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Ann Rheum Dis. 2020 Jan;79(1):31-38. doi: 10.1136/annrheumdis-2019-215315. Epub 2019 Jun 5.

2018 updated European League Against Rheumatism evidence-based recommendations for the diagnosis of gout.

Author information

1
Service de Rhumatologie, Hopital Lariboisiere Centre Viggo Petersen, Paris, France pascal.richette@aphp.fr.
2
Inserm UMR1132 Bioscar, Universite Paris Diderot UFR de Medecine, Paris, France.
3
Academic Rheumatology, University of Nottingham, Nottingham, UK.
4
Rheumatology, Hospital General Universitario de Alicante, Alicante, Spain.
5
Institute of Rheumatology, RAMS, Moscow, Russian.
6
Radiology, Lausanne University Hospital, Lausanne, Switzerland.
7
AP-HP, Hôpital Pitié-Salpêtrière, Département Biostatistique Santé Publique et Information Médicale, Centre de Pharmacoépidémiologie (Cephepi), INSERM, UMR 1123 ECEVE, CIC-1421, Paris, France, Paris, France.
8
Nottingham, UK.
9
Département d'Epidémiologie et Recherche Clinique, Paris, France.
10
Rheumatology, VieCuri, Venlo, Netherlands.
11
Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.
12
Department of Rhumatologie, Hôpital Lariboisière, Paris, France.
13
INSERM UMR-1132 and Université Paris Diderot, Paris, France.
14
Arthritis Research UK Primary Care Centre, Keele University, Keele, UK.
15
Centre Molecular Medicine, University of Edinburgh, Edinburgh, Scotland, UK.
16
Servicio de Reumatologia, Hospital de Cruces, Baracaldo, Spain.
17
Rheumatology Unit, Clínica Coração de Jesus, Lisbon, Portugal.
18
Department of Medicine, University of Padua, Padua, Italy.
19
Musculoskeletal Medicine, Service de RMR, Lausanne, Switzerland.
20
Department of Internal Medicine, Section of Rheumatology, University Clinic Carl Gustav Carus, Dresden, Saxonia, Germany.
21
Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.
22
Institute of Rheumatology, Prague, Czech Republic, Czech Republic.
23
Academic Rheumatology, Nottingham University, Nottingham, UK.
24
Biostatistics and epidemiology, APHP, Hopital Pitié Salpetrière, Paris, France.
25
Rheumatology, Assistance Publique - Hopitaux de Paris, Paris, France.

Abstract

Although gout is the most common inflammatory arthritis, it is still frequently misdiagnosed. New data on imaging and clinical diagnosis have become available since the first EULAR recommendations for the diagnosis of gout in 2006. This prompted a systematic review and update of the 2006 recommendations. A systematic review of the literature concerning all aspects of gout diagnosis was performed. Recommendations were formulated using a Delphi consensus approach. Eight key recommendations were generated. A search for crystals in synovial fluid or tophus aspirates is recommended in every person with suspected gout, because demonstration of monosodium urate (MSU) crystals allows a definite diagnosis of gout. There was consensus that a number of suggestive clinical features support a clinical diagnosis of gout. These are monoarticular involvement of a foot or ankle joint (especially the first metatarsophalangeal joint); previous episodes of similar acute arthritis; rapid onset of severe pain and swelling; erythema; male gender and associated cardiovascular diseases and hyperuricaemia. When crystal identification is not possible, it is recommended that any atypical presentation should be investigated by imaging, in particular with ultrasound to seek features suggestive of MSU crystal deposition (double contour sign and tophi). There was consensus that a diagnosis of gout should not be based on the presence of hyperuricaemia alone. There was also a strong recommendation that all people with gout should be systematically assessed for presence of associated comorbidities and risk factors for cardiovascular disease, as well as for risk factors for chronic hyperuricaemia. Eight updated, evidence-based, expert consensus recommendations for the diagnosis of gout are proposed.

KEYWORDS:

epidemiology; gout; health services research

Conflict of interest statement

Competing interests: PR has received honoraria from Ipsen/Menarini, Astra-Zeneca, Savient and Grünenthal. MD has received honoraria for ad hoc advisory boards on gout or osteoarthritis from Ardea Biosciences, AstraZeneca, Nordic Biosciences and Roche and was CI for a Nottingham University Investigator-led non-drug study on gout funded by AstraZeneca. EP received fees from Ipsen/Menarini and Astra-Zeneca. JC and SG are employed by the Centre de Pharmacoépidémiologie (Cephepi) of the Assistance Publique – Hôpitaux de Paris that has received research funding, grants and fees for consultant activities from a large number of pharmaceutical companies, which have contributed indiscriminately to the salaries of its employees. TJ received fees for lectures and/or advisory boards from Ardea Biosciences, Astra/Zeneca global, Abbvie, BMS, Celgene, Grünenthal, Janssen, Lilly, Menarini International, Novartis, Pfizer, Roche, UCB. FL received fees for advisory boards: Ardea BioSciences, Astra-Zeneca, Ipsen Pharma, Menarini, Novartis, Savient, Mayoly-Spindler. He also received unrestricted grants for organising the European Crystal Network Workshops (Convenor Frédéric Lioté, France& Alexander So, Switzerland) since 2010: Ardea BioSciences, Astra-Zeneca, Ipsen Pharma, Mayoly-Spindler, Menarini, Novartis, Savient, SOBI. He received fees for lectures from Ardea BioSciences, Grünenthal, Ipsen Pharma, Menarini France, Novartis Global.CDM is funded by the NIHR Collaborations for Leadership in Applied Health Research and Care West Midlands. CDM is also funded by the NIHR School for Primary Care Research and an NIHR Research Professorship in General Practice (NIHR-RP-2014-04-026). NEF, an NIHR Senior Investigator, was funded by an NIHR Research Professorship (NIHR-RP-2011-015). GN has received fees for advisory boards and consultations from Savient, Ipsen, Menarini and Grünenthal and indirectly from Ardea Biosciences and AstraZeneca for work on the IDMC’s for trials of lesinurad. FP-R has received fees from AstraZeneca, Grünenthal, Horizon, Menarini, Dyve Biosicence, Japan Tobaco, Logarithm, Astellas. LP has received consulting or speaker fees from Menarini, Fidia, Grünenthal, BMS. AKS has served as consultant to Astra-Zeneca and SOBI in regard to the treatment of gout. A-KT received fees from Berlin Chemie-Menarini, Novartis, AstraZeneca/Ardea Biosciences and Grünenthal Pharma. TU received fees from AstraZeneca/Ardea, Grünenthal Pharma and Novartis JZ received fees from Berlin Chemie-Menarini and Novartis. WZ received honorarium from Savient, AstraZeneca and Grünenthal. FT is head of the Centre de Pharmacoépidémiologie (Cephepi) of the Assistance Publique – Hôpitaux de Paris that has received research funding, grants and fees for consultant activities from a large number of pharmaceutical companies, that have contributed indiscriminately to the salaries of its employees. She did not receive any personal remuneration from these companies. TB has received consulting fees, speaker fees or grants from Ipsen Pharma, Menarini, AstraZeneca, Novartis, Sobi, Savient, Grünenthal and Cymabay.

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