What is the comprehensive evaluation for gout (gouty arthritis) in the inpatient setting?

From the Guidelines

The full workup for gout in the inpatient setting should include diagnostic testing, such as joint aspiration with synovial fluid analysis for monosodium urate crystals, complete blood count, comprehensive metabolic panel, inflammatory markers, and serum uric acid levels, as well as imaging studies like X-rays, ultrasound, or dual-energy CT to detect urate deposits.

Diagnostic Evaluation

• Joint aspiration of the affected joint with synovial fluid analysis for monosodium urate crystals is the gold standard for diagnosis 1
• Complete blood count, comprehensive metabolic panel, and inflammatory markers (ESR, CRP) should be obtained to assess for underlying conditions and disease severity
• Serum uric acid levels should be measured, though normal levels do not exclude acute gout as they may be normal or even low during an acute attack
• Imaging studies such as X-rays of the affected joint can help rule out other conditions, while ultrasound or dual-energy CT may detect urate deposits 1

Acute Management

• NSAIDs like indomethacin (50mg three times daily) or naproxen (500mg twice daily) are first-line for acute management if not contraindicated
• Alternatively, colchicine can be given (1.2mg followed by 0.6mg one hour later, then 0.6mg once or twice daily) or corticosteroids (prednisone 30-40mg daily with taper over 7-10 days, or intra-articular injection if only one joint is involved)
• Joint rest, elevation, and ice application are important supportive measures

Urate-Lowering Therapy

• Urate-lowering therapy (allopurinol, febuxostat) should not be initiated during an acute attack but can be started or continued if the patient is already on it 1
• The TFP recommended upwards dose titration of one XOI (allopurinol or febuxostat), to the respective maximum appropriate dose for the individual patient, and substitution of another XOI if the initial agent was not tolerated or did not achieve the serum urate target 1

Additional Recommendations

• Patients should be evaluated for underlying causes of hyperuricemia including medications, renal function, and metabolic disorders
• Dietary counseling regarding purine-rich foods, alcohol limitation, and weight management should be provided before discharge
• The TFP recommended pegloticase as appropriate only in the case scenarios with severe gout disease burden and refractoriness to, or intolerance of, appropriately dosed oral ULT therapy options 1

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Diagnosis of Gout

• Gout is caused by monosodium urate crystal deposition in joints and tissues 2
• Risk factors include male sex, obesity, hypertension, alcohol intake, diuretic use, and a diet rich in meat and seafood 2
• Diagnosis of gout can be made using several validated clinical prediction rules, and arthrocentesis should be performed when suspicion for an underlying septic joint is present 2
• Synovial fluid or tophus analysis should be performed if the diagnosis is uncertain 2

Treatment of Acute Gout

• Colchicine, nonsteroidal anti-inflammatory drugs, and corticosteroids relieve pain in adults with acute gout episodes 2
• Low-dose colchicine may improve treatment outcome compared to placebo with little or no increased risk of adverse events 3
• High-dose colchicine compared to placebo may improve symptoms, but with increased risk of harms 3
• Low-dose colchicine may be an effective treatment for acute gout when compared to placebo, and its benefits may be similar to NSAIDs 3

Urate-Lowering Therapy

• Indications for long-term urate-lowering therapy include chronic kidney disease, two or more flare-ups per year, urolithiasis, the presence of tophus, chronic gouty arthritis, and joint damage 2
• Allopurinol and febuxostat are used to prevent flare-ups, although febuxostat is associated with an increase in all-cause and cardiovascular mortality and is therefore not routinely recommended 2
• Febuxostat can play a major role in the treatment of hyperuricaemia and gout, and is a suitable pharmacological option for first line treatment of gout 4
• Urate-lowering medications should aim to lower serum uric acid concentrations at least below the target of 6 mg/dL (even below 5 mg/dL in patients with severe gout) 4

Management in the Inpatient Setting

• The management of gout in the inpatient setting involves the treatment of acute gout flares and the initiation of urate-lowering therapy 5
• Standard pharmacotherapies for gout flares include colchicine, NSAIDs, and oral or intramuscular corticosteroids, with IL-1 inhibitors newly established as an option for flare refractory to standard therapies 5
• Urate-lowering therapies aim to prevent gout flares, with an emphasis on treat-to-target strategy; the escalation of therapies until the target serum uric acid is reached 5