Is it necessary to recheck uric acid levels if the initial level is mildly elevated before diagnosing gout?

From the Guidelines

It is not strictly necessary to recheck uric acid levels if the initial level is mildly elevated before diagnosing gout, as the diagnosis should be based on a combination of clinical features, laboratory tests, and imaging studies, with the gold standard being joint fluid analysis showing monosodium urate crystals 1. The 2018 updated European League Against Rheumatism evidence-based recommendations for the diagnosis of gout emphasize the importance of a three-step approach for diagnosis, starting with the search for MSU crystals, followed by clinical diagnosis if crystal identification is not feasible, and finally imaging to search for evidence of MSU crystal deposition when the diagnosis is uncertain 1. Some key points to consider in the diagnosis of gout include:

• The presence of hyperuricaemia alone is not sufficient for a diagnosis of gout, as it has a low specificity ranging from 53% to 61% 1.
• The absence of hyperuricaemia, however, makes the diagnosis of gout unlikely, but does not completely exclude it, as roughly 10% of people with gout have normal serum uric acid levels 1.
• Clinical algorithms based on symptoms and signs have been developed, with sensitivities and specificities greater than 80% compared to the gold standard of MSU crystal demonstration in synovial fluid, but these should be used with caution and in conjunction with other diagnostic modalities 1.
• The American College of Physicians recommends using synovial fluid analysis when diagnostic testing is necessary in patients with possible acute gout, although this may not always be feasible in primary care settings 1. Given the complexity of diagnosing gout and the potential for misdiagnosis, a comprehensive approach considering clinical features, laboratory tests, and imaging studies is essential for accurate diagnosis and appropriate management.

From the Research

Uric Acid Levels and Gout Diagnosis

• The provided studies do not directly address the necessity of rechecking uric acid levels if the initial level is mildly elevated before diagnosing gout 2, 3, 4, 5, 6.
• However, it is mentioned that reduction of uric acid levels is key to avoiding gout flares, and urate-lowering therapies aim to prevent gout flares with an emphasis on a treat-to-target strategy 3, 5.
• The target serum uric acid level is not explicitly stated in the provided studies, but it is implied that treatment should continue until uric acid levels fall below a certain target goal 3.
• In patients with chronic kidney disease (CKD), hyperuricaemia is common, and urate-lowering therapy (ULT) has been shown to confer clinical benefits in slowing CKD progression 6.

Treatment and Management of Gout

• The management of gout involves treating the acute attack, lowering excess stores of uric acid to prevent flares, and providing prophylaxis to prevent acute flares 2, 3, 4, 5.
• Non-steroidal anti-inflammatory drugs, colchicine, and corticosteroids are options for the management of acute gout, while allopurinol and febuxostat are first-line medications for the prevention of recurrent gout 2, 3, 4, 5.
• Uricosuric drugs, such as probenecid, increase uric acid excretion and may be used as adjuncts to urate-lowering therapies 2, 4, 5.