From the Guidelines
The key indicator to differentiate between acute and chronic gout is the pattern and duration of symptoms, with acute gout presenting as sudden, intense joint pain, swelling, redness, and warmth, and chronic gout characterized by persistent inflammation, recurrent attacks, and progressive joint damage. According to the American College of Physicians guideline 1, the diagnosis of gout is based on clinical presentation, laboratory findings, and imaging studies. The guideline recommends that clinicians choose corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), or colchicine to treat patients with acute gout, and use low-dose colchicine when using colchicine to treat acute gout 1.
Key Indicators of Acute and Chronic Gout
- Acute gout: sudden, intense joint pain, swelling, redness, and warmth, often affecting a single joint (commonly the big toe) 1
- Chronic gout: persistent inflammation, recurrent attacks with decreasing pain-free intervals, development of tophi (hard, painless deposits of urate crystals under the skin), and progressive joint damage 1
- Definitive diagnostic test: joint aspiration with polarized light microscopy showing negatively birefringent monosodium urate crystals 1
- Laboratory findings: elevated serum uric acid levels (hyperuricemia), though these levels may be normal during acute attacks 1
- Imaging studies: conventional radiographs showing normal findings in acute gout but erosions with overhanging edges and tophi in chronic cases 1
Pathophysiology and Treatment
The underlying pathophysiology involves urate crystal deposition triggering inflammatory cascades, with chronic exposure leading to permanent joint damage and disability if left untreated 1. The American College of Physicians guideline recommends that clinicians discuss benefits, harms, costs, and individual preferences with patients before initiating urate-lowering therapy, including concomitant prophylaxis, in patients with recurrent gout attacks 1.
Clinical Decision Making
Clinicians should use synovial fluid analysis when clinical judgment indicates that diagnostic testing is necessary in patients with possible acute gout 1. The guideline also recommends against initiating long-term urate-lowering therapy in most patients after a first gout attack or in patients with infrequent attacks 1.
From the Research
Indicators of Acute or Chronic Gout
The indicators of acute or chronic gout are not explicitly stated in the provided studies. However, the following points can be inferred:
- Acute gout is characterized by severe pain, inflammation, and deposition of monosodium urate crystals within the synovium of joints 2.
- Chronic gout is associated with recurrent gout flares, joint damage, and the need for long-term uric acid reduction therapy 3, 4.
Diagnostic Considerations
The diagnosis of gout is often based on clinical presentation, medical history, and laboratory tests, including:
- Serum uric acid levels: a level below 360 µmol/l is considered a target for treatment 3.
- Joint aspiration and synovial fluid analysis to detect monosodium urate crystals 2.
- Medical history and physical examination to assess for comorbidities and joint damage 5, 4.
Treatment Options
Treatment options for acute and chronic gout include:
- Nonsteroidal anti-inflammatory drugs (NSAIDs) for acute gout attacks 6, 5, 4.
- Colchicine for acute gout attacks and prophylaxis of relapses 6, 3, 5.
- Corticosteroids for acute gout attacks and prophylaxis of relapses 6, 3, 5.
- Xanthine oxidase inhibitors (e.g., allopurinol, febuxostat) for long-term uric acid reduction 2, 3, 4.
- Uricosuric agents and novel uric acid reabsorption inhibitors as add-on therapies for urate-lowering therapy 4.