Study on clinical and paraclinical characteristics of patients with gout disease diagnosed by the 2015 EULAR/ACR criteria

Journal of military pharmaco-medicine

STUDY ON CLINICAL AND PARACLINICAL CHARACTERISTICS
OF PATIENTS WITH GOUT DISEASE DIAGNOSED BY THE 2015
EULAR/ACR CRITERIA
Ton Thanh Tung*; Nguyen Ngoc Chau*
SUMMARY
Objectives: To analyze the clinical and para-clinical characteristics of patients with gout
disease diagnosed by the 2015 EULAR/ACR criteria. Subjects and methods: 31 patients who
were diagnosed with gout disease were selected. The study had focused on age, gender,
lifestyles, history and current patterns of gout, VAS (Visual Analog Scale) index, plasma uric
acid levels, hs-CRP, ESR, ultrasound images of affected joints. Results: The majority were male
(96.8%). The mean age of onset was 47.3 ± 15.2 years, the common age group of onset was
from 20 to 40 (41.9%) and commonly with the heavy pain (74.2%). 45.2% of patients were not
diagnosed with the first episode of gout lower than previous study’s with statistical significance,
the mean time for the definite diagnosis was 4.64 ± 4.4 years. Hs-CRP and ESR were two
common inflammatory markers. 19.4% of patients had normal range of uric acid. The double
contour lesion accounted for 29.0%. There was a moderate positive correlation between the
2015 EULAR/ACR classification criteria for gout scores and the frequency of recurrence attacks
of gout per year (r = 0.46; p < 0.05). Conclusions: The clinical and para-clinical characteristics of
patients were almost consistent with the previous studies. There was an increase in the rate of
patients diagnosed with the first attack of gout. The higher score of the EULAR/ACR 2015
classification for gout predicted the higher frequency of recurrence attacks of gout per year.
*Keywords: Gout disease; EULAR/ACR 2015; Clinical, paraclinical characteristics.

INTRODUCTION
Gout is the most prevalent form of
inflammatory arthritis and is associated
with impaired quality of life. There are
many criteria for diagnosing gout disease,
existing criteria for the classification of

gout have suboptimal sensitivity and/or
specificity and were developed at a time
when advanced imaging was not available.
Therefore, it is necessary to develop a
new diagnostic tool. The 2015 EULAR/ACR
gout classification criteria are developed
using a data-driven and decision analytic
approach, have excellent performance

characteristics and incorporate current
modern evidence regarding gout, has higher
sensitivity (92%) and higher specificity
(89%) than existing criteria. In Vietnam,
Bennett & Wood classification criterion
has been mainly used to diagnose gout
disease, the advantages of these criteria
are to diagnose based on clinical
manifestations, easy to remember and apply
but with low sensitivity and specificity.
Thus, this study aims: To use new criteria
EULAR/ACR 2015 to diagnose gout
disease and analyze the collected clinical
and paraclinical characteristics of patients.

* 103 Military Hospital
Corresponding author: Nguyen Ngoc Chau ()
Date received: 30/06/2017
Date accepted: 06/08/2017

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Journal of military pharmaco-medicine
SUBJECTS AND METHODS
1. Subjects.
* Inclusion criteria:
31 patients including 30 male patients
were treated in the Rheumatology and
Endocrinology Department, 103 Hospital.
- Diagnosed with gout disease by the
EULAR/ACR 2015 criteria.
- The affected joints were in inflammatory
condition with or without joint effusion.
* Exclusion criteria: Suspected bacterial
infection of the joints or other infection
conditions that affect to the evaluation of
the inflammatory investigation results.
2. Methods.
Cross-sectional, descriptive analysis.
* Examination and diagnosis:
- Take a history, age, gender; examine
the affected joints and assess pain levels
of joints (VAS), investigate ESR, hs-CRP,
plasma uric acid concentration, performed
ultrasound the affected joints for detecting
double contour.
- Patients with gout disease were
definitely diagnosed by the 2015
EULAR/ACR criteria.
* Method of data analysis:

Collected data were analyzed by the
medical statistical method using SPSS
23.0 software.
RESULTS AND DISCUSSIONS
1.
Clinical
characteristics.

