Intended for healthcare professionals

Clinical Review


BMJ 2013; 347 doi: (Published 01 October 2013) Cite this as: BMJ 2013;347:f5648
  1. Edward Roddy, senior lecturer in rheumatology1,
  2. Christian D Mallen, professor of general practice research1,
  3. Michael Doherty, professor of rheumatology2
  1. 1Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele ST5 5BG, UK
  2. 2Academic Rheumatology, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, UK
  1. Correspondence to: E Roddy e.roddy{at}

Summary points

  • Gout is associated with serious comorbidity and increased risk of cardiovascular disease

  • The definitive diagnosis of gout requires microscopic identification of monosodium urate crystals

  • A clinical diagnosis can be made when typical features of inflammation affect the first metatarsophalangeal joint; serum urate values have limited diagnostic value

  • First line medical treatment options for acute gout are a non-steroidal anti-inflammatory drug or low dose colchicine

  • Long term management requires full patient education, dealing with any modifiable risk factors (such as overweight or obesity, chronic diuretic intake), and urate lowering drugs

  • Start allopurinol at a low dose (such as 100 mg daily) and increase gradually with the aim of lowering then maintaining serum urate below 360 µmol/L

Gout is the most common inflammatory arthritis, affecting 1-2% of the population. Acute gout is one of the most painful forms of arthritis and is characterised by the abrupt onset of severe joint pain (classically the first metatarsophalangeal joint), swelling, and erythema. The major risk factor is a raised serum urate concentration (hyperuricaemia), which results in the deposition of monosodium urate crystals in and around joints. Untreated, continuing crystal deposition can result in irreversible joint damage. Although effective treatments are available for acute and chronic gout, uptake is poor, and many patients experience repeated acute attacks and reduced quality of life. This clinical review summarises current evidence for the diagnosis and management of acute and chronic gout.

Sources and selection criteria

We searched Medline, Embase, PubMed, Cochrane Controlled Trials Register, ISI Web of Science, and AMED (Allied and Complementary Medicine Database) using the search terms “gouty arthritis”, “podagra”, “tophus”, “monosodium urate crystals” and “hyperuricaemia”. We also used personal archived references. Priority was given to systematic reviews, meta-analyses, randomised controlled trials, and prospective epidemiological studies where possible.

What is gout?

The pathogenesis of gout is well understood. If serum urate concentrations persistently exceed …

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