Gout Classification Criteria: Update and Implications

  • Ana Beatriz Vargas-Santos
  • William J. Taylor
  • Tuhina Neogi
Crystal Arthritis (MH Pillinger and SK Samuels, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Crystal Arthritis


Gout is the most common inflammatory arthritis, with a rising prevalence and incidence worldwide. There has been a resurgence in gout research, fueled, in part, by a number of advances in pharmacologic therapy for gout. The conduct of clinical trials and other observational research in gout requires a standardized and validated means of assembling well-defined groups of patients with gout for such research purposes. Recently, an international collaborative effort that involved a data-driven process with state-of-the art methodology supported by the American College of Rheumatology and the European League Against Rheumatism led to publication of new gout classification criteria.


Gout Classification criteria Conjoint analysis 



Dr. Vargas-Santos received a fellowship funding from Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Ministry of Science, Technology and Innovation of Brazil. Dr. Neogi’s work was supported by NIH grant AR 47785.

Compliance with Ethical Standards

Conflicts of Interest

ABVS and WJT declare that they have no conflicts of interest. TN reports that she was the ACR-PI of the 2015 ACR-EULAR Gout Classification Criteria report.

Human and Animal Rights and Informed Consent

All reported studies/experiments with human or animal subjects performed by the authors have been previously published and were in compliance with all applicable ethical standards (including the Helsinki declaration and its amendments, institutional/national research committee standards, and international/national/institutional guidelines).


