Guideline sources The following summarized guidelines for the evaluation and management of gout are prepared by our editorial team based on guidelines from the American College of Rheumatology (ACR 2023; 2020; 2012), the European League Against Rheumatism (EULAR 2022; 2020; 2017), the British Society for Rheumatology (BSR 2017), the Treat-to-target (T2T 2017), the American College of Physicians (ACP 2017), the American College of Radiology (ACR 2017), and the Clinical Pharmacogenetics Implementation Consortium (CPIC 2013). 1 2 3 4 5 6 7 8 9 10 11 12 13 13 14 15 16 16 Definition Gout is a type of inflammatory arthritis characterized by the deposition of monosodium urate monohydrate crystals in synovial fluid and other tissues. 13 https://web.pathway.md/diseases/recNUo9eCPgbgtHq6 1/14 7/1/23, 12:04 AM Gout Pathway Epidemiology Gout is due to persistently elevated blood levels of uric acid (hyperuricemia), which is often multifactorial (increased intake of purine-rich foods, defects in purine metabolism, older age, male sex, obesity, renal failure, diuretics). 16 Pathophysiology In the United States, the prevalence of gout is estimated at 3900 persons per 100,000 population. The incidence of gout is estimated at 400 per 100,000 person-years in men, and 140 per 100,000 person-years in women. 14 15 Disease course In patients with acute gout, deposition of urate monohydrate crystals inside joint cavities initiate an inflammatory response that results in the clinical manifestations of arthritis. Chronic synovitis, bony erosions, cartilage damage, and tophi formation may occur in patients with chronic gout. 16 Prognosis and risk of recurrence The 1-year recurrence rate for acute gout attack in patients who have experienced an attack in the past year is estimated at 69%. 13 Calculator Acute gout diagnosis rule Guidelines 1. Screening and diagnosis Diagnosis: include gout in the differential diagnosis of any adult patient with acute arthritis. B Show 2 more 2. Diagnostic investigations Clinical evaluation: As per EULAR 2020 guidelines, assess for risk factors for chronic hyperuricemia in all patients with gout, specifically CKD, overweight, medications (including diuretics, low-dose aspirin, cyclosporine, tacrolimus), consumption of excess alcohol (particularly beer and spirits), non-diet sodas, meat and shellfish. A https://web.pathway.md/diseases/recNUo9eCPgbgtHq6 2/14 7/1/23, 12:04 AM Gout Pathway As per ACR 2012 guidelines, elicit a history of articular symptoms, and perform a thorough physical exam for signs of gout (such as tophi and acute or chronic synovitis) as part of the clinical evaluation of patients with gout. B Diagnostic imaging: As per EULAR 2020 guidelines, obtain imaging to search for monosodium urate monohydrate crystal deposition and features of any alternative diagnosis when a clinical diagnosis of gout is uncertain and crystal identification is not possible. B Show 2 more As per ACR 2017 guidelines: Obtain radiography as initial imaging in patients with suspected gout. E Obtain ultrasound or CT, including dual-energy CT, to complement radiography in the detection of erosions and tophi. E As per ACR 2012 guidelines: Obtain high-resolution ultrasound, CT or dual energy CT to detect tophi. B Obtain plain radiographic findings to identify findings consistent with tophi, such as characteristic bone erosions. B Genetic testing: Consider HLA-B5801 testing before starting allopurinol in patients with gout of Southeast Asian descent (such as Han Chinese, Korean, Thai) and African American patients, who have a higher prevalence of HLA-B5801. C Do not obtain HLA-B5801 testing in all other patients with gout. D Evaluation for comorbidities: As per EULAR 2020 guidelines, obtain systematic assessment for the presence of associated comorbidities in patients with gout, including obesity, renal impairment, hypertension, ischemic heart disease, HF, diabetes and dyslipidemia. A As per BSR 2017 guidelines, screen for cardiovascular