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2018 updated European League Against Rheumatism evidence-based recommendations for the diagnosis of gout
  1. Pascal Richette1,2,
  2. Michael Doherty3,
  3. Eliseo Pascual4,
  4. Victoria Barskova5,
  5. Fabio Becce6,
  6. Johann Castaneda7,
  7. Malcolm Coyfish8,
  8. Sylvie Guillo9,
  9. Tim Jansen10,
  10. Hein Janssens11,
  11. Frédéric Lioté12,13,
  12. Christian D Mallen14,
  13. George Nuki15,
  14. Fernando Perez-Ruiz16,
  15. José Pimentao17,
  16. Leonardo Punzi18,
  17. Anthony Pywell8,
  18. Alexander K So19,
  19. Anne-Kathrin Tausche20,
  20. Till Uhlig21,
  21. Jakub Zavada22,
  22. Weiya Zhang23,
  23. Florence Tubach24,
  24. Thomas Bardin25
  1. 1 Service de Rhumatologie, Hopital Lariboisiere Centre Viggo Petersen, Paris, France
  2. 2 Inserm UMR1132 Bioscar, Universite Paris Diderot UFR de Medecine, Paris, France
  3. 3 Academic Rheumatology, University of Nottingham, Nottingham, UK
  4. 4 Rheumatology, Hospital General Universitario de Alicante, Alicante, Spain
  5. 5 Institute of Rheumatology, RAMS, Moscow, Russian
  6. 6 Radiology, Lausanne University Hospital, Lausanne, Switzerland
  7. 7 AP-HP, Hôpital Pitié-Salpêtrière, Département Biostatistique Santé Publique et Information Médicale, Centre de Pharmacoépidémiologie (Cephepi), INSERM, UMR 1123 ECEVE, CIC-1421, Paris, France, Paris, France
  8. 8 Nottingham, UK
  9. 9 Département d'Epidémiologie et Recherche Clinique, Paris, France
  10. 10 Rheumatology, VieCuri, Venlo, Netherlands
  11. 11 Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
  12. 12 Department of Rhumatologie, Hôpital Lariboisière, Paris, France
  13. 13 INSERM UMR-1132 and Université Paris Diderot, Paris, France
  14. 14 Arthritis Research UK Primary Care Centre, Keele University, Keele, UK
  15. 15 Centre Molecular Medicine, University of Edinburgh, Edinburgh, Scotland, UK
  16. 16 Servicio de Reumatologia, Hospital de Cruces, Baracaldo, Spain
  17. 17 Rheumatology Unit, Clínica Coração de Jesus, Lisbon, Portugal
  18. 18 Department of Medicine, University of Padua, Padua, Italy
  19. 19 Musculoskeletal Medicine, Service de RMR, Lausanne, Switzerland
  20. 20 Department of Internal Medicine, Section of Rheumatology, University Clinic Carl Gustav Carus, Dresden, Saxonia, Germany
  21. 21 Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
  22. 22 Institute of Rheumatology, Prague, Czech Republic, Czech Republic
  23. 23 Academic Rheumatology, Nottingham University, Nottingham, UK
  24. 24 Biostatistics and epidemiology, APHP, Hopital Pitié Salpetrière, Paris, France
  25. 25 Rheumatology, Assistance Publique - Hopitaux de Paris, Paris, France
  1. Correspondence to Professor Pascal Richette, Service de Rhumatologie, Hopital Lariboisiere Centre Viggo Petersen, Paris 75010, France; pascal.richette{at}


Although gout is the most common inflammatory arthritis, it is still frequently misdiagnosed. New data on imaging and clinical diagnosis have become available since the first EULAR recommendations for the diagnosis of gout in 2006. This prompted a systematic review and update of the 2006 recommendations. A systematic review of the literature concerning all aspects of gout diagnosis was performed. Recommendations were formulated using a Delphi consensus approach. Eight key recommendations were generated. A search for crystals in synovial fluid or tophus aspirates is recommended in every person with suspected gout, because demonstration of monosodium urate (MSU) crystals allows a definite diagnosis of gout. There was consensus that a number of suggestive clinical features support a clinical diagnosis of gout. These are monoarticular involvement of a foot or ankle joint (especially the first metatarsophalangeal joint); previous episodes of similar acute arthritis; rapid onset of severe pain and swelling; erythema; male gender and associated cardiovascular diseases and hyperuricaemia. When crystal identification is not possible, it is recommended that any atypical presentation should be investigated by imaging, in particular with ultrasound to seek features suggestive of MSU crystal deposition (double contour sign and tophi). There was consensus that a diagnosis of gout should not be based on the presence of hyperuricaemia alone. There was also a strong recommendation that all people with gout should be systematically assessed for presence of associated comorbidities and risk factors for cardiovascular disease, as well as for risk factors for chronic hyperuricaemia. Eight updated, evidence-based, expert consensus recommendations for the diagnosis of gout are proposed.

