Gout is characterized by painful inflammation in the joints, most commonly the big toe. Symptoms include podagra, which initially affects the big toe joint in 50% of cases, as well as arthritis in other joints like the wrist, fingers, knee, and ankle. Attacks typically reach maximum intensity within 8-12 hours and involve one joint, though multiple joints can be affected simultaneously. Without treatment, gout symptoms change over time and involve more joints, occur more frequently, and last longer, sometimes resembling rheumatoid arthritis. The ACR recommends pharmacologic therapy to lower uric acid levels for patients with gout who have tophi, frequent acute attacks, chronic kidney disease, or previous kidney stones. The target uric

1. GOUT

5. • Symptoms of gout or pseudogout include the following:
• Podagra (initial joint manifestation in 50% of gout cases and eventually involved
in 90%; also observed in patients with pseudogout and other conditions)
• Arthritis in other sites – In gout, the instep, ankle, wrist, finger joints, and knee; in
pseudogout, large joints (eg, the knee, wrist, elbow, or ankle)
• Monoarticular involvement most commonly, though polyarticular acute flares are
not rare, and many different joints may be involved simultaneously or in rapid
succession
• In gout, attacks that begin abruptly and typically reach maximum intensity within
8-12 hours; in pseudogout, attacks resembling those of acute gout or a more
insidious onset that occurs over several days
• Without treatment, symptom patterns that change over time; attacks can
become more polyarticular, involve more proximal and upper-extremity joints,
occur more often, and last longer
• In some cases, eventual development of chronic polyarticular arthritis that can
resemble rheumatoid arthritis

11. ACR INDICATIONS FOR PHARMACOLOGIC THERAPY TO
LOWER SERUM URIC ACID LEVELS IN PATIENTS WITH AN
ESTABLISHED DIAGNOSIS OF GOUTY ARTHRITIS INCLUDE
THE FOLLOWING:
•Tophus or tophi identified on clinical examination or
imaging study (evidence A)
•Frequent (≥2/yr) of acute gouty arthritis (evidence A)
•Chronic kidney disease (CKD) stage ≥2 (evidence C)
•Previous urolithiasis (evidence C)

12. •THE ACR RECOMMENDS TREATMENT TO TARGET
SERUM URIC ACID LEVEL, AS FOLLOWS:
•The minimum serum uric acid target is < 6 mg/dL
•A lower target (< 5 mg/dL) may be needed to improve
signs and symptoms
•Allopurinol or febuxostat is a first-line xanthine oxidase
inhibitor for urate-lowering therapy (ULT) (evidence A)
•If at least one xanthine oxidase inhibitor is
contraindicated or not tolerated, probenecid is an
alternative first-line agent (evidence B)