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Doherty M, Jansen TL, Nuki G, Pascual E, Perez-Ruiz F, Punzi L, et al. Gout: why is this curable disease so seldom cured? Ann Rheum Dis. 2012;71(11):1765–70. doi: 10.1136/annrheumdis-2012-201687.CrossRefPubMedGoogle Scholar
  2. 2.
    Perez-Ruiz F, Urionaguena I, Carmona-Ortells L. Epidemiology and health-related services. Curr Opin Rheumatol. 2016;28(2):104–9. doi: 10.1097/BOR.0000000000000258.CrossRefPubMedGoogle Scholar
  3. 3.
    Clarson LE, Chandratre P, Hider SL, Belcher J, Heneghan C, Roddy E, et al. Increased cardiovascular mortality associated with gout: a systematic review and meta-analysis. Eur J Prev Cardiol. 2015;22(3):335–43. doi: 10.1177/2047487313514895.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Liu SC, Xia L, Zhang J, Lu XH, Hu DK, Zhang HT, et al. Gout and risk of myocardial infarction: a systematic review and meta-analysis of cohort studies. PLoS One. 2015;10(7), e0134088. doi: 10.1371/journal.pone.0134088.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Wallace SL, Robinson H, Masi AT, Decker JL, McCarty DJ, Yu TF. Preliminary criteria for the classification of the acute arthritis of primary gout. Arthritis Rheum. 1977;20(3):895–900.CrossRefPubMedGoogle Scholar
  6. 6.
    Gout. In: Kellgren JH, Jeffery MR, Ball JF, editors. The epidemiology of chronic rheumatism. Vol. I. Oxford: Blackwell Scientific; 1963. p. 327.Google Scholar
  7. 7.
    Decker JL. Report from the subcommittee on diagnostic criteria for gout. In: Bennett PH, Wood PHN, editors. Population studies of the rheumatic diseases. Proceedings of the Third International Symposium. New York: Amsterdam: Excerpta Medica Foundation; 1968; 1966. p. 385–7.Google Scholar
  8. 8.••
    Dalbeth N, Fransen J, Jansen TL, Neogi T, Schumacher HR, Taylor WJ. New classification criteria for gout: a framework for progress. Rheumatology (Oxford). 2013;52(10):1748–53. doi: 10.1093/rheumatology/ket154. This paper discusses in details the rationale for developing new and validated classification criteria for gout.CrossRefGoogle Scholar
  9. 9.••
    Neogi T, Jansen TL, Dalbeth N, Fransen J, Schumacher HR, Berendsen D, et al. Gout Classification Criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheumatol. 2015;67(10):2557–68. doi: 10.1002/art.39254. The jointly published 2015 ACR-EULAR Gout Classification Criteria.CrossRefPubMedGoogle Scholar
  10. 10.••
    Neogi T, Jansen TL, Dalbeth N, Fransen J, Schumacher HR, Berendsen D, et al. Gout classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Ann Rheum Dis. 2015;74:1789–98. doi: 10.1136/annrheumdis-2015-208237. The jointly published 2015 ACR-EULAR Gout Classification Criteria.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.•
    Aggarwal R, Ringold S, Khanna D, Neogi T, Johnson SR, Miller A, et al. Distinctions between diagnostic and classification criteria? Arthritis Care Res. 2015;67(7):891–7. doi: 10.1002/acr.22583. Reviews the differences between classification criteria and diagnosis.CrossRefGoogle Scholar
  12. 12.•
    Taylor WJ, Fransen J. Distinctions between diagnostic and classification criteria: comment on the article by Aggarwal et al. Arthritis Care Res. 2016;68(1):149–50. doi: 10.1002/acr.22671. Reviews the differences between classification criteria and diagnosis.CrossRefGoogle Scholar
  13. 13.
    Pelaez-Ballestas I, Hernandez Cuevas C, Burgos-Vargas R, Hernandez Roque L, Teran L, Espinoza J, et al. Diagnosis of chronic gout: evaluating the american college of rheumatology proposal, European league against rheumatism recommendations, and clinical judgment. J Rheumatol. 2010;37(8):1743–8. doi: 10.3899/jrheum.091385.CrossRefPubMedGoogle Scholar
  14. 14.
    Janssens HJ, Fransen J, van de Lisdonk EH, van Riel PL, van Weel C, Janssen M. A diagnostic rule for acute gouty arthritis in primary care without joint fluid analysis. Arch Intern Med. 2010;170(13):1120–6. doi: 10.1001/archinternmed.2010.196.CrossRefPubMedGoogle Scholar
  15. 15.
    Taylor WJ, Fransen J, Dalbeth N, Neogi T, Schumacher HR, Brown M, et al. Performance of classification criteria for gout in early and established disease. Ann Rheum Dis. 2016;75(1):178–82. doi: 10.1136/annrheumdis-2014-206364.CrossRefPubMedGoogle Scholar
  16. 16.
    Malik A, Schumacher HR, Dinnella JE, Clayburne GM. Clinical diagnostic criteria for gout: comparison with the gold standard of synovial fluid crystal analysis. J Clin Rheumatol. 2009;15(1):22–4. doi: 10.1097/RHU.0b013e3181945b79.CrossRefPubMedGoogle Scholar
  17. 17.
    Nakayama DA, Barthelemy C, Carrera G, Lightfoot Jr RW, Wortmann RL. Tophaceous gout: a clinical and radiographic assessment. Arthritis Rheum. 1984;27(4):468–71.CrossRefPubMedGoogle Scholar
