Gout Treatment

For the acute attack: NSAIDs such as naproxen, colchicine, or a short course of oral steroids. Which one depends on your kidney function, stomach and heart history. Started early, all three work well.

For prevention: allopurinol is first-line and lowers uric acid production. Febuxostat is the alternative where allopurinol is not tolerated.

The principle behind prevention is simple and frequently misunderstood: the dose is titrated against a target uric acid level, usually below 360 µmol/L, and lower still if you have tophi. Being "on allopurinol" at a starting dose that was never increased is the commonest reason it appears not to work.

• Anyone in an acute attack who needs treatment today
• Anyone who has had two or more attacks in a year — the standard threshold for preventive treatment
• Anyone with tophi, joint damage on imaging, or kidney stones
• People with gout alongside high blood pressure, diabetes or kidney impairment
• People already on allopurinol who still have attacks — usually a dose problem, not a drug failure

1. Same-day assessment of the attack

A classic first-attack picture — sudden severe pain in the base of the big toe, red and untouchable — is usually diagnosable clinically, and we can prescribe the same day.

2. Testing, at the right time

Kidney function and urate, plus glucose and lipids — gout travels with metabolic and cardiovascular risk, and finding it is an opportunity worth taking.

An important caveat: uric acid is often normal or low during an attack. A normal level then does not exclude gout, and we retest a few weeks later.

3. Prevention, started properly

Allopurinol is begun at a low dose and increased every few weeks against repeat levels, with colchicine or an NSAID cover for the first few months.

4. Review the contributors

Diuretics for blood pressure raise urate and can often be switched. Alcohol — particularly beer — and fructose matter more than the red meat most people focus on.

The attack: expect improvement within a day or two

Started early, NSAIDs, colchicine and oral steroids all work well. Pain should be settling within 24–48 hours and largely resolved within a week.

Rest and elevate the joint, and keep the bedclothes off it — a cage or a pillow arrangement makes the nights considerably more bearable. Ice helps.

Test urate at the right time

Uric acid is often normal or even low during an attack. A normal level then does not exclude gout, and this is a common reason the diagnosis is dismissed.

We retest a few weeks after the attack has settled, which is when the number means something.

Prevention: titrate to a target, not to a starting dose

This is where gout treatment overwhelmingly goes wrong. Allopurinol is started low and increased every few weeks against repeat urate levels, aiming below 360 µmol/L — lower still if you have tophi.

Being "on allopurinol" at a starting dose that was never increased is the commonest reason it appears not to work. A great many people are on 100mg indefinitely and still having attacks, and conclude the drug failed.

• Urate rechecked every 2–4 weeks while titrating
• Then every 6–12 months once at target
• Kidney function monitored alongside

Two things everyone should know about starting allopurinol

• It can trigger an attack in the first months. This is expected, not a sign it is wrong — which is why colchicine or an NSAID is given as cover for the first few months
• Never stop allopurinol during an attack. Stopping and restarting causes more attacks, and it is an extremely common and counterproductive mistake

Stop and contact us

• Any rash on allopurinol — stop it and contact us. A rare but serious hypersensitivity reaction exists, and the risk is higher in people of Han Chinese, Thai and Korean heritage, where HLA-B*5801 testing is recommended before starting
• Diarrhoea on colchicine, which means the dose is too high — modern low-dose regimens are as effective and far better tolerated

A hot joint with fever is not gout until proven otherwise

Septic arthritis must be excluded urgently and in person. Go to A&E. It looks similar, it destroys a joint within days, and it is the one diagnosis not to get wrong here.

What gout tells you about the rest of your health

Gout travels with metabolic and cardiovascular risk. Blood pressure, glucose, lipids and kidney function are all worth checking — finding gout is an opportunity, and it is routinely wasted.

Review what is raising your urate

Often more productive than any dietary change:

• Diuretics for blood pressure — a very common contributor, and frequently switchable for something that does not raise urate. This alone resolves gout for some people
• Low-dose aspirin, though it is usually continued where it is needed for the heart
• Ciclosporin and some other medicines

Diet and alcohol — what actually matters

Not the red meat most people focus on.

• Alcohol, and beer in particular, which is high in purines as well as alcohol. The single biggest dietary lever for most people
• Fructose — sugary drinks and fruit juice, which raise urate directly and are widely overlooked
• Shellfish and organ meats, which matter more than steak
• Dairy, coffee and cherries, which are modestly protective
• Staying well hydrated

Honest framing: diet alone rarely achieves target urate in someone with recurrent gout. It helps, and it is not a substitute for treatment — people are frequently left to "manage it with diet" for years while their joints are damaged.

Weight, and the thing to avoid

Weight loss lowers urate meaningfully — but crash dieting and fasting raise it sharply and can trigger an attack. Gradual is the answer.

Prevention beyond allopurinol

Febuxostat where allopurinol is not tolerated or does not reach target. Rheumatology referral for tophi, chronic gouty arthritis, or where target urate cannot be achieved.

