oxidase inhibitor treatment
multiple and/or serious adverse events from pharmacologic urate-lowering therapy
B

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  • Serum urate monitoring

  • Indications for switching urate-lowering agents

  • Management of refractory disease