risk factors and comorbid conditions, such as cigarette smoking, hypertension, diabetes mellitus, dyslipidemia, obesity and renal disease, in all patients with gout, review at least annually and manage appropriately. B As per T2T 2017 guidelines: Obtain regular assessment of comorbidities associated with gout, and manage accordingly. B Assess renal function in all patients with gout at the time of diagnosis and then monitor regularly. B As per ACR 2012 guidelines, evaluate for secondary causes of hyperuricemia for all gout patients, and screen for the following specific comorbidities: obesity, dietary factors excessive alcohol intake metabolic syndrome T2DM hypertension https://web.pathway.md/diseases/recNUo9eCPgbgtHq6 3/14 7/1/23, 12:04 AM Gout Pathway hyperlipidemia modifiable risk factors for CAD or stroke serum urate-elevating medications history of urolithiasis CKD, glomerular or interstitial renal disease (e.g., analgesic nephropathy, polycyctsic kidney disease) in selected cases, potential genetic or acquired cause of uric acid overproduction (e.g., inborn error of purine metabolism, or psoriasis, myeloproliferative or lymphoproliferative disease, respectively) lead intoxication. B Screening for chronic infections: screen for HBV infection in all patients eligible for treatment with conventional synthetic, biological, or targeted synthetic DMARDs, immunosuppressants, or corticosteroids (according to dose and duration). B Show 3 more 3. Diagnostic procedures Synovial fluid analysis: As per EULAR 2020 guidelines: Perform synovial fluid aspiration and examination for crystals in any patient with undiagnosed inflammatory arthritis. B Assess for the presence of crystals in synovial fluid or tophus aspirates in all patients with suspected gout, because demonstration of monosodium urate monohydrate crystals allows a definitive diagnosis of gout. B As per ACP 2017 guidelines, perform synovial fluid analysis when clinical judgment indicates that diagnostic testing is necessary in patients with possible acute gout. B 4. Medical management Management of acute flares: As per ACR 2020 guidelines, initiate concomitant anti-inflammatory prophylaxis therapy (such as colchicine, NSAIDs, prednisone/prednisolone) in patients with gout. Select the specific agent of anti-inflammatory prophylaxis based on patient factors. B Show 5 more As per BSR 2017 guidelines, initiate an NSAID at maximum dose or colchicine in doses of 500 g 2-4 times daily as first-line therapy, with the drug choice depending on patient preference, renal function and comorbidities, if not contraindicated. Coprescribe a gastroprotective agent in patients on NSAIDs or COX-2 inhibitors. A Show 3 more https://web.pathway.md/diseases/recNUo9eCPgbgtHq6 4/14 7/1/23, 12:04 AM Gout Pathway As per EULAR 2017 guidelines, treat acute flares of gout as early as possible. Educate fully informed patients to self-medicate at the first warning symptoms. Decide on the drug choice based on the presence of contraindications, the patient's previous experience with treatments, time of initiation after flare onset and the number and type of joints involved. E Show 2 more As per T2T 2017 guidelines, treat acute attacks promptly with anti-inflammatory medications, taking safety issues into consideration. B Indications for urate-lowering therapy: As per ACR 2020 guidelines, initiate urate-lowering therapy in patients with 1 subcutaneous tophi A , or with radiographic damage attributable to gout with any imaging modality. B Show 6 more As per ACP 2017 guidelines, avoid initiating long-term urate-lowering therapy in most patients after a first gout attack or in patients with infrequent attacks. D As per BSR 2017 guidelines: Discuss and offer urate-lowering therapy in all patients with a diagnosis of gout, particularly in patients with the following: recurring attacks - 2 attacks/year A tophi A chronic gouty arthritis A joint damage A renal impairment, eGFR < 60 mL/min A history of urolithiasis B