Gout - Treatment 

Treating gout 

Gout

Gout is a recurrent and painful form of arthritis. Find out how it affects the body, the treatments available and why the condition is a warning to look at your whole lifestyle.

Media last reviewed: 20/08/2013

Next review due: 20/08/2015

Vitamin C

There is evidence that people who take regular vitamin C supplements (500mg per day) have a lower risk of developing gout. This may be because vitamin C increases the amount of uric acid that is passed out through the kidneys into the urine.

It only has a relatively modest effect in terms of lowering uric acid levels. However, if you are more at risk of gout, you may want to consider taking a regular daily vitamin C supplement. 

Talk to your GP first, as taking vitamin C (or any other dietary supplements) is not suitable or safe for everyone.

If you are diagnosed with gout, your treatment plan will first aim to relieve the symptoms of an attack. Further treatment aims to prevent attacks by lowering uric acid levels.

Relieving symptoms

Self-care techniques

During a gout attack, it is important to rest, raise your limb and avoid knocking or damaging the affected joint.

Keeping the affected joint cool should also help. Remove surrounding clothing and apply an ice pack to it, such as a bag of frozen peas or some ice wrapped inside a towel.

Apply the ice pack to your joint for around 20 minutes. Do not apply ice directly to your skin and do not apply it for more than 20 minutes at a time because this could damage the skin.

Medication

Non-steroidal anti-inflammatory drugs (NSAIDs) are a type of painkiller usually recommended as an initial treatment for gout. They work by reducing the levels of pain and inflammation.

NSAIDs often used to treat gout include:

If you have been prescribed NSAIDs for gout, it is best to keep them near you at all times so you can use them at the first sign of a gout attack. Continue to take your medication throughout the attack and for 48 hours after the attack has finished.

NSAIDs should be prescribed together with a medication called a proton pump inhibitor (PPI), which reduces the risk of the NSAID causing indigestionstomach ulcers and bleeding from the stomach.

People who have reduced kidney function, conditions such as stomach ulcers or bleeding, or who are using certain medications such as warfarin or treatments for blood pressure should avoid using NSAIDs.

Colchicine

If you are unable to take NSAIDs or if NSAIDs are ineffective, colchicine can be used instead.

Colchicine is derived from the Autumn crocus plant. It is not a painkiller, but works by reducing the ability of the urate crystals to inflame the joint lining (synovium), which reduces some of the inflammation and pain associated with a gout attack.

It is best to keep them near you at all times so you can use them at the first sign of a gout attack.

Colchicine can be an effective treatment for gout. However, it should be used at low doses as it can cause side effects, including:

Colchicine can cause major gut problems if taken in too high a dose. It is important to follow the recommended dose. For most people, this means taking no more than two to four tablets a day.

Corticosteroids

Corticosteroids are a type of steroid sometimes used to treat severe cases of gout in people that:

  • do not respond to other treatment
  • are unable to take or cannot tolerate an NSAID or colchicine

A short course of steroid tablets often provides relief, but can't be used long-term in high doses as they cause side effects, including: 

  • weight gain
  • thinning of the bones (osteoporosis)
  • bruising
  • muscle weakness
  • thinning of the skin
  • increased vulnerability to infection

Corticosteroids can also exacerbate diabetes and glaucoma (an eye condition that can cause blindness if left untreated).

Corticosteroids may not be suitable for you if you have:

  • impaired kidney function
  • impaired liver function
  • heart failure 

Corticosteroids can also be given by injection, either into muscle or directly into the affected joint, which can provide rapid pain relief. 

Preventing attacks

Two methods used to try to prevent further attacks of gout are:

  • medication to reduce uric acid levels
  • making lifestyle changes to reduce uric acid levels

Medication

Drug treatment is recommended on a long-term basis for:

  • frequent attacks of gout and signs of tophi under the skin (tophi are small white lumps that can form under the skin)
  • evidence of joint damage – either in terms of associated symptoms or damage detected by X-ray
  • a history of kidney stones
  • reduced kidney function

Around 40% of people meet these criteria when gout is first diagnosed. More than 80% of people develop these symptoms within five years. Drug treatment is therefore considered and explained to most people before their gout becomes more severe.

