Table 3

 Propositions and strength of recommendation (SOR): order according to topic (clinical, urate crystals, biochemical, radiographic, and risk factors/comorbidities)

PropositionSOR (95% CI)
VAS 100A–B%*
*A–B%: percentage of strongly to fully recommended, based on the EULAR ordinal scale (A = fully recommended, B = strongly recommended, C = moderately recommended, D = weakly recommended, E = not recommended).
CI, confidence interval; MSU, monosodium urate; SOR, strength of recommendation; VAS, visual analogue scale (0–100 mm, 0 = not recommended at all, 100 = fully recommended).
1In acute attacks the rapid development of severe pain, swelling, and tenderness that reaches its maximum within just 6–12 hours, especially with overlying erythema, is highly suggestive of crystal inflammation though not specific for gout88 (80 to 96)93
2For typical presentations of gout (such as recurrent podagra with hyperuricaemia) a clinical diagnosis alone is reasonably accurate but not definitive without crystal confirmation95 (91 to 98)100
3Demonstration of MSU crystals in synovial fluid or tophus aspirates permits a definitive diagnosis of gout96 (93 to 100)100
4A routine search for MSU crystals is recommended in all synovial fluid samples obtained from undiagnosed inflamed joints90 (83 to 97)87
5Identification of MSU crystals from asymptomatic joints may allow definite diagnosis in intercritical periods84 (78 to 91)93
6Gout and sepsis may coexist, so when septic arthritis is suspected Gram stain and culture of synovial fluid should still be performed even if MSU crystals are identified93 (87 to 99)93
7While being the most important risk factor for gout, serum uric acid levels do not confirm or exclude gout as many people with hyperuricaemia do not develop gout, and during acute attacks serum levels may be normal95 (92 to 99)93
8Renal uric acid excretion should be determined in selected gout patients, especially those with a family history of young onset gout, onset of gout under age 25, or with renal calculi72 (62 to 81)60
9Although radiographs may be useful for differential diagnosis and may show typical features in chronic gout, they are not useful in confirming the diagnosis of early or acute gout86 (79 to 94)93
10Risk factors for gout and associated co-morbidity should be assessed, including features of the metabolic syndrome (obesity, hyperglycaemia, hyperlipidaemia, hypertension)93 (88 to 98)100