OUTPATIENT RHEUMATOLOGY CLINIC: IS IT GOUT? THE USEFULNESS OF THE 2015 CLASSIFICATION IN A CLINICAL SETTING
I. Hotea 1, T. Crișan 1, Mm. Tamas 1,2, I. Felea 2, Sp. Simon 1,2, L. Damian 2, S. Rednic 1,2, L. Joosten 1,3, C. Pamfil 1 Presented by T. Onea
1. Luliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania 2. Clinical Emergency County Hospital, Cluj-Napoca, Romania 3. Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
Background: Diagnosing gout according to the golden standard is frequently hampered in the clinical settings due to lack of access to microscopy or imaging techniques. The ACR/EULAR Classification criteria for gout were developed to homogenize patients with gout with the purpose of enrolling patients in clinical studies.
Objective: The aim of this study was to access the usefulness of the application of these criteria in the absence of microscopy in patients with a suspicion of gout.
Methods: We enrolled 250 consecutive patients with presumed gout at the first presentation in a rheumatology outpatient clinic. We applied the EULAR/ACR score at referral, soliciting further imaging and laboratory tests in patients in which a score of 8 was not reached . We used the definitions stated in the 2012 ACR Guidelines for gout severity, extension and number of flares .
Results: The cohort included predominantly Caucasian patients (97%), of which 82%(n=204) male with an overall mean(±SD) age of 63(±11.4) years. A third of patients presented during acute flares and 24% had chronic tophaceous gout. Upon first presentation, 56/250 (22%) patients fulfilled an ACR score of 8 by applying the clinical criteria alone. The addition of laboratory criteria increased the percentage of patients to 89%, leaving only tenth of patients requiring further imaging or crystal assessment. Conversely, the imaging criteria in the absence of uric acid determination increased the proportion of patients fulfilling ≥8 points from 22% (clinical criteria alone) to only 50%. The mean (±SD) ACR/EULAR score at first presentation was 12.1(±3.9) with a mean(±SD) cumulated ACR/EULAR score for the clinical and laboratory criteria of 9.9(±2.3). The mean individual scores for the clinical, laboratory and imaging domains were 7.3(±1.9), 2.5(±1.2) and 2.2(±2.4), respectively. As expected we found that the EULAR/ACR score strongly correlated with the clinical evidence of tophi (r=0.68, p<0.0001) and with a very high level uricemia (>10 mg/dL; r=0.37, p<0.0001); similarly the score was negatively correlated with the presence of ≤1 flare until presentation (r=-0.35, p<0.0001). With regard to gout characteristics, the ACR score was positively correlated with the number of flares per year (r=0.34, p<0.0001), the extension of the attack (r=0.28, p=0.0083), the severity of the present attack (r=0.35, p=0009) and the severity of the gouty arthritis (r=0.37, p=0.003). Not surprisingly, we found no correlations with the presence and number of associated comorbidities within the metabolic syndrome, nor with the report of excessive alcohol consumption.
Conclusions: The clinical criterion and uricemia are the highest contributors to the EULAR/ACR score in a clinical setting, with only a minority of patients needing further imaging or crystal analysis for classification. Gout characteristics such as extension and severity of gout attacks or the number of flares are associated with higher ACR scores.
References: 1. Neogi T et al. 2015 Gout Classification Criteria: An American College of Rheumatology/ European League Against Rheumatism Collaborative Initiative. Arthritis Rheumatol. 2015 Oct; 67(10): 2557–2568. 2. Khanna D et al. 2012 American College of Rheumatology Guidelines for Management of Gout Part I: Systematic Non-pharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia. Arthritis Care Res (Hoboken). 2012 Oct; 64(10): 1431–1446.