The threshold for preventive treatment

Two or more attacks in a year is the standard threshold — and also tophi, joint damage on imaging, kidney stones, or kidney impairment.

Fewer than half of the people who should be on preventive treatment ever receive it, which is why gout so often becomes a recurring, joint-damaging condition when it need not.

What does not work

Cherry extract supplements at the doses sold. "Alkalising" diets and drinks. And treating each attack in isolation forever, which is the real failure — gout is a curable-in-effect condition if urate is brought below target and kept there.

What you pay us

• £40 for the consultation, with a same-day prescription for an attack where appropriate
• Urate, kidney function, glucose and lipids, quoted before arranging
• £40 for each titration review, with urate rechecked every 2–4 weeks while the dose is being increased
• Sick note where an attack stops you working — included

Reaching target urate usually takes several rounds of titration, and it is worth knowing that at the start.

What you pay the pharmacy

Everything used here is cheap. Allopurinol, colchicine, naproxen and prednisolone are all inexpensive generics. We earn nothing from what is prescribed.

Where the appointment earns its money

Two things, and neither is the prescription for the attack.

• Getting the preventive treatment right. Titrating allopurinol to a target urate is what stops gout recurring — and most people never get past the starting dose
• Testing urate at the right time. A normal level during an attack does not exclude gout, and that misunderstanding delays diagnoses

The NHS point

Gout is treated free on the NHS, and prescriptions are free in Scotland, Wales and Northern Ireland. Where we are useful is speed during an attack — which is genuinely painful and worth not waiting for — and a proper titration for someone who has been left on a starting dose for years.

What untreated gout actually costs

Recurrent attacks, days off work, and eventually permanent joint damage and tophi. Preventive treatment costs a few pounds a month.

It is one of the clearest examples in medicine of a cheap treatment preventing an expensive outcome, and it is routinely not offered.

Where not to spend money

• Cherry extract and "uric acid" supplements, at the doses sold
• Alkaline water and "detox" products
• Repeated appointments for individual attacks without ever addressing prevention — the most expensive way to have gout

Can you treat an attack today?

Usually yes. A classic first attack — sudden severe pain in the base of the big toe, red, swollen and untouchable — is generally diagnosable clinically, and we can prescribe the same day.

Started early, NSAIDs, colchicine and a short course of steroids all work well. Which one depends on your kidneys, stomach and heart history.

My uric acid was normal. Does that rule out gout?

No — and this is a common reason gout gets dismissed. Uric acid is frequently normal or even low during an attack.

It needs retesting a few weeks after things have settled, which is when the number is meaningful.

When is it not gout?

A hot, swollen joint with fever or feeling generally unwell needs septic arthritis excluded urgently and in person. Go to A&E.

It looks similar, it destroys a joint within days, and it is the one thing here not to get wrong. Pseudogout also looks similar and affects larger joints, more often in older people.

Should I be on allopurinol?

If you have had two or more attacks in a year, yes — that is the standard threshold. Also with tophi, joint damage, kidney stones or kidney impairment.

Fewer than half the people who should be on preventive treatment ever receive it, which is why gout so often becomes a recurring, joint-damaging condition.

I am on allopurinol and still getting attacks.

Almost always a dose problem rather than a drug failure.

Allopurinol must be titrated against a target urate — usually below 360 µmol/L — and a great many people are left on 100mg indefinitely and never rechecked.

Ask what your urate level is. If nobody has measured it since you started, that is the answer.

Starting allopurinol gave me an attack. Should I stop it?

No — and this is important. Starting allopurinol can trigger an attack, which is expected rather than a sign it is wrong.

Never stop allopurinol during an attack. Stopping and restarting causes more attacks. That is why colchicine or an NSAID is given as cover for the first few months.

How long will I be on preventive treatment?

Usually indefinitely. Urate rises again when it stops, and the crystals reaccumulate.

Kept below target for long enough, existing crystal deposits dissolve and attacks stop altogether — which makes gout, uniquely, a condition that treatment effectively resolves rather than merely controls.

Is it caused by eating too much red meat?

Less than the reputation suggests — and the moralising around gout is both unfair and unhelpful.

Alcohol, particularly beer, and fructose from sugary drinks matter more, as do shellfish and organ meats. Genetics and kidney handling of urate matter most of all, and diuretics for blood pressure are a very common contributor that is frequently switchable.

Can I manage it with diet alone?

Diet helps, and it rarely achieves target urate in someone with recurrent gout. Both are true.

People are left to "manage it with diet" for years while their joints are damaged, which is the part worth pushing back on.

What should I do about the pain right now?

Rest and elevate the joint, keep bedclothes off it — a cage or a pillow arrangement makes the nights bearable — apply ice, and drink plenty.

Start treatment as early in the attack as you can, which makes more difference than which drug is used.

Is there anything else I should have checked?

Yes — gout travels with metabolic and cardiovascular risk. Blood pressure, glucose, lipids and kidney function are all worth checking.

Finding gout is an opportunity to catch those, and it is routinely wasted.