diuretics use B primary gout starting at a young age. B Initiate urate-lowering therapy ideally after inflammation has settled, as urate-lowering therapy is better discussed when the patient is not in pain. B As per EULAR 2017 guidelines, discuss and consider initiating urate-lowering therapy in the first presentation of all patients with a definite diagnosis of gout. E Show 2 more Treatment targets: As per ACR 2020 guidelines, continue urate-lowering therapy in all patients with gout taking urate-lowering therapy to achieve and maintain an serum urate target of < 6 mg/dL. A Show 2 more As per BSR 2017 guidelines: Set the initial aim of urate-lowering therapy to reduce and maintain the serum urate level 300 mcmol/L to prevent further urate crystal formation and to dissolve away existing crystals. Recognize that the lower the serum urate level the greater the velocity of crystal elimination. B https://web.pathway.md/diseases/recNUo9eCPgbgtHq6 5/14 7/1/23, 12:04 AM Gout Pathway Adjust the dose of urate-lowering therapy to maintain the serum urate level 360 mcmol/L after some years of successful treatment when tophi have resolved and the patient remains free of symptoms, to avoid further crystal deposition and the possibility of adverse effects associated with a very low serum urate level. B As per EULAR 2017 guidelines, maintain serum urate level to < 6 mg/dL (< 360 mcmol/L) in patients on urate-lowering therapy. E Show 2 more As per T2T 2017 guidelines, target and maintain a serum urate level < 6 mg/dL (< 360 mmol/L) in all patients with gout. B Show 2 more Allopurinol: As per ACR 2020 guidelines, select allopurinol over all other urate-lowering agents as the preferred first-line agent for all patients with gout starting any urate-lowering therapy, including in those with CKD stage 3. B Show 2 more As per BSR 2017 guidelines: Initiate allopurinol as first-line urate-lowering therapy at a low dose (50-100 mg/day) and the dose then increased in 100 mg increments approximately every 4 weeks until the serum urate level target has been achieved (maximum dose 900 mg). B Use smaller increments (50 mg) in patients with renal impairment, with a lower maximum dose but the same target urate levels. B As per EULAR 2017 guidelines: Initiate allopurinol as first-line urate-lowering therapy in patients with normal kidney function, starting at a low dose (100 mg/day) and increasing by 100 mg increments every 2-4 weeks if required, to reach the uricemia target. E Adjust the allopurinol maximum dosage to CrCl in patients with renal impairment. Switch allopurinol to febuxostat or benzbromarone, or add benzbromarone to allopurinol, if the serum urate target cannot be achieved at this dose, except in patients with eGFR < 30 mL/min. E As per ACR 2012 guidelines, initiate allopurinol at a maximal dose of 100 mg/day for any patient, and initiate at 50 mg/day in patients with stage 4 or worse CKD. B Xanthine oxidase inhibitors: As per ACR 2020 guidelines, select a xanthine oxidase inhibitor over probenecid for patients with gout and CKD stage 3. B Show 2 more Landmark trials: CARES In patients with gout and major cardiovascular coexisting conditions, febuxostat was noninferior to allopurinol with respect to CV death, nonfatal MI, nonfatal CVA, or UA requiring urgent revascularization. All-cause mortality and cardiovascular mortality were higher with febuxostat than with allopurinol. https://web.pathway.md/diseases/recNUo9eCPgbgtHq6 6/14 7/1/23, 12:04 AM Gout Pathway White WB et al. N Engl J Med. 2018 Mar 29. As per BSR 2017 guidelines, consider initiating febuxostat (80 mg/day and, if necessary, increase after 4 weeks to 120 mg/day) as an alternative second-line xanthine oxidase inhibitor in patients not tolerating allopurinol or if renal impairment prevents allopurinol dose escalation sufficient to achieve the therapeutic target. B Uricosuric therapy: As per ACR 2020 guidelines: Consider starting probenecid at a low dose (500 mg once or BID) with