Podcast: Gout: A Primary Care Primer, Part 2

Part 2, Diagnosis
Although the gold standard for diagnosis is joint aspiration and synovial fluid analysis, compensated polarized light microscopy is not available in most primary care practices. In part 2 of this 3-part podcast, I discuss the diagnosis of gout in real-world practice.

Gout: A Primary Care Primer, Part 2
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What are the characteristics of an acute attack of gout? Typically, the lower extremities are involved. About 80% of initial gout attacks are monoarticular, and the first metatarsophalangeal (MTP) joint is eventually affected in about 90% of patients with gout. Untreated, an attack usually resolves within 3 to 14 days

To help make a presumptive diagnosis of gout, here are some questions to ask the patient:
•When did the symptoms start? Was the onset sudden?
•Was this the first time you experienced pain or swelling at this joint?
•If not, which other joints have been affected?
•Do you have a fever?
•Do you have relatives with similar complaints?
•Are you taking medications that may contribute to gout, such as thiazide diuretics?
•What have you been eating or drinking recently? How often do you consume red meat, shellfish, and beer?

A presumptive diagnosis is usually correct, particularly in a patient who presents with podagra.

In this podcast, I also walk you through the differential diagnosis, which includes:
•Infectious arthritis
•Pseudogout
•Reactive arthritis or psoriatic arthritis
•Lyme disease
•Osteoarthritis of the first MTP joint
•Rheumatoid arthritis
•Cellulitis

My clinical practice recommendations for gout diagnosis:
•For a typical presentation of gout, a clinical diagnosis alone is reasonably accurate. But it is not definitive without confirmation of characteristic urate crystals from synovial fluid or tophi.
•The corollary is that asymptomatic hyperuricemia is not routinely treated. However, there may be circumstances in which urate-lowering therapies are appropriate.

Disclosure:
Dr Lieberman reports that he is on the advisory board of and a speaker for Takeda Pharmaceuticals North America, Inc. He is also a consultant to URL Pharma, Inc.