and

paraclinical

* Clinical characteristics:
In total, we identified 31 patients with
gout disease. In most cases, the

classification diagnosis was made by the
2015 EULAR/ACR criteria with the total
mark more than 8 marks (96.8%). Only
one patient with poor clinical findings was
diagnosed by detecting urate crystal using
polarized light microscopy.
In our study, the mean age of onset
was rather young (47.3 ± 15.2). The most
common age group of onset was 20 - 40
(41.9%). This result was consistent with
the result of Hoang Thi Thu Trang
(48.8%). It also suggested that the onset
of gout had the tendency of rejuvenation.
This matched with the tendency of having

metabolism diseases in our modern
society.
The group with overweight and obesity
accounted for 41.9%, the mean BMI was
22.4 ± 2.6. This result was also consistent
with the result of Hoang Thi Thu Trang
studied on Vietnamese (50.1%). In the
study of L Annemans (2010), obesity
accounted for 27.7% of UK patients [2].
According to Lucía Cea Soriano (2011),
this rate was 65.99% [6]. Recent studies
have approved that obesity played an
important role in increasing the prevalence
of gout [7].
The heavy pain was the highest ratio
(74.2%) and the mean VAS was 73.5 ±
21.2. The result was consistent with the
result of Hoang Thi Thu Trang (68.8%)
[1], Pham Thi Minh Nham (79.2%) [5].
The result also matched with the
intensely painful
condition
in
the
pathophysiology of gout.
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Journal of military pharmaco-medicine
Table 1: Inhabit of alcoholic beverage using.

Quantity

Acid uric

p

Min - Max
Alcohol (n = 26)

Quantity (g/day)

108.3 ± 80.9

16 - 320

(83.9%)

Time (year)

31.9 ± 14.5

5 - 60

Beer (n = 14)

Quantity (g/day)

57.3 ± 37.2

4 - 120

(45.2%)

Time (year)

27.7 ± 12.2

10 - 50

497.9 ± 110.4
> 0.05
485.2 ± 90.9

We have known that alcohol and beer had played a big role in increasing the uric
acid concentration by the mechanisms of overproduction and reduced excretion uric
acid. In our study, 100% of patients had the history of using too much alcohol or beer in
the long term (83.9% of patients used alcohol, 45.2% of patients used beer). The mean
quantity of alcohol using was 108.3 ± 80.9 g/day, the mean quantity of beer using was
57.3 ± 37.2 g/day. However, in our study, alcohol and beer affected to the uric acid
concentration equally without statistical significance (p > 0.05).
Table 2: Diagnostic features.
Diagnostic features
Diagnosed with the first episode

Time to be definitely diagnosed with gout
disease (years)

Number of patients

Percentage

Yes

17

54.8

No

14

45.2

Min

1 year

Max

15 years
4.64 ± 4.4 years

Diagnosing gout has been a challenge
to the physicians in many cases because
of its various manifestations. In our study,
there was still a high ratio of patients who
were not diagnosed with the first episode
(45.2%). The mean time for the definite
diagnosis was 4.64 years. In the study of
Hoang Thi Thu Trang, this rate was

higher than ours (68.75%, p < 0.05). This
may be in the study of Hoang Thi Thu
Trang using the Bennet Wood criteria so
the sensitivity and the specificity were
lower. With whom the diagnosis was not
established by the first episode, the
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shortest time for the definite diagnosis
was 1 year, the longest time was 15 years
and the mean time was 4.64 ± 4.4 years.
Our result was shorter than the previous
study of Le Thi Vien (2006): 5.98 ± 5.9
years [3] and consistent with the result of
Hoang Thi Thu Trang (2.34 ± 5.19 years).
Because the patients paid more and more
attention to their health, so they visited
hospital earlier, at the same time, the
level of expertise of general doctors have
improved and physicians in primary
health care facilities have had a better
understanding of gout.


