Arthritis Treatment: Who Has Better Diagnostic Criteria for Gout - Yanks or Euros?

Gout is a disease characterized by elevated levels of serum uric acid (SUA). The end result is deposition of monosodium urate (MSU) crystals in joints and eventually internal organs as well. The diagnosis is not always easy. There is a mistaken notion by many, including some physicians, that joint pain plus an elevated SUA= gout. Not true. There are diseases where the SUA can be elevated and the patient doesn't have gout. And by the same token, a patient can have a gout attack with a normal SUA.

The classic attack is a very rapid development of joint inflammation occurring in one joint, usually the mid foot or great toe. If the great toe is affected, it is referred to as "podagra."

There are two sets of diagnostic criteria that have been used as guidelines.

The first set is from the American College of Rheumatology in 1977. These include:

1. Presence of MSU crystals in joint fluid and/or

2. Presence of a tophus (collection of uric acid crystals forming a lump) and/or

3. Presence of 6 of the following 12 criteria:

a. More than one attack of acute arthritis
b. Development of maximum inflammation within a day
c. Attack of arthritis affecting one joint
d. Redness surrounding the joint
e. Pain or swelling in the great toe joint
f. Attack affecting only one great toe joint and not the other at the same time
g. Attack affecting the mid foot on one side
h. Suspected tophus
i. Elevate SUA
j. Non-symmetric joint swelling on x-ray
k. A bony cyst found near a joint on x-ray
l. No bacteria found in the joint fluid during an acute arthritis attack

Nothing wrong with these criteria.

But to try and one up the Americans, the Europeans came out with their own set of guidelines, entitled EULAR (European League Against Rheumatism) recommendations for the diagnosis of gout. What they posited is using these criteria as a diagnostic ladder. Each criterion has a score. What they did was create a "Likelihood Ratio" for making the diagnosis. The more "ladder rungs" a patient has means the greater likelihood of gout. Here are a few of the likelihood guidelines:

MSU crystals in joint fluid. Score >500
Tophus. Score =40
Classic gout attack in great toe. Score= 30.6
Elevated SUA. Score=9.7
Bony cysts near joints seen on x-ray. Score <7

So. Take your pick. Yanks or Euros.