Introduction

If asked to describe a typical gout sufferer, many people are likely to paint a picture of a middle-aged man with a florid complexion and a bulging waistline. While aspects of this description certainly point to some of the risk factors that make gout more likely, it is by no means the full story. 

Gout is the most common form of inflammatory arthritis, affecting between two and three in every 100 people in the UK. 

The inflammation most commonly associated with the condition results from uric acid accumulation, usually around a distal joint such as in the toes, fingers, ankles or knees. 

The build-up of uric acid crystals in the synovial fluid around a joint causes sudden flares of heat and swelling as the body tries to clear the affected site, and severe pain due to nerves jangling as a result of increased pressure in surrounding tissues. The uric acid accumulates because the level of purines in the body gets too high to be contained in the bloodstream. Purines are a by-product of the metabolism of certain foods and drinks.

Unmanaged, gout can lead to long-term complications and significant disability. 

Diagnosis

The presenting symptoms of gout are usually definitive: rapid onset (often overnight) of severe pain, redness and swelling in one or more distal joints, most commonly the big toe, but sometimes the midfoot, ankle, knee, hand, wrist or elbow. There may also be tophi – firm white nodules under translucent skin that are usually painless, but can become inflamed, infected or ulcerated and may exude – on the surfaces of affected joints, suggestive of longstanding and untreated gout. 

A history of similar, self-limiting (seven to 14 days) attacks supports the diagnosis, as does tenderness and limited range of movement, which is likely to be impacting negatively on functioning. Dietary habits, comorbidities, risk factors, and family history (of gout, hyperuricaemia or renal disease) should also be established.

In its June 2022 guidance, NICE recommends testing the serum uric acid level of someone who is exhibiting signs of gout, with 360micromol/l or 6mg/dl regarded as diagnostic. If the level during an attack is lower than this, at least two weeks should elapse before repeating the test. 

Joint aspiration and microscopy of synovial fluid should be considered if a diagnosis of gout remains uncertain or unconfirmed. If this cannot be performed, imaging techniques are regarded as a sensible way forward.