dose titration in patients with gout. C Do not offer urine alkalinization in patients with gout taking uricosuric treatment. D As per BSR 2017 guidelines, consider initiating uricosuric agents in patients resistant to, or intolerant of, xanthine oxidase inhibitors. Prefer sulfinpyrazone (200-800 mg/day) or probenecid (500-2,000 mg/day) in patients with normal or mildly impaired renal function, or benzbromarone (50-200 mg/day) in patients with mild-to-moderate renal insufficiency. B Show 2 more As per ACR 2012 guidelines, use probenecid as the first choice among uricosurics for urate- lowering therapy monotherapy. B Show 3 more Pegloticase: As per ACR 2020 guidelines: Do not offer pegloticase as first-line therapy for patients with gout. D Do not offer pegloticase in patients with gout for whom xanthine oxidase inhibitor, uricosurics, and other interventions have failed to achieve serum urate target and who have infrequent gout flares (< 2 per year) and no tophi. D As per EULAR 2017 guidelines, initiate pegloticase in patients with crystal-proven, severe debilitating chronic tophaceous gout and poor quality of life, if the serum urate target cannot be reached with any other available drug at the maximal dosage (including combinations). E Anti-inflammatory therapy: As per ACP 2017 guidelines, use corticosteroids, NSAIDs, or colchicine for the treatment patients with acute gout. A As per BSR 2017 guidelines: Consider initiating colchicine 500 g 1-2 times daily as prophylaxis against acute attacks resulting from initiation or uptitration of any urate-lowering therapy and continue for up to 6 months. C Consider initiating a low-dose NSAID or COX-2 inhibitor (with gastroprotection), if not contraindicated, as an alternative in patients not tolerating colchicine. C As per EULAR 2017 guidelines, explain and discuss prophylaxis against flares with the patient. Administer prophylaxis during the first 6 months of urate-lowering therapy. E https://web.pathway.md/diseases/recNUo9eCPgbgtHq6 7/14 7/1/23, 12:04 AM Gout Pathway Show 3 more As per T2T 2017 guidelines, initiate prophylaxis against attacks and continue for at least 6 months after starting urate-lowering therapy. B 5. Nonpharmacologic interventions Discontinuation of contributing medications: discontinue non-essential medications that are associated with elevation in serum urate levels (such as thiazide diuretics, loop diuretics, niacin, and calcineurin inhibitors). B Rest and ice packs: As per ACR 2020 guidelines, advise topical ice as an adjuvant treatment in patients experiencing a gout flare. B As per BSR 2017 guidelines, advise providing rest for the affected joints, elevate and expose in a cool environment. B Advise ice packs B and bed cages as adjuncts to management. B Dietary modifications: As per ACR 2020 guidelines: Advise limiting purine intake in patients with gout, regardless of disease activity. B Advise limiting high-fructose corn syrup in patients with gout, regardless of disease activity. B As per BSR 2017 guidelines, counsel regarding diet in all patients with gout. Encourage a following a well-balanced diet low in fat and added sugars, and high in vegetables and fiber. Advise avoiding sugar-sweetened soft drinks containing fructose, excessive intake of alcoholic drinks and high-purine foods. Encourage inclusion of skimmed milk B and/or low fat yogurt, soy beans and vegetable sources of protein, and cherries in the diet. B As per EULAR 2017 guidelines, advise avoiding sugar-sweetened drinks, heavy meals and excessive intake of meat and seafood in patients with gout. Encourage consuming low-fat dairy products. B As per ACR 2012 guidelines: Advise that patients with gout limit their consumption of purine-rich meat and seafood B as well as high fructose corn syrup sweetened soft drinks and energy drinks B , and encourage consumption of low-fat or non-fat dairy products B Advise that patients with gout reduce consumption of alcohol (particularly beer, but also wine