The main treatment for gout is known as urate-lowering therapy (ULT). The goal of ULT is to lower uric acid levels below the levels required for crystals to form (the saturation point).

This prevents any new crystals forming and also helps to dissolve existing crystals. This eventually leads to the removal of all the crystals in your body and prevents any further attacks or joint damage. But you normally need to continue with ULT on a daily basis for the rest of your life to maintain this "cure".

Many people with gout begin ULT as soon as they are diagnosed to reduce the frequency of future attacks and the risk of developing joint damage. This has to be balanced against possible side effects that can occur with ULT, although these are rare.

Discuss the potential benefits and disadvantages of ULT with your GP or the doctor in charge of your care. If you agree to start ULT, allopurinol is usually the medication that is tried first.

Allopurinol

Allopurinol helps to lower uric acid levels by inhibiting the enzyme (xanthine oxidase) responsible for converting purines into uric acid, which reduces the production of uric acid. However, allopurinol is not a painkiller and will have no effect during an attack of gout.

Allopurinol is a tablet taken once a day. The dose needs to be adjusted to ensure that the target level of serum uric acid is achieved. The aim is to maintain the level well below 360 umol/L or 6mg/dl.

The dose is usually increased every three to four weeks, depending on the results of the blood tests for uric acid. 

Once this target is achieved, it often takes up to a year or two before all crystals have dissolved and no further attacks occur. The medication will then usually be taken for the rest of your life.

It can take a while to assess the most effective dose for your circumstances. You may need to have several blood tests to find the most effective dose.

When you first start taking allopurinol, it can sometimes cause a gout attack, because the rapid reduction of uric acid levels to below the saturation point causes existing crystals in the joint cartilage to partially dissolve and become smaller.

The smaller crystals can escape more easily or "shed" from the cartilage into the joint cavity, and then inflame the joint lining (synovium).

The risk of this happening is reduced by slowly increasing the dose of allopurinol as described above.

You may continue to have gout attacks until all the existing crystals have dissolved, which is perfectly normal.

If this does happen, you shouldn't lose confidence in the effectiveness of ULT. It's important to persevere with treatment to achieve the maximum benefit.

If you do develop a flare-up of gout while taking allopurinol, continue taking the medication while your doctor prescribes additional treatment to settle the attack.

Although allopurinol is taken without any side effects in most patients, around 10% do experience problems. A skin rash is the most common side effect. In most cases, this is mild and soon goes away.

However, in a small number of cases, it can be a sign of an allergic reaction. If you develop a skin rash while taking allopurinol, stop taking the medication immediately and contact your GP for advice. It may be necessary to stop taking allopurinol and try an alternative ULT.

Other possible side effects of allopurinol include:

You will probably not be able to take allopurinol for safety reasons if you are currently being treated with immunosuppressant medications (often used to prevent your body rejecting a donated organ) or a type of medication called cyclophosphamide (used in the treatment of some cancers).

Patients with kidney problems may be started on a lower dose (50mg daily) and have lower monthly increases (50mg) of allopurinol. 

Allopurinol may also not be suitable if you have severe kidney disease. Those with severe kidney disease may not even be started on allopurinol, but prescribed an alternative ULT such as febuxostat.

Febuxostat

Febuxostat acts in the same way as allopurinol by inhibiting the enzyme (xanthine oxidase) that produces uric acid and reducing the body's production of uric acid.

However, unlike allopurinol, it is mainly broken down by the liver rather than the kidney, which is why it can be used more easily in patients with kidney disease.

Febuxostat may be very effective at lowering the serum uric acid level. As with allopurinol, febuxostat may cause temporary worsening of your symptoms when you first start taking it.

To try to reduce the frequency and severity of this side effect, your doctor may prescribe you regular daily oral NSAIDs or colchicine (one to two tablets daily) for up to six months following the start of febuxostat as preventative treatment (prophylaxis).

Common side effects of febuxostat include:

  • an increased number of acute gout attacks
  • diarrhoea
  • headache
  • feeling sick
  • skin rash

If you experience more serious symptoms, such as breathing difficulties or facial swelling, stop taking febuxostat and contact your GP for advice. 

Currently, febuxostat is not considered to be suitable for people with heart problems, especially heart failure.

Less commonly used ULT medications

Less commonly used ULT medications include:

  • benzbromarone
  • sulphinpyrazone
  • probenecid

They work by helping the kidneys to remove uric acid from the body.

Sulphinpyrazone and probenecid are now rarely used as they are not as effective as other types of ULT medications and are not suitable for people with kidney disease.

Benzbromarone is more effective in removing uric acid and can be used in people with kidney disease.

These types of medication tend to only be used if people are unable to take allopurinol or febuxostat. They need to be prescribed under the supervision of a specialist.

Lifestyle changes

Food

Some foods are high in purines. Avoiding eating the foods below can help reduce the risk of a gout attack:

  • offal – liver and kidneys, heart and sweetbreads
  • game – rabbit, pheasant and venison
  • oily fish – anchovies, herring, mackerel, sardines, sprats, whitebait and trout
  • seafood – mussels, crab, shrimp and other shellfish, fish roe and caviar
  • foods or supplements that contain yeast or meat extract – Marmite, Bovril, commercial gravy and beer

For more detailed information on foods to eat in moderation and low purine foods, see the following factsheet on gout and diet (PDF, 711kb) produced by the UK Gout Society.

Weight

If you are overweight, the levels of uric acid in your blood often rise. Losing weight will help reduce your uric acid levels significantly.

If you need to lose weight, it is important to follow a balanced, calorie-controlled diet. Do not crash diet. A high-protein, low-carbohydrate diet should be avoided, because high-protein foods often contain high levels of purines.

Ensure you get plenty of regular exercise. Not only will this reduce your urate levels and decrease your risk of developing gout, it will also make you feel more energised and healthier.

If you have a gout attack, keep the joint rested and elevated (raised). Avoid exercise that puts strain on the affected muscles or joints. Swimming is a good way to stay fit without putting pressure on your joints, as the water supports your weight.

Read more about losing weight safely and getting fit with exercise.

Water

It is important to drink plenty of water to avoid dehydration. Aim to drink about 1.2 litres (six to eight glasses) a day, or more if you are exercising or when it is hot.

Keeping yourself well hydrated will reduce the risk of crystals forming in your joints.

Alcohol

Some types of alcoholic drinks are associated with a greater risk of developing gout than others.

Beer and stout, which contain significant quantities of purines, carry a greater risk for the development of gout than equivalent units of spirits, such as vodka and whiskey.

Studies have shown that, as long as you stick to the maximum recommended levels of alcohol intake, wine is not associated with an increased risk of developing gout.

However, binge drinking of any kind of alcohol can bring on an attack in people who have previously suffered with gout. Men should not drink more than three to four units of alcohol a day and women no more than two to three units a day.

Read more lifestyle advice about alcohol and its potential impact on health.

Page last reviewed: 13/01/2014

Next review due: 13/01/2016

Ratings

How helpful is this page?

Average rating

Based on 1485 ratings

All ratings

Add your rating

Comments

The 18 comments posted are personal views. Any information they give has not been checked and may not be accurate.

A_Patient said on 12 August 2014

Hi hellonearth... I see your post was 4 months ago so hopefully the gout is under control now... however, I thought I'd share my experience, anyway. I totally agree with everything in the article: I've suffered since 2004, and also had problems with kidney stones that put me in hospital a few times. I blame myself for poor diet - drinking too much when I got depressed, for example - and probably being overweight. At one time, I thought I would never again be able to climb stairs without this excruciating pain in my right knee and my feet would often become affected... feeling just like red-hot needles. When affected, I had to wear sandals instead of shoes... not cool for an ICT teacher! I also had this awful swelling on my left elbow which took ages to go down and left behind a large outcrop of bone... probably a tophus... but the hospital still did not diagnose it as uric acid-related. After several years of suffering, a new GP realised what it was and prescribed Allopurinol... sigh... within just a couple of weeks the pain in my knee simply stopped - unbelievable! I also found Naproxen to be effective during attacks to reduce swelling and pain, but do take the inhibitor too as proscribed. Best wishes :)

Report this content as offensive or unsuitable

WallyMcDonald said on 12 April 2014

Indomethacin is the best anti-inflammatory for relief from the severe pain and inflammation of a gout attack. Prescription only as is risky especially for bleeding stomach or cardiac illness. Naproxen is also ok but not as effective.

Report this content as offensive or unsuitable

hellonearth said on 01 April 2014

I found this website and read these posts this morning before seeing GP. At that stage it had been in L toe mostly since Friday but escalated last night. Since then it has got considerably worse.

This afternoon the pain is unbearable and I can only get around a bit if I hop.Its in my L big toe and foot and has swollen up. I live alone and cannot even get to the front door to take out the key so friends with keys can get in.

Luckily I managed to drive to my GP this morning, before it really flared up. So far I have taken 2 x doses Colchicine, 2x paracetamol, 1 Dramadol and copious applications of a Diclofenac gel.

This is my first attack (precipitated by Paclitaxel? in just 1 session of chemo in January, which has caused so many side effects).

Can anyone recommend anything else to reduce the pain? I tried elevating my foot and cooling it but it seemed to make it worse. Any ideas on how long it will take before the Colchicine kicks in?

thank you

Report this content as offensive or unsuitable

CRanjan said on 17 February 2014

I have had two gout attacks in the past six months. The first passed in a couple of days, and the second most recent one has had me in its thrall for the last three weeks.

A am a vegetarian and my uric acid levels are normal. The only causative factor that I can think of is that I started on statins about a month before the first attack. I have also not been drinking as much of water as I used to.

If statins are the cause, there appears to be evidence in support of that hypothesis:
http://www.spacedoc.com/statins_gout.htm
http://www.telegraph.co.uk/health/8316351/Statins-I-was-in-agony-for-months.html

Report this content as offensive or unsuitable

GarethRees said on 29 January 2014

I had my first attack of gout about 15 years ago which coincided with dropping a concrete block on my foot. I was in denial for quite a while despite blood tests showing high Uric Acid levels. My GP offered to put me on medication but as he said it was for life I declined. I get an attack maybe once a year sometimes less.
One of the things that definitely brings it on is fasting - I would sometimes not eat until the evening. Since I stopped doing that the attacks have decreased.
When I get an attack I eat Morello cherries, I read about this a few years ago, the attack is usually controlled within a day or so. I don't know why it works but it certainly does for me. I am also very careful about knocking my left foot(big toe) while working in the garden or handling any heavy items. If I do knock it and it starts to feel sore, I take an NSAID as a precautionary measure, but be careful they can damage the stomach if taken too frequently.
Interestingly I went on a high protein diet in July last year and subsequently lost nearly two stone - I am now between 12 and 12.5 stone. However, despite the warnings the diet did not bring on an attack of gout, maybe I was just lucky.
I have an attack at the moment (which is why I am back reading these pages) I have taken some Dichlophenac which seems to have eased it a fair bit and I will be getting some cherries later today. I used to keep them in stock permanently but since I haven't had an attack for nearly two years I got a bit complacent.
I hope this info helps someone else to manage their gout - good luck!

Report this content as offensive or unsuitable

roj2003 said on 02 January 2014

I had gout for some 15 years, culminating in a situation where I woke, swung my legs out of bed, stood up, screamed, fell over and hobbled for a fortnight. I had been using anti-inflammatory pills but these not enough.
I asked to be put on allopurinol daily for life and, apart from 2 half hour bouts of swollen toes over the next 2 months, I have never had another gout attack - some 3 years now and counting.

Report this content as offensive or unsuitable

JayJayDubya said on 17 November 2013

As Jonken60 (21 August 2013) says the pain, inflammation etc are a result of the bodies immune system acting against the Uric Acid cyrstals not the presence of the cyrstals themselves. So in order to reduce the symptons ie the pain, I have been using antihistamines. I use a topical cream marketed for stings applied to the swollen area and if the attack is bad then I take an anti-hayfever tablet. This does seem to help reduce the pain and inflammation, however I suppose that by preventing the bodies immune system working I am interfering with the natural reduction of the Uric Acid crystals. In order to help maintain this reduction I ensure that I keep well hydrated by drinking plenty of water. Basic chemistry shows that salts crystalise out of a saturated solution but diluting the solution prevents crystals forming and will cause any crystals already formed to disolve back into solution. I just hope this applies to the Uric Acid.
Of course I do not advocate the above as an alternative to consulting your doctor and following a prescibed treatment.

Report this content as offensive or unsuitable

sarsons said on 12 October 2013

I have been on Allopurinol for months now and only one week into 300mg a day. No longer on colcochine and woke up today to a gout attack. This surprised me as I was led to believe that allopurinol would prevent future attacks. Thats why I came here for advice. Wish I'd have been told that I could still have attacks for potentially years before this breaks down all the uric acid crystals. And to think only yesterday a Dr asked if I had any flare ups of gout since starting the medication. If this attack had started yesterday I could have asked for colcochine lol

Report this content as offensive or unsuitable

Jonken60 said on 21 August 2013

I'm in the middle of a severe attack just now. Been prescribed allopurinol for life, but lapsed the medication of one per day to see how I got on. Several years have passed since i've had an attack of gout like this, it's come back with a vengeance though. I stick to a strict diet quite easily, as the foods i'm asked to avoid to prevent an attack, I don't like or eat/ drink anyway, so I don't understand why i've got this crippling attack just now.
From what i've read on the subject an attack can be taking place without the bearer realising it. It's just when the immune system of the body decides it's time to act that the pain, swelling, discomfort takes place, and by then it's too late to do anything about it, and normally have to let the attack run it's course. Very sneaky condition to have. Hard to prevent and control. I've learned my lesson I'll take the allopurinol every day from now on.

Report this content as offensive or unsuitable

Basvandergoor said on 08 July 2013

I have had an attack of gout every year for 4 years, either in right big toe or left knee, which last about 4-5 days.
I self treat by eating lots of cherries, an English folk remedy, either fresh or bottle, plenty of water and take fish oil tablets every day all year and cherry extract or cranberry extract from health food store. Grapefruit seems to kick it off so I read fruit juice labels carefully

Report this content as offensive or unsuitable

comet4c said on 22 April 2013

I have been taking ullopurinol for the past 9 yrs and have had no attacks of gout since. I now realise that my lifestyle in the Forces didn't help and also that when i got a job in a brewery that things got worse. Since i have been diagnosed as Diabetic i have stopped drinking alchohol completely and havn't done for a couple of years. I'm now thinking of asking my GP if it would be ok to come off of the tablet to see if it come back. Any thought on this please.

Report this content as offensive or unsuitable

Johnny S said on 17 October 2012

I have experienced recurrent attacks over 20 years or so, maybe two or three times a year. It nearly always occurs in the right foot and lasts a few days.

I have consulted the doctor twice, but he has not prescribed any treatment.

I take water tablets for high blood pressure, I am a moderate drinker of mainly white wine.

It has been said that Cranberry juice can help prevent gout, but it is not mentioned here. Also the warnings about taking NSAID with water tablets do not distinguish between tablets and creams that can be applied to the affected area. I wonder if it is safe to use the creams.

Experience makes me think that my attacks are provoked by high levels of exercise and perspiration. One should drink plenty of water when exerting oneself for long periods. I often forget though.

Report this content as offensive or unsuitable

robfs said on 05 September 2012

I am currently mid attack and not sure what is triggering it to last so long: 10 days with two very bad days so far. Previously diclofenac has (I think) stopped the attack completely. This time it isn't. I have a prescription for Allopurinol which I am debating using.
Currently, I am taking half a teaspoon of bicarbonate of soda diluted in water first thing in the morning and last thing at night. I have using this for 4.5 days - so far I'd say I have improved until this morning. I will try this for a bit longer or its allopurinol for life. Watch this space.

Report this content as offensive or unsuitable

JohnNB said on 13 July 2012

Another cause of gout is diuretics, which are widely prescribed for reducing blood pressure and for other reasons. The mechanism is complicated, but they effectively inhibit excretion of uric acid, which then builds up in the body. Eventually, which can be after several years of taking diuretics, it builds up to a level at which it crystallizes and causes gout. Even though there have been several articles on this subject in reputable medical journals, it is not generally not mentioned in patient information leaflets as a side effect of taking diuretics, and many GPs seem to be unaware of it. I was also unable to find any mention of it on this website, even though it is quite a common cause of gout.

Report this content as offensive or unsuitable

ammerfan said on 22 May 2012

I have suffered from gout on and off for 15 years. I take daily medication. I retired 5 years ago from a desk job in the City and since then I have not suffered from Gout until today. What is different? When working I appeared to get gout attacks when I sat for long periods at my computer, flew on business trips and had a few days in a row of excess alcohol consumption especially beer. I gave up drinking beer, stout and spirits and normally drink Lager or white wine. However this weekend we flew as a family to Aberdeen for a wedding, had three nights of excess alcohol consuption which included Guinness and spirits (whisky).
Conclusion: I have come to the conclusion flying coupled with beer/ stout and spirit consumption must be avoided.

Report this content as offensive or unsuitable

Garland 101 said on 26 April 2012

I’ve had gout for many years, but by watching what I eat and drink I have been able to keep the attacks to a minimum, even when I over indulge when on holiday or at a work function.
However this week I have had the worse attack I have had for years , and I have been in bed know for 3 days treating myself with DICLOFLEX ,
It’s worth a note that last weekend I consumed an unusual amount of coffee and bread because we bought a coffee bread making machine
This is by no means scientific but I am convinced this is what bout on such a severe attack

Report this content as offensive or unsuitable

yorweth said on 29 June 2011

Hi Beemer just having a excruciating case of gout in my left toe . you seem to have reserched it. Im on colchicine , but its doing no good at all . the last time i had gout was 4 years ago this is only my fourth time . i stoped eating prawns, liver and lowered my intake of red wine. And that seems to controlle it . the only thing i have been eating a regular amount of lately is bannanas . And i have just had my blood pressure tablets changed from nebivalol beta blockers. to ramiprill. have you experianced something similar.

Report this content as offensive or unsuitable

beemer1 said on 29 May 2011

I have had Gout for many years,I'm now 68.
Some of the foods that trigger my Gout are,Faggots,Black pudding,Smoked bacon(Not dry cured),Gravy made with Beef meat juice,Yeast spread products,Beef dripping on toast,Fortified wines,Cider(Scrumpy)Strong real ales,Strong black proper Coffee(Not 100% certain on this one yet),lack of exercise,and most of the listed foods etc in the doctors list!
By the way,I have suffered Gout in many different joints in my body,feet ankles knee's hands elbow's wrists,so as you can see it is not just the big toe area as most people relate too,and its not rich people's food,just basic pensioner foods in my case!I also take Colchicine when flare ups are about to happen(Tingling soreness in the joint about to be attacked)I take my Colchicine with plenty of cold semi skimmed milk,for no nasty side effects!

Report this content as offensive or unsuitable

cloud

Over 60 and
feeling under
the weather?

Find out how your local pharmacy can help.

Learn more about how a pharmacist can help you

Which painkiller?

The drugs you should take to treat pain depend on what type of pain you have