Should You Check Uric Acid Before Treating Suspected Gout?
No, you should not delay treatment of suspected gout to check uric acid levels first—diagnosis is clinical, and serum uric acid during an acute flare is often misleadingly normal or low. 1
Why Uric Acid Testing During Acute Gout Is Unreliable
Uric acid behaves as a negative acute phase reactant during inflammation, meaning levels can be normal or even low during an acute gout attack despite the patient having chronic hyperuricemia. 1 This makes it an unreliable diagnostic test during the acute presentation.
The diagnosis of gout is primarily clinical, based on American College of Rheumatology criteria, with the gold standard being identification of monosodium urate crystals in synovial fluid of the affected joint. 2
The highest clinical diagnostic value comes from the presence of monosodium urate crystals and/or tophus, and response to colchicine—not from serum uric acid levels during the acute attack. 3
When to Check Uric Acid Levels
Serum uric acid should be measured as a baseline after the acute flare has been treated, to guide long-term urate-lowering therapy decisions and subsequent dose titration. 1
The target for urate-lowering therapy is serum urate <6 mg/dL (360 μmol/L), but this measurement is most useful when obtained outside of an acute inflammatory episode. 1
Baseline uric acid helps establish the starting point for dose titration of medications like allopurinol, with rechecking every 2-5 weeks during dose escalation. 1
Practical Approach to Suspected Gout
Treat the acute attack immediately based on clinical presentation—typically with NSAIDs, colchicine, or corticosteroids—without waiting for laboratory confirmation. 4, 2
The most important determinant of therapeutic success is how soon treatment is initiated, not which specific agent is chosen. 4
For acute gout treatment, colchicine dosing is 1.2 mg at first sign of flare followed by 0.6 mg one hour later (maximum 1.8 mg over one hour). 5
After treating the acute attack, measure serum uric acid to determine if the patient meets criteria for long-term urate-lowering therapy. 1
Indications for Long-Term Urate-Lowering Therapy
Once you've confirmed gout and measured baseline uric acid, strongly recommend urate-lowering therapy for patients with: 6
- Frequent gout flares (≥2 per year) 6
- One or more subcutaneous tophi 6
- Radiographic damage attributable to gout on any imaging modality 6
Conditionally recommend urate-lowering therapy for first flare if: 6, 1
Common Pitfalls to Avoid
Do not withhold acute gout treatment while waiting for uric acid results—this delays appropriate therapy and worsens patient outcomes. 1
Do not rule out gout based on a "normal" uric acid level during an acute attack—up to 40% of patients with acute gout have normal serum uric acid at presentation. 1
Do not start urate-lowering therapy during the first visit for acute gout without anti-inflammatory prophylaxis—while you can start allopurinol during a flare, you must provide concomitant colchicine, NSAIDs, or corticosteroids for prophylaxis. 1, 7