and spirits), and avoid alcohol overuse. B Weight loss: As per ACR 2020 guidelines, advise weight loss in patients with gout who are overweight/obese, regardless of disease activity. B As per BSR 2017 guidelines, encourage dietary modifications to achieve a gradual reduction in body weight and subsequent maintenance in overweight patients with gout. B Exercise: advise regular exercise in patients with gout. B https://web.pathway.md/diseases/recNUo9eCPgbgtHq6 8/14 7/1/23, 12:04 AM Gout Pathway Alcohol intake: as per ACR 2020 guidelines, advise limiting alcohol intake in patients with gout, regardless of disease activity. B Alkohol intake: as per EULAR 2017 guidelines, advise avoiding alcohol (especially beer and spirits) in patients with gout. B Vitamin C: As per ACR 2020 guidelines, do not offer vitamin C supplements to patients with gout, regardless of disease activity. D As per BSR 2017 guidelines, recognize that vitamin C supplements (500-1,500 mg/day) have a weak uricosuric effect. B 6. Specific circumstances Carriers of HLA-B5801: avoid prescribing allopurinol in carriers of the HLA-B5801 allele. D Patients taking antihypertensive medications: As per ACR 2020 guidelines: Consider switching hydrochlorothiazide to an alternate antihypertensive when feasible in patients with gout, regardless of disease activity. C Consider choosing losartan preferentially as an antihypertensive when feasible in patients with gout. C As per BSR 2017 guidelines: Consider switching to an alternative antihypertensive agent in patients receiving diuretic drugs for hypertension, as long as BP is controlled. C Do not use losartan or fenofibrate as a primary urate-lowering therapy, but consider initiating for the treatment of hypertension or dyslipidemia, respectively, as they have a weak uricosuric effect. D As per EULAR 2017 guidelines: Substitute the diuretic in patients with gout receiving loop or thiazide diuretics, if possible. E Consider initiating losartan or CCBs for hypertension and statins or fenifibrate for hyperlipidemia in patients with gout. E Patients taking aspirin: consider not stopping low-dose aspirin in patients with gout (in those who are taking this medication for appropriate indications). D Patients taking fenofibrate: do not add or switch to fenofibrate in patients with gout. D 7. Patient education Patient education: As per BSR 2017 guidelines, educate patients on the importance of initiating treatment for attacks as soon as an attack occurs. Ensure that patients are aware of the importance of https://web.pathway.md/diseases/recNUo9eCPgbgtHq6 9/14 7/1/23, 12:04 AM Gout Pathway continuing any established urate-lowering therapy during an attack. B Show 4 more As per EULAR 2017 guidelines: Inform all patients with gout about the pathophysiology of the disease, the existence of effective treatments, associated comorbidities and the principles of managing acute attacks and eliminating urate crystals through lifelong lowering of serum urate level below a target level. B Provide full information in patients with gout and involve them fully in decision-making concerning the use of urate-lowering therapy. E As per T2T 2017 guidelines: Provide education about all aspects of the disease in patients with gout, and involve the patient fully in shared decision-making. E Make information about gout and its management readily available to patients. B Address modifiable risk factors primarily through patient education and support. B 8. Preventative measures Routine immunizations: consider offering high-dose or adjuvanted influenza vaccination, rather than regular-dose influenza vaccination, in 65 years old patients with rheumatic or musculoskeletal diseases and in 18-65 years old patients with rheumatic or musculoskeletal diseases on immunosuppressive medications. C Show 17 more Prophylaxis for Pneumocystis jirovecii pneumonia: consider administering prophylaxis against P. jirovecii pneumonia in patients initiating high-dose corticosteroids, especially