From the Guidelines
Healthcare providers should prioritize synovial fluid analysis for diagnosing acute gout when clinical judgment indicates that diagnostic testing is necessary, as recommended by the American College of Physicians 1.
Diagnosis and Management of Gout
Gout is a prevalent disease caused by excess urate crystals accumulating in body tissues and fluid, resulting in inflammatory arthritis. The diagnosis of gout relies on crystal identification in synovial fluid, clinical presentation, and serum uric acid levels.
- Key aspects of gout diagnosis include:
- Synovial fluid analysis for monosodium urate (MSU) crystals
- Clinical presentation, such as joint swelling and pain
- Serum uric acid levels
- Treatment of gout includes:
- Acute flare management with colchicine, NSAIDs, or corticosteroids
- Long-term management with urate-lowering therapy, such as allopurinol or febuxostat
- Prophylaxis with colchicine when initiating urate-lowering therapy to prevent flares
Importance of Certification
Certification in gout management demonstrates a provider's ability to effectively diagnose and manage this common but often suboptimally treated condition.
- Key components of certification include:
- Understanding the pathophysiology of gout, including impaired uric acid excretion or overproduction
- Knowledge of gout comorbidities, such as hypertension, diabetes, and kidney disease
- Familiarity with lifestyle modifications, including weight loss, limiting purine-rich foods, and reducing alcohol consumption
- According to the European League Against Rheumatism (EULAR) gout task force, evidence-based recommendations for the diagnosis of gout were developed using a combination of research-based evidence and expert consensus 1.
Clinical Decision Making
Clinical decision making in gout diagnosis and management involves considering the patient's clinical presentation, laboratory results, and medical history.
- Providers should be aware of the risk factors associated with gout, including male sex, overweight or obesity, hypertension, excess alcohol intake, diuretic use, and poor kidney function 1.
- The certification process requires understanding the importance of correctly diagnosing gout and differentiating it from other inflammatory arthritic conditions, such as rheumatoid arthritis, septic arthritis, and inflammatory episodes of osteoarthritis.
From the Research
Gout Certification Questions
- Gout is a common form of acute inflammatory arthritis caused by the deposition of monosodium urate crystals within synovium of joints, leading to severe pain and reduced quality of life for patients with this condition 2.
- 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 2, 3.
- Urate-lowering therapies aim to prevent gout flares, with an emphasis on treat-to-target strategy, and initial treatments include allopurinol and febuxostat, with uricosuric agents as adjuncts 2, 3.
- Lifestyle modifications form a part of gout prevention, and novel therapies, such as verinurad and arhalofenate, are a class for continued drug development 3.
- For patients with recalcitrant gout, pegloticase is effective, but its immunogenicity significantly threatens the achievement of sustained urate lowering responses 3.
- The treatment of acute gout includes nonpharmacologic and pharmacologic treatments, monotherapy versus combination therapy, suggested recommendations, guidelines for treatment, and drugs under development 4.
- A systematic review of the published data on the pharmacologic and non-pharmacologic agents used for the treatment of acute gouty arthritis showed that NSAIDs and COX-2 inhibitors are effective agents for the treatment of acute gout attacks 5.
- Long-term persistence of xanthine oxidase inhibitors (XOIs) as first-line urate-lowering therapy among patients with gout was suboptimal, and allopurinol had worse persistence rates than febuxostat among patients with gout 6.
Treatment Options
- First-line agents for gout flares:
- NSAIDs
- Colchicine
- Glucocorticoids
- Urate-lowering therapies:
- Allopurinol
- Febuxostat
- Uricosuric agents (e.g. probenecid, sulfinpyrazone, benzbromarone)
- Emerging therapies:
- IL-1 inhibitors
- Verinurad
- Arhalofenate
- Pegloticase
Patient Considerations
- Comorbidities (e.g. chronic kidney disease, ischemic heart disease) should be considered when adjusting pharmacotherapy 2.
- Patient preference should be taken into account when selecting treatment options 2.
- Poor health literacy is a common reason for XOI withdrawal, highlighting the need for patient education and support 6.