  18. 18.
    Kuo CF, Grainge MJ, Zhang W, Doherty M. Global epidemiology of gout: prevalence, incidence and risk factors. Nat Rev Rheumatol. 2015;11(11):649–62. doi: 10.1038/nrrheum.2015.91.CrossRefPubMedGoogle Scholar
  19. 19.
    Zhu Y, Pandya BJ, Choi HK. Prevalence of gout and hyperuricemia in the US general population: the National Health and Nutrition Examination Survey 2007-2008. Arthritis Rheum. 2011;63(10):3136–41. doi: 10.1002/art.30520.CrossRefPubMedGoogle Scholar
  20. 20.
    Centers for Disease Control and Prevention. The Third National Health and Nutrition Examination Survey (NHANES III 1988–94) reference manuals and reports [CD-ROM]. Hyattsville (MD): National Center for Health Statistics. 1996.Google Scholar
  21. 21.
    Kuo CF, Grainge MJ, Mallen C, Zhang W, Doherty M. Rising burden of gout in the UK but continuing suboptimal management: a nationwide population study. Ann Rheum Dis. 2015;74(4):661–7. doi: 10.1136/annrheumdis-2013-204463.CrossRefPubMedGoogle Scholar
  22. 22.
    Klemp P, Stansfield SA, Castle B, Robertson MC. Gout is on the increase in New Zealand. Ann Rheum Dis. 1997;56(1):22–6.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Winnard D, Wright C, Taylor WJ, Jackson G, Te Karu L, Gow PJ, et al. National prevalence of gout derived from administrative health data in Aotearoa New Zealand. Rheumatology (Oxford). 2012;51(5):901–9. doi: 10.1093/rheumatology/ker361.CrossRefGoogle Scholar
  24. 24.
    Stamp LK, Wells JE, Pitama S, Faatoese A, Doughty RN, Whalley G, et al. Hyperuricaemia and gout in New Zealand rural and urban Maori and non-Maori communities. Intern Med J. 2013;43(6):678–84. doi: 10.1111/imj.12062.CrossRefPubMedGoogle Scholar
  25. 25.
    Wijnands JM, Viechtbauer W, Thevissen K, Arts IC, Dagnelie PC, Stehouwer CD, et al. Determinants of the prevalence of gout in the general population: a systematic review and meta-regression. Eur J Epidemiol. 2015;30(1):19–33. doi: 10.1007/s10654-014-9927-y.CrossRefPubMedGoogle Scholar
  26. 26.
    Karis E, Crittenden DB, Pillinger MH. Hyperuricemia, gout, and related comorbidities: cause and effect on a two-way street. South Med J. 2014;107(4):235–41. doi: 10.1097/SMJ.0000000000000082.CrossRefPubMedGoogle Scholar
  27. 27.
    Zhu Y, Pandya BJ, Choi HK. Comorbidities of gout and hyperuricemia in the US general population: NHANES 2007-2008. Am J Med. 2012;125(7):679–87 e1. doi: 10.1016/j.amjmed.2011.09.033.CrossRefPubMedGoogle Scholar
  28. 28.
    Scire CA, Manara M, Cimmino MA, Govoni M, Salaffi F, Punzi L, et al. Gout impacts on function and health-related quality of life beyond associated risk factors and medical conditions: results from the KING observational study of the Italian Society for Rheumatology (SIR). Arthritis Res Ther. 2013;15(5):R101. doi: 10.1186/ar4281.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Shields GE, Beard SM. A Systematic Review of the Economic and Humanistic Burden of Gout. Pharmacoeconomics. 2015;33(10):1029–47. doi: 10.1007/s40273-015-0288-5.CrossRefPubMedGoogle Scholar
  30. 30.
    Chandratre P, Roddy E, Clarson L, Richardson J, Hider SL, Mallen CD. Health-related quality of life in gout: a systematic review. Rheumatology (Oxford). 2013;52(11):2031–40. doi: 10.1093/rheumatology/ket265.CrossRefGoogle Scholar
  31. 31.
    Han GM, Michaud K, Yu F, Watanabe-Galloway S, Mikuls TR. The increasing public health burden of arthritis, other rheumatic conditions, and comorbidity: results from a statewide health surveillance system, 2007 to 2012. Arthritis Care Res. 2016. doi: 10.1002/acr.22856.Google Scholar
  32. 32.
    Robinson PC, Merriman TR, Herbison P, Highton J. Hospital admissions associated with gout and their comorbidities in New Zealand and England 1999-2009. Rheumatology (Oxford). 2013;52(1):118–26. doi: 10.1093/rheumatology/kes253.CrossRefGoogle Scholar
  33. 33.
    Neogi T. Clinical practice. Gout. N Engl J Med. 2011;364(5):443–52. doi: 10.1056/NEJMcp1001124.CrossRefPubMedGoogle Scholar
  34. 34.
    Robinson PC, Dalbeth N. Advances in pharmacotherapy for the treatment of gout. Expert Opin Pharmacother. 2015;16(4):533–46. doi: 10.1517/14656566.2015.997213.CrossRefPubMedGoogle Scholar
  35. 35.
    Dumusc A, So A. Interleukin-1 as a therapeutic target in gout. Curr Opin Rheumatol. 2015;27(2):156–63. doi: 10.1097/BOR.0000000000000143.CrossRefPubMedGoogle Scholar
  36. 36.
    Durcan L, Grainger R, Keen HI, Taylor WJ, Dalbeth N. Imaging as a potential outcome measure in gout studies: a systematic literature review. Semin Arthritis Rheum. 2015. doi: 10.1016/j.semarthrit.2015.09.008.Google Scholar
  37. 37.
