Skip to main content

Main menu

  • Home
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
    • COVID-19 Articles
  • Authors & Reviewers
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
    • Open access
    • Patient engagement
  • Members & Subscribers
    • Benefits for CMA Members
    • CPD Credits for Members
    • Subscribe to CMAJ Print
    • Subscription Prices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
    • Trousse média 2023
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN

User menu

Search

  • Advanced search
CMAJ
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN
CMAJ

Advanced Search

  • Home
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
    • COVID-19 Articles
  • Authors & Reviewers
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
    • Open access
    • Patient engagement
  • Members & Subscribers
    • Benefits for CMA Members
    • CPD Credits for Members
    • Subscribe to CMAJ Print
    • Subscription Prices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
    • Trousse média 2023
  • Visit CMAJ on Facebook
  • Follow CMAJ on Twitter
  • Follow CMAJ on Pinterest
  • Follow CMAJ on Youtube
  • Follow CMAJ on Instagram
Practice
Open Access

Gout

Timothy S.H. Kwok, Victoria Y.Y. Xu and Shirley L. Lake
CMAJ February 01, 2021 193 (5) E171; DOI: https://doi.org/10.1503/cmaj.201392
Timothy S.H. Kwok
Department of Medicine (Kwok, Xu, Lake), and Divisions of Geriatric Medicine (Xu) and Rheumatology (Lake), University of Toronto; Division of Rheumatology (Lake), Sunnybrook Health Sciences Centre, Toronto, Ont.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Victoria Y.Y. Xu
Department of Medicine (Kwok, Xu, Lake), and Divisions of Geriatric Medicine (Xu) and Rheumatology (Lake), University of Toronto; Division of Rheumatology (Lake), Sunnybrook Health Sciences Centre, Toronto, Ont.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Shirley L. Lake
Department of Medicine (Kwok, Xu, Lake), and Divisions of Geriatric Medicine (Xu) and Rheumatology (Lake), University of Toronto; Division of Rheumatology (Lake), Sunnybrook Health Sciences Centre, Toronto, Ont.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Tables
  • Related Content
  • Responses
  • Metrics
  • PDF
Loading

The prevalence of gout is rising, and many patients have common comorbidities

The prevalence of gout is about 4%, reflecting a 59% increase over the past decade.1 More than 60% of patients with gout also have a metabolic syndrome, so patients should be assessed with this in mind. Risk factors for gout include male sex, increasing age, chronic kidney disease, dehydration (including diuretic use), hyperuricemia from rapid cell turnover (e.g., hemolysis, chemotherapy) and excessive purine consumption (Appendix 1A and B available at www.cmaj.ca/lookup/doi/10.1503/cmaj.201392/tab-related-content).2

Gout flares are typically monoarticular, reaching maximal intensity within hours

Flares often occur at night and usually target distal joints (e.g., first metatarsophalangeal joint). Joints with previous trauma and degenerative changes are predisposed to gout (Appendix 1C). Periarticular erythema, warmth and overlying desquamation may mimic infection.2 The differential diagnosis for acute gout includes septic arthritis, traumatic arthritis and hemarthrosis, especially among patients on anticoagulants. In contrast to gout, osteoarthritis tends to present as a chronic condition, and inflammatory arthritis is typically of polyarticular distribution.2

Synovial fluid crystal analysis is the diagnostic gold standard

Microscopy shows needle-shaped monosodium urate crystals with negative birefringence. Gout and septic arthritis can co-occur; therefore, it is important to rule out infection with Gram staining and cultures. Radiographs may show tophi or overhanging erosions. Although serum uric acid can be elevated, normal levels do not preclude gout. A validated diagnostic rule can aid in diagnosis without arthrocentesis (Appendix 1A).3

Gout treatment within 24 hours of symptom onset reduces flare intensity and duration

Acute pharmacotherapy depends on patient comorbidities. Nonsteroidal anti-inflammatory drugs, colchicine and corticosteroids are first-line therapies (Appendix 1D). Pre-existing urate-lowering therapy (ULTs) should be continued during flares.4

ULTs should be started in patients with tophaceous disease, radiographic damage from gout or ≥ 2 gout attacks/year

ULTs (Appendix 1D) should be titrated to serum urate < 360 μmol/L by assessing levels monthly. Serum urate levels < 360 μmol/L promote crystal dissolution and reduce the chance of recurrent flare by about 80%.5 Acute gout prophylaxis with colchicine, naproxen or prednisone should be prescribed during the initial 3–6 months of ULT (Appendix 1D). Losing weight (i.e., decreasing body mass index by > 5% ), limiting alcohol (< 1–2 units/day), and reducing fructose (< 1g/kg/day) and purine intake may help reduce urate levels.4 Multidisciplinary approaches for comorbidity management and subspecialist referrals should be considered, if appropriate.

