Does the erythrocyte sedimentation rate (ESR) increase during an acute gout flare?

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Last updated: September 11, 2026 • View editorial policy

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ESR Elevation During Acute Gout Flares

Yes, the erythrocyte sedimentation rate (ESR) typically increases during an acute gout flare as part of the inflammatory response to monosodium urate crystal deposition.

Evidence for ESR Elevation in Acute Gout

During acute gout attacks, inflammatory markers become elevated because the condition is fundamentally an inflammatory reaction to urate crystal deposition in joints. Multiple recent studies confirm ESR elevation during acute flares:

  • In a 2014 study of 30 patients with acute gout attacks, 76.6% demonstrated elevated ESR levels 1. Notably, this inflammatory response occurred even when serum uric acid levels were normal (63.3% of patients had normal uric acid during acute attacks).

  • A 2023 study comparing acute versus intercritical gout found significantly higher ESR in the acute phase 2. ESR correlated positively with other inflammatory markers and was identified as an independent predictor of acute gout attacks in multivariate analysis.

  • A 2024 study examining post-surgical gout flares documented that ESR was significantly elevated in both acute gout attacks and infections, though C-reactive protein (CRP) was higher in infections (220.97 mg/L) versus acute gout (120.67 mg/L) 3.

Clinical Context and Interpretation

The inflammatory cascade in acute gout involves neutrophil activation and cytokine release, which drives ESR elevation 4, 5. However, several important caveats exist:

ESR is non-specific: While ESR rises during acute flares, it cannot distinguish gout from other inflammatory or infectious conditions. The 2024 surgical study showed both gout flares and joint infections produce elevated ESR 3.

CRP may be more discriminative: Recent evidence suggests CRP provides better disease discrimination than ESR across rheumatic conditions 6. In the 2023 study, CRP had an AUC of 0.755 for diagnosing acute gout versus 0.664 for ESR 2.

Discordance occurs: Approximately 27% of patients show isolated elevation of either CRP or ESR but not both, indicating these markers provide complementary rather than redundant information 6.

Practical Implications

When evaluating suspected acute gout:

  • Expect ESR elevation in most (but not all) acute flares - roughly 75-80% of cases based on available data
  • Normal ESR does not exclude acute gout - the diagnosis rests on clinical presentation and response to anti-inflammatory therapy 4, 1
  • Use ESR alongside CRP for better diagnostic accuracy, as discordance is common 6
  • Remember that serum uric acid may be normal during acute attacks due to increased urinary excretion and inflammatory factors 1

The definitive diagnosis of gout requires either synovial fluid analysis showing monosodium urate crystals or clinical diagnosis based on characteristic presentation and therapeutic response to colchicine, NSAIDs, or corticosteroids 4, 5.

References

1
Research

Acute gout attack with normal serum uric acid levels.

Revista medico-chirurgicala a Societatii de Medici si Naturalisti din Iasi, 2014

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