Gout is an inflammatory arthritis triggered by elevated uric acid in the bloodstream, leading to intensely painful attacks. To standardize care, the American College of Rheumatology (ACR) develops evidence-based guidelines for clinicians. These guidelines provide a framework for diagnosis, flare management, and long-term treatment.
Confirming a Gout Diagnosis
The diagnostic process begins with hallmark symptoms: a sudden, severe episode of pain, redness, and swelling in a single joint, most commonly the big toe. While these signs are strong indicators, the ACR guidelines outline a definitive process to ensure an accurate diagnosis before starting lifelong therapy. A blood test to measure serum urate (uric acid) is a standard step, but a high level alone is not enough to confirm gout.
The most conclusive test involves analyzing synovial fluid from an affected joint for needle-shaped monosodium urate crystals. Clinicians may also use criteria from the ACR and the European Alliance of Associations for Rheumatology (EULAR) that combines clinical, lab, and imaging findings to classify a patient as having gout.
Managing Acute Gout Attacks
When a gout flare occurs, the goal is to control pain and inflammation. The ACR guidelines recommend initiating treatment as quickly as possible for the best results. The choice among several first-line options depends on the patient’s overall health, other medical conditions, and potential drug interactions.
One primary option is nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen or indomethacin, to reduce pain and swelling. Another recommended first-line treatment is colchicine. The guidelines specify a low-dose regimen of colchicine, as it is as effective as older, high-dose regimens but with fewer side effects.
A third option for managing flares is corticosteroids, like prednisone, taken orally. If only one or two joints are affected, a corticosteroid injection directly into the joint can provide rapid relief. The guidelines also note that topical ice can be a useful therapy for pain control.
When to Start Long-Term Medication
A single gout attack does not automatically mean a person needs long-term medication. The decision to start urate-lowering therapy (ULT) is based on the patient’s disease pattern and risk factors. The ACR guidelines recommend initiating ULT for individuals with specific disease features indicating a more persistent course.
The guidelines advise starting ULT for any patient with one or more tophi. Tophi are chalky, subcutaneous deposits of urate crystals that can cause erosion of the underlying bone. Another indication for this therapy is joint damage from gout visible on imaging studies.
Frequent gout flares are another trigger for initiating ULT, which the ACR recommends for patients with two or more attacks per year. For patients with a first flare or less frequent attacks, the decision is conditional. ULT may be recommended if they also have co-existing conditions, such as chronic kidney disease (stage 3 or worse), a serum urate level above 9 mg/dL, or a history of uric acid kidney stones.
Goals of Long-Term Treatment
Long-term gout management is centered on a ‘treat-to-target’ strategy. This approach aims to lower uric acid levels to prevent future attacks and resolve existing crystal deposits. The primary goal is to achieve and maintain a serum urate level below 6 mg/dL. This target stops new crystals from forming and allows existing ones to dissolve over time.
To achieve this, the guidelines recommend allopurinol as the first-line ULT medication, including for patients with chronic kidney disease. Treatment begins with a low dose that is gradually increased based on regular monitoring of serum urate levels until the target is reached. For patients who cannot take or do not respond to allopurinol, medications like febuxostat may be used.
Initiating ULT can temporarily increase the risk of gout flares as dissolving crystals trigger an inflammatory response. To mitigate this, the ACR recommends a concurrent anti-inflammatory medication, such as low-dose colchicine or an NSAID. This prophylactic treatment should continue for at least three to six months to prevent attacks as the body adjusts.
Lifestyle and Co-existing Condition Recommendations
While medical therapy is the primary focus, the ACR guidelines also provide conditional recommendations for lifestyle modifications. These are helpful but are not a substitute for urate-lowering medication. Patients are advised to limit their consumption of alcohol (especially beer) and purine-rich foods like red meat and some seafood.
The guidelines also conditionally recommend limiting high-fructose corn syrup, found in sugary drinks, and encourage gradual weight loss for overweight patients. Managing co-existing medical conditions is also addressed. For a patient with gout and high blood pressure, losartan is a preferable choice as it lowers blood pressure and has a modest effect on uric acid. Conversely, certain diuretics like hydrochlorothiazide can raise uric acid levels, so switching to an alternative may be considered.