What are the ACP guidelines for the diagnosis of acute gout?

Updated: Jan 26, 2021
  • Author: Bruce M Rothschild, MD; Chief Editor: Herbert S Diamond, MD  more...
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Answer

The ACP guideline recommends using synovial fluid analysis when clinical judgment indicates that diagnostic testing is necessary in patients with possible acute gout (weak recommendation, low-quality evidence). The guideline advises that synovial fluid analysis is considered the reference standard for gout diagnosis but may be difficult to perform in a primary care setting. Synovial fluid analysis is recommended if the following criteria can be met [189]

  • An experienced clinician can aspirate the joint without substantial patient discomfort and can minimize the risk of infection
  • A reliable and accurate source (including a trained operator with a polarizing microscope) is available to assess the fluid for the presence of urate crystals
  • The clinical situation is ambiguous and a probability of joint infection exists

If the criteria for synovial fluid analysis cannot be met, the ACP recommends that clinicians either refer the patient to a source that can meet the criteria or use their clinical judgment regarding the need for joint aspiration. Clinical judgment is especially appropriate in situations that are less clinically ambiguous and the probability of infection is not significant. For example, a patient with podagra, appropriate risk factors (eg, age), and no sign of an overlying skin wound) could be considered to have gout without undergoing joint aspiration.

The ACP notes that algorithms for clinical diagnosis of gout exist and have sensitivities and specificities >80%, but little evidence exists that they can be used to identify septic joints. Current evidence is insufficient to support the use of dual-energy computed tomography or ultrasonography to diagnose acute gout. [189]


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