Journal of military pharmaco-medicine
* Paraclinical characteristics:
80.6% of patients in our study had
elevated uric acid level. The mean plasma
uric acid was 503.9 ± 106.4 µmol/L.
These results were consistent with

previous studies Hoang Thi Thu Trang
(69.4%; 499.13 ± 143.0 µmol/L) [1], Pham
Hoai Thu (65.3%; 470.2 ± 120.1 µmol/L)
[4]. However, 19.4% of patients were
diagnosed acute gout and acute flare of
chronic gout with normal plasma uric acid
concentration. This rate was similar to the
result in the study by Hoang Thi Thu
Trang (30.6%) [1]. This result showed that
the uric acid concentration was not the
definitive factor to activate the acute flares
of gout. This had reported by previous
studies of many authors [8].
Gout is an inflammatory joint disease.
So investigating the markers of inflammatory
condition could show us the level of the
inflammation. Hs-CRP, ESR and WBC
were the common inflammatory markers.
In our study, the elevated level of hs-CRP

was more common (80.6%), followed by
the elevated level of ESR (53.6%), WBC
was almost normal (54.8%) with the mean
WBC 8.39 ± 4.9. These results were
consistent with the results of Hoang Thi
Thu Trang (93.8%, 73.1% and 55.9%) [1].
The results matched with the clinical
manifestations of acute gout and acute
flares of chronic gout disease. The WBC
increased without statistically significant

difference (42.5% vs. 54.8%, p > 0.05), this
was absolutely consistent with the infectious
inflammatory process of gout disease.
Synovitis was the most common lesion
on the ultrasound (41.9%), followed by
the double contour (29.0%). This result
was also similar to a previous study [1].
The double contour was a very valuable
lesion for diagnosing gout on ultrasound.
It indicated the deposition of urate crystals
in the joints and distributed 4 marks into
the total 2015 score if positive. In our
study, we met 2 cases who were detected
tophi on ultrasound (6.5%).

Table 3: Plasma uric acid features.
Plasma acid uric
(µmol/L)

Acute gout (n = 23)

Acute flare of chronic gout
(n = 8)

Total

n

%

n

%

n

%

Increase

20

64.5

5

16.1

25

80.6

Normal

3

9.7

3

9.7

6

19.4

491.2 ± 141.9
p

478.3 ± 142.3

503.9 ± 106.4

> 0.05

80.6% of patients had elevated uric acid level, 19.4% of patients had a normal
plasma uric acid level. The mean plasma uric acid was 503.9 ± 106.4 µmol/L. There
was no difference of uric acid level between acute gout and acute flare of chronic gout
(p > 0.05).
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Journal of military pharmaco-medicine
2. The correlation of the EULAR/ACR 2015 classification for gout scores with
the frequency of recurrent attacks per year.

Frequency (numbers per year)

Through analyzing the data of 31 patients, we found that there was a moderate
positive correlation between the 2015 EULAR/ACR criteria classification for gout

scores and the frequency of recurrence attacks of gout per year (r = 0.46; p < 0.05).
These result showed that the higher scores of the EULAR/ACR 2015 classification for
gout may predict the higher frequency of recurrence of gout. No previous studies
mentioned about this. We considered if there will be a cut-off value of the 2015
EULAR/ACR classification criteria for gout scores that has meaning in prevention
management of gout but needs more studies.
30
25
20
15
10

y = 0.8842x - 2.8457
R2 = 0.2086

5
0
0

5

10

15

20

25

EULAR/ACR classification for gout marks

Figure 1: The correlation between the EULAR/ACR 2015 classification for gout scores
with the frequency of recurrence attacks of gout per year.
CONCLUSION
- The majority were male (96.8%) with
the mean age of onset 47.3 ± 15.2 years,
the common age group of onset was from
20 to 40 (41.9%) and commonly with the
heavy pain (74.2%). 45.2% of patients
were not diagnosed with the first episode
lower than previous study’s with statistical
significance, the mean time for the
definite diagnosis was 4.64 ± 4.4 years.
- 19.4% of patients who were diagnosed
acute gout and acute flare of chronic gout,
had normal value. Hs-CRP and ESR were
162

two common inflammatory markers. The
double contour lesion accounted for 29.0%.
- There was a moderate positive
correlation between the EULAR/ACR
2015 classification for gout scores and the
frequency of recurrence attacks of gout
per year (r = 0.46; p < 0.05).
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Journal of military pharmaco-medicine
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