Can a patient have both Rheumatoid Arthritis (RA) and gout?

Can a Patient Have Both RA and Gout?

Yes, patients can definitively have both rheumatoid arthritis and gout simultaneously, despite historical beliefs to the contrary. This coexistence is increasingly recognized and should be suspected when RA patients have oligoarthritis that fails to respond to standard treat-to-target antirheumatic therapy 1, 2.

Evidence for Coexistence

• More than 33 documented cases of concomitant RA and gout have been reported in the medical literature since 1964, with 13 patients identified in a recent University of Alberta case series 1.
• A 2025 nationwide South Korean cohort study of 34,356 RA patients demonstrated that RA patients have a 2.7-fold higher risk of developing gout compared to matched non-RA participants 3.
• Both seropositive RA (SPRA) and seronegative RA (SNRA) are associated with elevated gout risk, with SPRA showing slightly higher risk (adjusted hazard ratio 2.79 vs 2.56) 3.

Clinical Presentation Patterns

• In the majority of coexistence cases (8 of 13 patients), RA develops first and gout occurs subsequently, though the reverse sequence also occurs 1.
• The mean age at onset of the first disease is 55.3 years, with the second disease appearing at mean age 64.4 years 1.
• When both diseases affect the same joints, radiographic findings show gout changes predominating with milder RA changes 1.

Key Diagnostic Clues

Suspect coexistent gout in RA patients when:

• Oligoarthritis (particularly knee joints) persists despite aggressive RA treatment including biologics 2.
• Inflammatory symptoms are disproportionate to RA disease activity markers 4.
• Serum uric acid is elevated and inflammatory markers (ESR, CRP) are highly elevated beyond typical RA levels 4.

Diagnostic Confirmation

• Synovial fluid analysis demonstrating monosodium urate crystals under polarized microscopy is the gold standard 1, 2.
• Dual-energy CT has 87% sensitivity and 84% specificity for detecting monosodium urate deposition 5.
• Synovial or nodule biopsy can confirm urate crystal deposition when joint aspiration is not feasible 1.

Management Approach

For acute gout flares in RA patients:

• Treat immediately with colchicine (1 mg loading dose, then 0.5 mg one hour later) or oral corticosteroids (prednisolone 30-35 mg/day for 3-5 days) 6.
• Avoid NSAIDs given the high prevalence of comorbidities in this population 6.

For long-term management:

• Initiate urate-lowering therapy with allopurinol starting at 100 mg daily, titrating by 100 mg every 2-4 weeks to achieve serum uric acid <6 mg/dL 6.
• Mandatory flare prophylaxis with colchicine 0.5-1 mg daily for the first 6 months when starting urate-lowering therapy 6.
• Continue RA-directed therapy including biologics, as biologic/targeted synthetic DMARDs may actually reduce gout risk (adjusted hazard ratio 1.93 vs 2.78 for those not using these medications) 3.

Common Pitfalls

• Do not assume RA and gout are mutually exclusive—this outdated belief delays diagnosis and appropriate treatment 1, 7.
• Do not attribute all joint inflammation to RA alone when oligoarticular disease fails standard RA therapy 2.
• Do not stop urate-lowering therapy during acute flares, as this perpetuates the cycle of recurrent attacks 6.