If you are diagnosed with gout, your treatment plan will have two goals:
- relieving the symptoms of a gout attack
- preventing further attacks
Relieving symptoms
Self-care techniques
During a gout attack, it is important to rest, elevate (raise) your limb and avoid accidentally 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 approximately 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:
- diclofenac
- indometacin
- naproxen
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) that reduces the risk of the NSAID causing indigestion, stomach ulcers and bleeding from the stomach.
People with reduced kidney function or those with conditions such as stomach ulcers or bleeding should avoid using NSAIDs.
Colchicine
If you are unable or do not want 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.
Colchicine can be an effective treatment for gout. However, it should be used at low doses since it can cause upsets, 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 that do not respond to other treatment (above).
A short course of steroid tablets often provides relief, but can’t be used long-term 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 which can cause blindness if untreated).
Corticosteroids may not be suitable for you if you have:
- bone marrow disease
- 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
Usually 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
The main treatment for gout is known as urate-lowering therapy or ULT. The goal of ULT is to lower uric acid levels below the levels required for crystals to form (the saturation point).
This should also help to dissolve existing crystals leading to an effective cure for gout. But to maintain the “cure” you would need to continue with ULT on a daily basis.
Many people with gout begin ULT as soon as they are diagnosed to reduce the frequency of 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, usually the ULT medication to try first is called allopurinol.
Allopurinol
Allopurinol helps to lower uric acid levels by inhibiting the enzyme (xanthine oxidase) responsible for converting purines into uric acid, thus reducing 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 and usually for up to a year or two before all crystals have dissolved and no further attacks can 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 rapid reduction of uric acid levels to below the saturation point causes existing crystals in 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 from a low starting dose (e.g. 100mg daily) to the recommended dose.
You may continue to have gout attacks until all the existing crystals have dissolved, which is perfectly normal.
So if this does happen, don’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 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, it’s 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 (see below).
Other side effects of allopurinol include:
- indigestion
- headache
- diarrhoea
If you are currently being treating 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) then you will probably not be able to take allopurinol for safety reasons.
Allopurinol may also not be suitable if you have severe kidney disease.
Patients with kidney problems may be started on a lower dose (50mg daily) and have lower monthly increases (50mg) of allopurinol.
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, thus reducing the body’s production of uric acid.
However, unlike allopurinol, it is broken down by the liver and not the kidney, so can be used in patients with kidney disease without concerns over side effects.
Also unlike allopurinol, it only comes in two doses (80mg or 120 mg daily). Because even 80 mg daily may quickly reduce uric acid levels below the saturation point, initiation of even the lowest dose of febuxostat often triggers acute attacks.
To try to reduce the frequency and severity of this side effect your doctor may prescribe you regular daily oral NSAID or colchicine (one-to-two tablets daily) for up to six months following the start of febuxostat as “prophylaxis” (preventative treatment).
Common side effects of febuxostat include:
- an increased number of acute gout attacks (discussed above)
- 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 suitable for people with heart problems (especially heart failure), or with serious kidney disease.
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 only to 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 frequently or in large quantities can help reduce the risk of a gout attack:
- meat, particularly kidney, liver, veal, turkey and venison
- seafood, particularly anchovies, herring, mackerel, sardines, fish roe, mussels and scallops
- certain types of vegetables, such as asparagus, kidney beans, lima beans, lentils and spinach
- foods or supplements that contain yeast extract, such as Marmite and Quorn
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. 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.
A survey has shown that daily consumption of a small glass of 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.
