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Monoarticular Arthritis: Which Patients to Treat for Gout?

A new clinical score supports decision making.

Researchers at an academic rheumatology department in the Netherlands prospectively developed a diagnostic rule for gout using data from 381 consecutive patients with monoarticular arthritis who were referred by family physicians. Within 24 hours of visits to family practitioners, patients underwent joint aspiration, examination of synovial fluid for monosodium urate (MSU) crystals, physical examination, and laboratory testing. Researchers, who were blinded to the family practitioners' diagnoses of gout or nongouty arthritis, analyzed predefined potentially diagnostic variables in logistic regression models; variables that were significantly associated with presence of MSU crystals were weighted and used to develop a clinical prediction model. The best-fit model included seven clinical variables, with a maximum clinical score of 13 (see the table).

MSU crystals were identified in 216 patients (57%). The prevalence of gout was 2.8% among patients with scores 4 and 80.4% among those with scores 8. The authors recommend that patients with scores 8 should receive therapy for gout and that those with scores between 4 and 8 should undergo joint aspiration and examination for MSU crystals, as well as examination for the remote prospect of infection, depending on history and clinical presentation.

Comment: Joint aspiration can be painful and risks infection, although the risk with proper arthrocentesis technique is negligible and should not preclude use of the procedure if the diagnostic rule cannot eliminate the possibility of infection and clinical suspicion exists. A diagnostic rule — such as this one — that can reliably reduce the need for aspiration could prove quite useful in emergency medicine and primary care practice. A clinical calculator for this score is available at http://www.umcn.nl/goutcalc.

— J. Stephen Bohan, MD, MS, FACP, FACEP

Published in Journal Watch Emergency Medicine September 10, 2010

Citation(s):

Janssens HJEM et al. A diagnostic rule for acute gouty arthritis in primary care without joint fluid analysis. Arch Intern Med 2010 Jul 12; 170:1120.

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Reader Remarks:

Review and add to remarks on this article

• what about infection?
  Joan papp, 28 Sep 2010 7:44 AM EST
  Did this article address the potentially higher risk of missing septic arthritis when these patients with high scores are not... [more]

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