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The treatment of gout is subject to different national and international guidelines. These guidelines differ in the extent to which they consider cardiovascular risk factors when deciding to start allopurinol. Observational studies and limited trial data suggest that treatment with allopurinol may reduce the risk of cardiovascular events in patients with gout. However, at this moment allopurinol remains an unproven strategy. There is need for a large randomized placebo-controlled trial with sufficient power and duration of follow-up.

In a recent equivalence clinical trial, prednisolone was reported to be equally effective as naproxen in the treatment of acute gout arthritis. The authors stated that the study provides a strong argument to consider prednisolone as first-line therapy for acute gout. For this double-blind placebo-controlled trial patients with the clinical diagnosis of acute gout (n = 381) were referred from primary care centers, but only those patients with crystal-proven gout and absence of contraindications for the trial medication were included (n = 120). They were randomly assigned to oral treatment for 5 days with either once-daily prednisolone 35 mg or twice-daily naproxen 500 mg and respective placebos. Points of discussion are whether there was indeed equivalence in effect, whether equivalence in adverse effects of the two treatments can be determined from the trial or from literature, and whether the results may be generalised. Although in selected acute gout patients prednisolone may be a good choice, available data still are too scarce to conclude that oral prednisolone is the first-line therapy for gout arthritis.

An 89-year-old woman was admitted for high fever and debilitating pelvic pain, notably in the pubic area. Physical examination revealed multiple gouty tophi in her hands and feet. Laboratory investigation revealed severe leukocytosis and a sharply increased C-reactive protein level. The patient was treated with broad-spectrum antibiotics in view of the possibility of a serious bacterial infection, but there was no clinical effect. CT of the pelvis revealed an osteolytic process and a mass anterior to the pubic symphysis. Histological investigation of a biopsy revealed an inflammatory infiltrate with signs of gout. Culture of the biopsy specimen was negative. The diagnosis was confirmed by the finding ofneedle-like urate crystals under the polarizing microscope. After treatment with colchicine and later with prednisone, the symptoms disappeared. She was given uric acid-lowering therapy with allopurinol as a preventive measure.

The typical form of acute gout can be clinically diagnosed. The term 'complicated gout' is used if there are more than three acute attacks of gout per year, tophi or urate stones in the urinary tracts. In the case of recurrent probable acute gout, a diagnostic fine needle aspirate from the joint during an attack is indicated. First choice treatment of acute gout consists of NSAIDs. Colchicine is the second choice treatment and the third choice treatment consists of corticosteroids. Excessive alcohol use should be limited. Treatment of chronic gout depends on the uric acid excretion in the 24-hour urine. If the level of excretion is too low, the first choice should be benzbromarone, and if the uric acid output is too high, allopurinol should be the treatment of first choice. Increased fluid intake is recommended; maintenance treatment with colchicine is not advised. Consultation with or referral to a rheumatologist is indicated in the case of doubt about the diagnosis of 'acute gout' or 'complicated gout', or (suspected) bacterial arthritis and insufficient treatment effect.

A 65-year old man had gout and a secondary infection of a tophus with Pseudomonas at the metatarsophalangeal joint of the right first toe.