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Gout: what causes flares, and how to keep them from coming back

Gout is one of the most common kinds of inflammatory arthritis. It happens when urate (uric acid) builds up over time and forms sharp crystals in a joint, which sets off sudden, intense pain. The good news: with early diagnosis and the right long-term treatment, gout is one of the most controllable forms of arthritis.

  • 9.2 millionU.S. adults have gout, per the 2015 to 2016 national health survey
  • Big toewhere flares often begin, though another joint in the leg or foot can be first
  • Under 6 mg/dLthe blood urate level that long-term treatment aims to keep you below
  • 1 in 3people with gout were taking urate-lowering medicine in national survey data

What is gout?

Your body makes urate when it breaks down purines, natural compounds found in your own cells and in many foods and drinks. Most of it leaves through the kidneys. When urate stays high for a long time, it can form needle-shaped crystals in and around your joints. