Gout - Treating gout

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:

naproxen
diclofenac
etoricoxib

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 indigestion, stomach 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, 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:

nausea
abdominal pain
diarrhoea

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:

indigestion
headache
diarrhoea

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.