From the Guidelines
Diagnosing a gout flare requires joint aspiration with synovial fluid analysis showing negatively birefringent monosodium urate crystals under polarized microscopy, as this is the gold standard for diagnosis, according to the 2020 European League Against Rheumatism evidence-based recommendations 1.
Key Diagnostic Features
- Sudden, severe joint pain, most commonly affecting the big toe (podagra), but can also occur in ankles, knees, elbows, wrists, and fingers
- The affected joint becomes red, swollen, hot, and extremely tender, often waking patients at night with intense pain
- Blood tests revealing elevated uric acid levels (typically >6.8 mg/dL) support the diagnosis but aren't definitive as levels may be normal during acute flares
- Imaging studies like ultrasound can show the "double contour" sign or X-rays may reveal punched-out erosions in chronic cases
Diagnostic Approach
- Search for crystals in synovial fluid or tophus aspirates is recommended in every person with suspected gout 1
- Gout should be considered in the diagnosis of any acute arthritis in an adult, with suggestive features including monoarticular involvement of a foot or ankle joint, previous similar acute arthritis episodes, rapid onset of severe pain and swelling, erythema, male gender, and associated cardiovascular diseases and hyperuricaemia 1
- The diagnosis of gout should not be made on the presence of hyperuricaemia alone 1
Management
- For immediate management, NSAIDs like indomethacin, colchicine, or corticosteroids can be used for pain relief
- Patients should rest the affected joint, apply ice, and maintain hydration
- The underlying cause is hyperuricemia resulting from either overproduction or underexcretion of uric acid, which forms crystal deposits in joints triggering an inflammatory response when crystals shift. Note that while other studies, such as those from the American College of Physicians 1, provide additional guidance on diagnosing acute gout, the 2020 European League Against Rheumatism evidence-based recommendations 1 are the most recent and highest quality study, and therefore take priority in guiding diagnosis and management.
From the Research
Diagnosing a Gout Flare
Diagnosing a gout flare involves several methods, including:
- Synovial fluid aspiration and analysis, which is considered the gold standard for diagnosis 2
- Clinical diagnosis based on patient history, physical examination, and serum urate measurement 2
- Use of validated clinical prediction rules 3
Clinical Presentation
Gout is characterized by:
- Swelling, pain, or tenderness in a peripheral joint or bursa 3
- Development of a tophus 3
- Severe pain, reducing quality of life for patients with this condition 4
Diagnostic Methods
- Arthrocentesis should be performed when suspicion for an underlying septic joint is present 3
- Synovial fluid or tophus analysis should be performed if the diagnosis is uncertain 3
- Serum urate measurement at the time of an acute attack and at follow-up 2 weeks later can aid in diagnosis 2
Treatment
Treatment for acute gout episodes includes: