EULAR releases 2018 updated recommendations for diagnosis of Gout

European League Against Rheumatism, EULAR has released its 2018 updated evidence-based recommendations for the diagnosis of gout. It is an update of the 2006 recommendations.

Gout is the most common inflammatory arthritis but is frequently misdiagnosed. New data on imaging and clinical diagnosis have become available since the first European League Against Rheumatism, EULAR recommendations for the diagnosis of gout in 2006. This prompted a systematic review and update by using a Delphi consensus approach and in all eight evidence-based, expert consensus recommendations were generated.

European League Against Rheumatism, EULAR recommends a search for crystals in synovial fluid or tophus aspirates in every person with suspected gout because the demonstration of monosodium urate (MSU) crystals allows a definite diagnosis of gout. European League Against Rheumatism, EULAR formed a 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 hyperuricemia. 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 a consensus that a diagnosis of gout should not be based on the presence of hyperuricemia alone. There was also a strong recommendation that all people with gout should be systematically assessed for the presence of associated comorbidities and risk factors for cardiovascular disease, as well as for risk factors for chronic hyperuricemia.

Following are the major European League Against Rheumatism, EULAR recommendations:

1. Search for crystals in S For tophus aspirates is recommended in every person with suspected gout because the demonstration of MSU crystals allows definitive diagnosis of gout.

2. Gout should be considered in the diagnosis of any acute arthritis in an adult. When SF analysis is not feasible, a clinical diagnosis of gout is supported by the following suggestive features: monoarticular involvement of a foot (especially the first MTP) or ankle joint; previous similar acute arthritis episodes; rapid onset of severe pain and swelling (at its worst in<24hours); erythema; male gender and associated cardiovascular diseases and hyperuricaemia. These features are highly suggestive but not specific for gout.

3. It is strongly recommended that SF aspiration and examination for crystals is undertaken in any patient with undiagnosed inflammatory arthritis.

4. The diagnosis of gout should not be made on the presence of hyperuricemia alone.

5. When a clinical diagnosis of gout is uncertain and crystal identification is not possible, patients should be investigated by imaging to search for MSU crystal deposition and features of an alternative diagnosis.

6. Plain radiographs are indicated to search for imaging evidence of MSU crystal deposition but have limited value for the diagnosis of a gout flare. US scanning can be more helpful in establishing a diagnosis in patients with suspected gout flare or chronic gouty arthritis by detection of tophi not evident on clinical examination, or a double contour (DC) sign at cartilage surfaces, which is highly specific for urate deposits in joints.

7. Risk factors for chronic hyperuricemia should be searched for in every person with gout, specifically: chronic kidney disease(CKD); overweight, medications (including diuretics, low-dose aspirin, cyclosporine and tacrolimus); consumption of excess alcohol (particularly beer and spirits), non-diet sodas, meat and shellfish.

8. Systematic assessment for the presence of associated comorbidities in people with gout is recommended including obesity, renal impairment, hypertension, ischaemic heart disease, heart failure, diabetes, and dyslipidemia.

For more details click on the link: http://dx.doi.org/10.1136/annrheumdis-2019-215315