Who should be referred to a rheumatologist for gout management?

Who Should Be Referred to a Rheumatologist for Gout Management

Refer patients with gout to a rheumatologist when they have unclear etiology of hyperuricemia, refractory signs or symptoms despite treatment, difficulty reaching target serum urate (especially with renal impairment after trial of xanthine oxidase inhibitor), or multiple/serious adverse events from urate-lowering therapy. 1

Specific Referral Indications

The 2012 American College of Rheumatology guidelines explicitly identify four clinical scenarios requiring specialist referral 1:

1. Unclear Etiology of Hyperuricemia

• When the underlying cause of elevated uric acid cannot be determined through standard evaluation 1
• This includes cases where secondary causes remain uncertain despite appropriate workup 1

2. Refractory Disease

• Patients with persistent gout symptoms or signs despite appropriate first-line therapy 1
• Those experiencing frequent acute flares (≥2 attacks per year) that continue despite standard management 1
• Presence of chronic tophaceous gouty arthropathy with ongoing inflammation or deformity 1

3. Difficulty Achieving Target Serum Urate

• Particularly important in patients with renal impairment who have failed a trial of xanthine oxidase inhibitor (XOI) treatment 1
• When serum urate cannot be lowered below 6 mg/dL (360 μmol/L) despite dose escalation of first-line agents 1
• Patients with CKD stage 2 or worse who require complex medication adjustments 1

4. Multiple or Serious Adverse Events from Pharmacologic ULT

• Patients who develop significant side effects from allopurinol, febuxostat, or other urate-lowering medications 1
• Those requiring alternative therapeutic strategies due to drug intolerance 1

Additional Clinical Contexts Warranting Referral

Severe Tophaceous Disease

• Patients with multiple tophi on physical examination requiring aggressive urate-lowering to achieve target serum urate below 5 mg/dL (300 μmol/L) 1
• Cases where surgical intervention may be considered for nerve compression, mechanical impingement, or infection 1

Complex Comorbidity Management

• Patients with multiple comorbidities (metabolic syndrome, cardiovascular disease, chronic kidney disease) where medication selection becomes challenging 1
• Those requiring coordination between multiple specialists for optimal gout and comorbidity management 1

Common Pitfalls to Avoid

Do not delay referral in patients with refractory disease—early specialist involvement improves long-term outcomes and prevents irreversible joint damage 1. Many primary care providers wait too long before referring patients who are clearly not responding to standard therapy.

Do not refer patients with straightforward gout who respond well to first-line therapy—most gout can be managed effectively in primary care with allopurinol titration and lifestyle modifications 1. Referral should be reserved for the specific scenarios outlined above.

Do not assume all patients with tophi require immediate referral—if tophi are responding to medical management with sustained serum urate reduction, continued primary care management is appropriate 1.