in combination with immunosuppressants and depending on the risk-benefit ratio. C 9. Follow-up and surveillance Indications for specialist referral: Refer patients for specialist consultation in the following situations: unclear etiology of hyperuricemia refractory signs or symptoms of gout difficulty in reaching the target serum urate level, particularly with renal impairment and a trial of xanthine oxidase inhibitor treatment multiple and/or serious adverse events from pharmacologic urate-lowering therapy. B Serum urate monitoring: As per EULAR 2017 guidelines, monitor and maintain a defined serum urate level in patients on urate-lowering therapy. E https://web.pathway.md/diseases/recNUo9eCPgbgtHq6 10/14 7/1/23, 12:04 AM Gout Pathway As per T2T 2017 guidelines, monitor serum urate must regularly and adjust urate-lowering therapy to attain the therapeutic target. B As per ACR 2012 guidelines, monitor serum urate every 2-5 weeks during urate-lowering therapy titration, and obtain follow-up measurements every 6 months once the serum urate target is achieved. B Indications for switching urate-lowering agents: As per ACR 2020 guidelines, consider switching to an alternative urate-lowering agent, if available and consistent with other recommendations in this guideline, in patients with gout taking febuxostat with a history of CVD or a new cardiovascular event. C Show 2 more As per EULAR 2017 guidelines: Switch allopurinol to febuxostat or a uricosuric or combined with a uricosuric, if the serum urate target cannot be reached by an appropriate dose of allopurinol or when allopurinol is not tolerated. E Switch allopurinol to febuxostat or benzbromarone, or add benzbromarone to allopurinol, if the serum urate target cannot be achieved in patients with renal impairment (except in patients with eGFR < 30 mL/min) receiving allopurinol maximum dosage adjusted to CrCl. E Management of refractory disease: attempt upwards dose titration of one xanthine oxidase inhibitor to the maximum appropriate dose. A Clinical findings Symptoms Past medical history Ankle pain CKD Joint pain Diabetes mellitus Joint swelling Obesity Knee pain Social history Family history Alcohol consumption Genetic predispositions Musculoskeletal exam Vital signs Arthritis Hypertension Joint line tenderness Podagra Integument exam Polyarticular synovitis Tophus on pinna Lab findings Histological findings serum uric acid urine uric acid Synovial fluid monosodium urate crystals https://web.pathway.md/diseases/recNUo9eCPgbgtHq6 11/14 7/1/23, 12:04 AM Gout Pathway Urine uric acid crystals Likelihood Ratios Pertinent positives The following findings increase the probability of gout in adults. 16 Finding LR+ Value Presence of synovial fluid monosodium urate crystals 94 Presence of podagra 32 Increased serum uric acid* 3 measuring levels in acute attacks is not recommended, as they can be normal. Pertinent negatives The following findings decrease the probability of gout in adults. 16 Finding LR- Value Absence of podagra 0.04 Absence of synovial fluid monosodium urate crystals 0.2 serum uric acid not increased* 0.4 measuring levels in acute attacks is not recommended, as they can be normal. Studies 2022 STOP GOUT In patients with gout and hyperuricemia, allopurinol was noninferior to febuxostat with respect to the percentage of patients experiencing 1 gout flare at week 49 to 72. James R O'Dell et al. NEJM Evid. 2022 Mar. 2018 CARES In patients with gout and major cardiovascular coexisting conditions, febuxostat was noninferior to allopurinol with respect to CV death, nonfatal MI, nonfatal CVA, or UA requiring urgent revascularization. All-cause mortality and cardiovascular mortality were higher with febuxostat than with allopurinol. White WB et al. N Engl J Med. 2018 Mar 29. References https://web.pathway.md/diseases/recNUo9eCPgbgtHq6 12/14 7/1/23, 12:04 AM Gout Pathway 1. Michelle Hui, Alison Carr, Stewart Cameron et al. The British Society for Rheumatology Guideline for the Management of Gout. Rheumatology Oxford). 