Acknowledgements

The authors would like to acknowledge Drs. Lucille Chan, Betty Lee and Mark Leung for their constructive comments on drafts of this manuscript.

Footnotes

  • Competing interests: None declared.

  • This article has been peer reviewed.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) license, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e. research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/

References

  1. ↵
    1. Rai SK,
    2. Aviña-Zubieta JA,
    3. McCormick N,
    4. et al
    . The rising prevalence and incidence of gout in British Columbia, Canada: population-based trends from 2000–2012. Semin Arthritis Rheum 2017;46:451–6.
    OpenUrl
  2. ↵
    1. Dalbeth N,
    2. Merriman TR,
    3. Stamp LK
    . Gout. Lancet 2016;388:2039–52.
    OpenUrlCrossRefPubMed
  3. ↵
    1. Janssens HJ,
    2. Fransen J,
    3. van de Lisdonk EH,
    4. et al
    . A diagnostic rule for acute gouty arthritis in primary care without joint fluid analysis. Arch Intern Med 2010;170:1120–6.
    OpenUrlCrossRefPubMed
  4. ↵
    1. FitzGerald JD,
    2. Dalbeth N,
    3. Mikuls T,
    4. et al
    . 2020 American College of Rheumatology guideline for the management of gout. Arthritis Care Res (Hoboken) 2020;72:744–60.
    OpenUrl
  5. ↵
    1. Shoji A,
    2. Yamanaka H,
    3. Kamatani N
    . A retrospective study of the relationship between serum urate level and recurrent attacks of gouty arthritis: evidence for reduction of recurrent gouty arthritis with antihyperuricemic therapy. Arthritis Rheum 2004;51:321–5.
    OpenUrlCrossRefPubMed
PreviousNext
Back to top

In this issue

Canadian Medical Association Journal: 193 (5)
CMAJ
Vol. 193, Issue 5
1 Feb 2021
  • Table of Contents
  • Index by author

Article tools

Respond to this article
Print
Download PDF
Article Alerts
To sign up for email alerts or to access your current email alerts, enter your email address below:
Email Article

Thank you for your interest in spreading the word on CMAJ.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Gout
(Your Name) has sent you a message from CMAJ
(Your Name) thought you would like to see the CMAJ web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Gout
Timothy S.H. Kwok, Victoria Y.Y. Xu, Shirley L. Lake
CMAJ Feb 2021, 193 (5) E171; DOI: 10.1503/cmaj.201392

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
‍ Request Permissions
Share
Gout
Timothy S.H. Kwok, Victoria Y.Y. Xu, Shirley L. Lake
CMAJ Feb 2021, 193 (5) E171; DOI: 10.1503/cmaj.201392
Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like

Jump to section

  • Article
    • The prevalence of gout is rising, and many patients have common comorbidities
    • Gout flares are typically monoarticular, reaching maximal intensity within hours
    • Synovial fluid crystal analysis is the diagnostic gold standard
    • Gout treatment within 24 hours of symptom onset reduces flare intensity and duration
    • ULTs should be started in patients with tophaceous disease, radiographic damage from gout or ≥ 2 gout attacks/year
    • Acknowledgements
    • Footnotes
    • References
  • Figures & Tables
  • Related Content
  • Responses
  • Metrics
  • PDF

Related Articles

  • La goutte
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Parechovirus infections in infants
  • Radiation dermatitis in a patient treated for hepatocarcinoma
  • Spontaneous bacterial peritonitis in cirrhosis
Show more Practice

Similar Articles

Collections

  • Article Types
    • Five Things to Know About
  • Topics
    • Drugs: musculoskeletal & joint
    • Family medicine, general practice, primary care
    • Internal medicine
    • Nutrition
    • Rheumatology

 

View Latest Classified Ads

Content

  • Current issue
  • Past issues
  • Collections
  • Sections
  • Blog
  • Podcasts
  • Alerts
  • RSS
  • Early releases

Information for

  • Advertisers
  • Authors
  • Reviewers
  • CMA Members
  • CPD credits
  • Media
  • Reprint requests
  • Subscribers

About

  • General Information
  • Journal staff
  • Editorial Board
  • Advisory Panels
  • Governance Council
  • Journal Oversight
  • Careers
  • Contact
  • Copyright and Permissions
  • Accessibiity
  • CMA Civility Standards
CMAJ Group

Copyright 2023, CMA Impact Inc. or its licensors. All rights reserved. ISSN 1488-2329 (e) 0820-3946 (p)

All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association or its subsidiaries.

To receive any of these resources in an accessible format, please contact us at CMAJ Group, 500-1410 Blair Towers Place, Ottawa ON, K1J 9B9; p: 1-888-855-2555; e: cmajgroup@cmaj.ca

Powered by HighWire