    Glazebrook KN, Guimaraes LS, Murthy NS, Black DF, Bongartz T, Manek NJ, et al. Identification of intraarticular and periarticular uric acid crystals with dual-energy CT: initial evaluation. Radiology. 2011;261(2):516–24. doi: 10.1148/radiol.11102485.CrossRefPubMedGoogle Scholar
  38. 38.
    McQueen FM, Doyle A, Dalbeth N. Imaging in gout--what can we learn from MRI, CT, DECT and US? Arthritis Res Ther. 2011;13(6):246. doi: 10.1186/ar3489.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.•
    Ogdie A, Taylor WJ, Weatherall M, Fransen J, Jansen TL, Neogi T, et al. Imaging modalities for the classification of gout: systematic literature review and meta-analysis. Ann Rheum Dis. 2015;74(10):1868–74. doi: 10.1136/annrheumdis-2014-205431. Represents some of the work performed during the development of the 2015 ACR-EULAR Gout Classification Criteria.CrossRefPubMedGoogle Scholar
  40. 40.
    Taylor WJ, Fransen J, Dalbeth N, Neogi T, Ralph Schumacher H, Brown M, et al. Diagnostic Arthrocentesis for Suspicion of Gout Is Safe and Well Tolerated. J Rheumatol. 2016;43(1):150–3. doi: 10.3899/jrheum.150684.CrossRefPubMedGoogle Scholar
  41. 41.
    Roddy E, Zhang W, Doherty M. Concordance of the management of chronic gout in a UK primary-care population with the EULAR gout recommendations. Ann Rheum Dis. 2007;66(10):1311–5. doi: 10.1136/ard.2007.070755.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Choi HK, Atkinson K, Karlson EW, Willett W, Curhan G. Purine-rich foods, dairy and protein intake, and the risk of gout in men. N Engl J Med. 2004;350(11):1093–103. doi: 10.1056/NEJMoa035700.CrossRefPubMedGoogle Scholar
  43. 43.•
    Prowse RL, Dalbeth N, Kavanaugh A, Adebajo AO, Gaffo AL, Terkeltaub R, et al. A delphi exercise to identify characteristic features of gout - opinions from patients and physicians, the first stage in developing new classification criteria. J Rheumatol. 2013;40(4):498–505. doi: 10.3899/jrheum.121037. Represents some of the work performed during the development of the 2015 ACR-EULAR Gout Classification Criteria.CrossRefPubMedGoogle Scholar
  44. 44.•
    Taylor WJ, Fransen J, Jansen TL, Dalbeth N, Schumacher HR, Brown M, et al. Study for Updated Gout Classification Criteria: identification of features to classify gout. Arthritis Care Res. 2015;67(9):1304–15. doi: 10.1002/acr.22585. Represents some of the work performed during the development of the 2015 ACR-EULAR Gout Classification Criteria.CrossRefGoogle Scholar
  45. 45.
    Berendsen D, Jansen TL, Taylor W, Neogi T, Fransen J, Pascual E, et al. A critical appraisal of the competence of crystal identification by rheumatologists [abstract]. Ann Rheum Dis. 2013;72 Suppl 3:A981–2. doi: 10.1136/annrheumdis-2013-eular.2951.CrossRefGoogle Scholar
  46. 46.•
    Hansen P, Ombler F. A new method for scoring additive multi-attribute value models using pairwise rankings of alternatives. J Multi-Criteria Decis Anal. 2008;15(3-4):87–107. Outlines the theory behind the conjoint analytic methodology used in the development of several recent classification criteria efforts by the ACR and EULAR.CrossRefGoogle Scholar
  47. 47.•
    Taylor WJ. Pros and cons of conjoint analysis of discrete choice experiments to define classification and response criteria in rheumatology. Curr Opin Rheumatol. 2016;28(2):117–21. doi: 10.1097/BOR.0000000000000259. Provides a review of the experience in using discrete choice experiments in various applications of relevance to rheumatology, including the 2015 ACR-EULAR Gout Classification Criteria.CrossRefPubMedGoogle Scholar
  48. 48.
    Neogi T, Aletaha D, Silman AJ, Naden RL, Felson DT, Aggarwal R, et al. The 2010 American College of Rheumatology/European League Against Rheumatism classification criteria for rheumatoid arthritis: phase 2 methodological report. Arthritis Rheum. 2010;62(9):2582–91. doi: 10.1002/art.27580.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Johnson SR, Naden RP, Fransen J, van den Hoogen F, Pope JE, Baron M, et al. Multicriteria decision analysis methods with 1000Minds for developing systemic sclerosis classification criteria. J Clin Epidemiol. 2014;67(6):706–14. doi: 10.1016/j.jclinepi.2013.12.009.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    June RR, Aggarwal R. The use and abuse of diagnostic/classification criteria. Best Pract Res Clin Rheumatol. 2014;28(6):921–34. doi: 10.1016/j.berh.2015.04.004.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Ana Beatriz Vargas-Santos
    • 1
  • William J. Taylor
    • 2
  • Tuhina Neogi
    • 1
  1. 1.Clinical Epidemiology Research and Training UnitBoston University School of MedicineBostonUSA
  2. 2.Department of MedicineUniversity of Otago WellingtonWellingtonNew Zealand

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