2017 Jul 1;56 7):e1-e20. Open 2. Khanna D, Fitzgerald JD, Khanna PP et al. 2012 American College of Rheumatology guidelines for management of gout. Part 1 systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res Hoboken). 2012 Oct;64 10 1431 46. Open 3. P Richette, M Doherty, E Pascual et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis. 2017 Jan;76 1 29 42. Open 4. Pascal Richette, Michael Doherty, Eliseo Pascual et al. 2018 updated European League Against Rheumatism evidence-based recommendations for the diagnosis of gout. Ann Rheum Dis. 2020 Jan;79 1 31 38. Open 5. John D FitzGerald, Nicola Dalbeth, Ted Mikuls et al. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Care Res Hoboken). 2020 Jun;72 6 744 760. Open 6. U Kiltz, J Smolen, T Bardin et al. Treat-to-target T2T recommendations for gout. Ann Rheum Dis. 2017 Apr;76 4 632 638. Open 7. Qaseem A, McLean RM, Starkey M et al. Diagnosis of Acute Gout: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017 Jan 3;166 1 52 57. Open 8. Anne R Bass, Eliza Chakravarty, Elie A Akl et al. 2022 American College of Rheumatology Guideline for Vaccinations in Patients With Rheumatic and Musculoskeletal Diseases. Arthritis Rheumatol. 2023 Jan 4. Online ahead of print. Open 9. Qaseem A, Harris RP, Forciea MA. Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017 Jan 3;166 1 58 68. Open 10. George E Fragoulis, Elena Nikiphorou, Mrinalini Dey et al. 2022 EULAR recommendations for screening and prophylaxis of chronic and opportunistic infections in adults with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis. 2022 Nov 3;ard-2022 223335. Open 11. Hershfield MS, Callaghan JT, Tassaneeyakul W et al. Clinical Pharmacogenetics Implementation Consortium guidelines for human leukocyte antigen-B genotype and allopurinol dosing. Clin Pharmacol Ther. 2013 Feb;93 2 153 8. Open 12. Expert Panel on Musculoskeletal Imaging:, Jon A Jacobson, Catherine C Roberts et al. ACR Appropriateness Criteria Chronic Extremity Joint Pain-Suspected Inflammatory Arthritis. J Am Coll Radiol. 2017 May;14 5S S81 S89. Open 13. Neogi T. Gout. Ann Intern Med. 2016 Jul 5;165 1 ITC1 ITC16. Open 14. Singh G, Lingala B, Mithal A. Gout and hyperuricaemia in the USA prevalence and trends. Rheumatology Oxford). 2019 Jun 5. pii: kez196. Open 15. Roddy E, Choi HK. Epidemiology of gout. Rheum Dis Clin North Am. 2014 May;40 2 155 75. Open 16. Ragab G, Elshahaly M, Bardin T. Gout: An old disease in new perspective A review. J Adv Res. 2017 Sep;8 5 495 511. Open 17. Zhang W, Doherty M, Pascual E et al. EULAR evidence based recommendations for gout. Part I Diagnosis. Report of a task force of the Standing Committee for International Clinical Studies Including Therapeutics ESCISIT . Ann Rheum Dis. 2006 Oct;65 10 1301 11. Open https://web.pathway.md/diseases/recNUo9eCPgbgtHq6 13/14 7/1/23, 12:04 AM Gout Pathway 18. Jeff A Simerville, William C Maxted, John J Pahira. Urinalysis: a comprehensive review. Am Fam Physician. 2005 Mar 15;71 6 1153 62. Open 19. Khanna D, Khanna PP, Fitzgerald JD et al. 2012 American College of Rheumatology guidelines for management of gout. Part 2 therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res Hoboken). 2012 Oct;64 10 1447 61. Open 20. Sharan K Rai, J Antonio Avi a-Zubieta, Natalie McCormick et al. The rising prevalence and incidence of gout in British Columbia, Canada: Population-based trends from 2000 to 2012. Semin Arthritis Rheum. 2017 Feb;46 4 451 456. Open 21. A Scuiller, T Pascart, A Bernard et al. Gout]. Rev Med Interne. 2020 Jun;41 6 396 403. Open 22. Francisca Sivera, Mariano Andr s, Neus Quilis. Gout: Diagnosis and treatment. Med Clin Barc). 2017 Mar 22;148 6 271 276. Open 23. James R O'Dell, Mary T Brophy, Michael H Pillinger et al. Comparative Effectiveness of Allopurinol and Febuxostat in Gout Management. NEJM Evid. 2022 Mar;1 3 10.1056/evidoa2100028. Open https://web.pathway.md/diseases/recNUo9eCPgbgtHq6 14/14