The Diagnosis and Treatment of Gout

Robert G. Smith, DPM, MSc, RPh, CPed


US Pharmacist. 2009;34(5):40-47. 

In This Article

Typical Presentation of Gout

Gouty attacks are usually associated with a precipitating event.[6,20] These attacks consist of intense pain involving the lower extremity, with 80% of first attacks involving a monoarticular joint; however, after long periods of time, gout attacks may become polyarticular.[6,20,21] This pain and inflammation is a result of a dramatic inflammatory response. Some authors have estimated that between 50% to 90% of the initial attacks occur in the first metatarsophalangeal joint (podagra).[6,21,22,23] In postmenopausal women, the distal interphalangeal joints may be involved.[6] Attacks often occur at night and are associated with a precipitating event.[6,20] Acute gouty arthritis may be accompanied by low-grade fever, chills, and malaise.[6,21,23] The majority of patients experience a second acute gout attack within 1 year of the first episode.[24] Untreated initial acute gout attacks resolve completely within 3 to 14 days.[6,20,23]

There are four clinical stages of gout.[23] At serum urate concentrations greater than 6.8 mg/dL, urate crystals may start to deposit. Hence, the first stage of gout is known as asymptomatic hyperuricemia. During this first period, urate deposits may directly contribute to organ damage. After sufficient urate deposits have developed around a joint and some traumatic event triggers the release of crystals into the joint space, a patient will suffer an acute gout attack and move into the second stage, known as acute gouty arthritis. During this second stage, acute inflammation in the joint caused by urate crystallization and crystal phagocytosis is present. This episode is known as a "flare" and is self-resolving and likely to recur. The interval between acute flare gout attacks with persistent crystals in the joints is the third stage and is known as an intercritical period. When crystal deposits continue to accumulate, patients develop chronically stiff and swollen joints leading to the final stage—advanced gout, which includes the long-term complications of uncontrolled hyperuricemia characterized by chronic arthritis and tophi. The nodular mass of uric acid crystals is described as a tophus and is characteristically deposited in different soft tissue areas of the body in gout. This advanced stage of gout is uncommon because it is avoidable with interventional therapy.[23]