In the latest updated EULAR recommendations on the treatment of Gout, it is suggested that Urate Lowering Therapy (ULT) be initiated as early as from the first gouty arthritis attack.
It also suggested that hyperuricaemia itself be targeted in the absence of arthritis, if there exists concomitant hypertension, heart failure or renal impairment.
This is in growing recognition of the critical role uric acid plays in the pathogenesis of renal and cardiovascular disease. This is a paradigm shift in ULT, an escalation in hostilities!
This should interest rheumatologists: recurrent gouty arthritis attacks may sensitize the immune system to collagen, providing an autoimmune means to joint destruction.
When Gout presents true to form (big toe joint swelling, rapid crescendo in half a day, abates in a week), diagnosis is not an issue.
However, as the disease progresses to the chronic tophaceous form, it can mimic other arthritides like Rheumatoid Arthritis and Spondyloarthritis, charting a persistently inflammatory course, and involving multiple joints and upper limb ones even, without clinically evident tophi. This is when advanced imaging like ultrasound and DECT can help.
Gout can also coexist with arthritides it mimics, like Psoriatic Arthritis, Pseudogout and Septic Arthritis. It's complicated.