  • gout
  • epidemiology
  • health services research

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  • Handling editor Josef S Smolen

  • Collaborators Augustin Latourte.

  • Contributors JC, SG and PR performed the systematic literature review under the supervision of FT. All authors were part of the Task Force, participated in the Delphi rounds and attended the face-to-face meeting. TB organised and chaired the meetings, along with MD and EP. PR wrote the manuscript, with contribution and approval of all coauthors.

  • Funding This project was funded by the European League Against Rheumatism.

  • Disclaimer The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

  • Competing interests PR has received honoraria from Ipsen/Menarini, Astra-Zeneca, Savient and Grünenthal. MD has received honoraria for ad hoc advisory boards on gout or osteoarthritis from Ardea Biosciences, AstraZeneca, Nordic Biosciences and Roche and was CI for a Nottingham University Investigator-led non-drug study on gout funded by AstraZeneca. EP received fees from Ipsen/Menarini and Astra-Zeneca. JC and SG are employed by the Centre de Pharmacoépidémiologie (Cephepi) of the Assistance Publique – Hôpitaux de Paris that has received research funding, grants and fees for consultant activities from a large number of pharmaceutical companies, which have contributed indiscriminately to the salaries of its employees. TJ received fees for lectures and/or advisory boards from Ardea Biosciences, Astra/Zeneca global, Abbvie, BMS, Celgene, Grünenthal, Janssen, Lilly, Menarini International, Novartis, Pfizer, Roche, UCB. FL received fees for advisory boards: Ardea BioSciences, Astra-Zeneca, Ipsen Pharma, Menarini, Novartis, Savient, Mayoly-Spindler. He also received unrestricted grants for organising the European Crystal Network Workshops (Convenor Frédéric Lioté, France& Alexander So, Switzerland) since 2010: Ardea BioSciences, Astra-Zeneca, Ipsen Pharma, Mayoly-Spindler, Menarini, Novartis, Savient, SOBI. He received fees for lectures from Ardea BioSciences, Grünenthal, Ipsen Pharma, Menarini France, Novartis Global.CDM is funded by the NIHR Collaborations for Leadership in Applied Health Research and Care West Midlands. CDM is also funded by the NIHR School for Primary Care Research and an NIHR Research Professorship in General Practice (NIHR-RP-2014-04-026). NEF, an NIHR Senior Investigator, was funded by an NIHR Research Professorship (NIHR-RP-2011-015). GN has received fees for advisory boards and consultations from Savient, Ipsen, Menarini and Grünenthal and indirectly from Ardea Biosciences and AstraZeneca for work on the IDMC’s for trials of lesinurad. FP-R has received fees from AstraZeneca, Grünenthal, Horizon, Menarini, Dyve Biosicence, Japan Tobaco, Logarithm, Astellas. LP has received consulting or speaker fees from Menarini, Fidia, Grünenthal, BMS. AKS has served as consultant to Astra-Zeneca and SOBI in regard to the treatment of gout. A-KT received fees from Berlin Chemie-Menarini, Novartis, AstraZeneca/Ardea Biosciences and Grünenthal Pharma. TU received fees from AstraZeneca/Ardea, Grünenthal Pharma and Novartis JZ received fees from Berlin Chemie-Menarini and Novartis. WZ received honorarium from Savient, AstraZeneca and Grünenthal. FT is head of the Centre de Pharmacoépidémiologie (Cephepi) of the Assistance Publique – Hôpitaux de Paris that has received research funding, grants and fees for consultant activities from a large number of pharmaceutical companies, that have contributed indiscriminately to the salaries of its employees. She did not receive any personal remuneration from these companies. TB has received consulting fees, speaker fees or grants from Ipsen Pharma, Menarini, AstraZeneca, Novartis, Sobi, Savient, Grünenthal and Cymabay.

  • Patient and public involvement statement Two patients with gout were involved in the elaboration of these recommendations. They participated in the face-to-face meeting, in the Delphi rounds and approved the manuscript.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement The data analysed in the current study are available from the corresponding author on request.