Gout causes some of the most intense joint pain a person can experience, often starting suddenly overnight in the big toe. It is the most common form of inflammatory arthritis in adults and is becoming more common. The good news is that gout is very treatable, and with the right long-term approach, many people stop having flares altogether.
What causes gout
Gout is caused by high levels of uric acid in the blood, a condition called hyperuricemia. Uric acid is a waste product formed when the body breaks down purines, substances found in your own cells and in certain foods and drinks. Normally, the kidneys remove it in urine. When uric acid builds up, it can form sharp, needle-like crystals in and around joints, triggering intense inflammation.
Symptoms of a gout flare
- Sudden, severe joint pain, often starting at night
- Swelling, redness and warmth over the joint
- Extreme tenderness, so that even a bed sheet can be painful
- Most often affects the big toe joint, but can involve the ankle, midfoot, knee, wrist, fingers or elbow
A flare usually peaks within 24 hours and settles over one to two weeks, even without treatment. Over time, untreated gout can cause more frequent flares, multiple affected joints, chronic joint damage and lumps of crystals under the skin called tophi.
Risk factors
- Male sex, and women after menopause
- Obesity
- High blood pressure, kidney disease, diabetes and metabolic syndrome
- Certain medicines, especially thiazide and loop diuretics and low-dose aspirin
- Family history
- Diet and drinks: beer and spirits, sugary drinks sweetened with fructose, and large amounts of red meat, organ meats and some seafood
Common flare triggers
- Alcohol, especially beer
- Large meals rich in red meat or shellfish
- Dehydration
- Illness, surgery or injury
- Rapid weight loss or crash dieting
- Starting or changing doses of uric acid-lowering medicine
Diagnosis
The most definitive test is taking fluid from the affected joint with a needle and finding uric acid crystals under a microscope. This also helps rule out a joint infection, which can look similar and is an emergency. A blood test for uric acid is helpful but can be normal during a flare. Ultrasound or a special CT scan (dual-energy CT) can show crystal deposits.
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See a doctor urgently if a hot, swollen joint comes with fever or chills, because a joint infection must be ruled out.
Treating a flare
Start treatment as early as possible. Options include:
- NSAIDs such as naproxen or indomethacin, if safe for your kidneys, stomach and heart
- Colchicine, most effective when started within the first 12 to 36 hours, at a low dose
- Corticosteroids, taken by mouth or injected into the joint, useful for people who cannot take NSAIDs or colchicine
Rest the joint, raise it, and apply ice packs wrapped in a cloth. Keep drinking water.
Long-term treatment: lowering uric acid
Treating flares does not stop crystals from building up. Urate-lowering therapy dissolves crystals over time and prevents future flares and joint damage. It is generally recommended for people who:
- Have two or more flares a year
- Have tophi
- Have joint damage on X-ray
- Have kidney stones or chronic kidney disease along with gout
The usual goal is to keep blood uric acid below 6 mg/dL (lower in some people with tophi).
Allopurinol is the first-choice medicine for most people. It is started at a low dose and increased gradually until the target is reached. Some people, particularly those of certain Asian ancestries, may be tested for a gene (HLA-B*58:01) linked to a rare severe skin reaction before starting it.
Febuxostat is an alternative for people who cannot take allopurinol. Probenecid helps the kidneys remove uric acid. For severe, difficult-to-treat gout, an intravenous medicine called pegloticase may be used.
Starting urate-lowering therapy can briefly trigger flares as crystals dissolve, so doctors usually prescribe low-dose colchicine or an NSAID for the first three to six months as protection. Do not stop urate-lowering medicine during a flare unless told to.
Lifestyle steps
- Limit alcohol, especially beer and spirits
- Cut back on sugary drinks and foods high in fructose
- Eat red meat, organ meats and shellfish in moderation
- Choose low-fat dairy, vegetables, whole grains and plant proteins
- Stay well hydrated
- Lose weight gradually if you are overweight
- Ask your doctor whether any of your medicines raise uric acid
Diet alone usually lowers uric acid only modestly, so many people still need medicine.
The bottom line
Gout is caused by uric acid crystals, and flares can be treated quickly with NSAIDs, colchicine or steroids. For frequent flares, long-term urate-lowering therapy such as allopurinol, taken consistently to keep uric acid below target, can stop flares and prevent joint damage.
This article is for general information and does not replace medical advice.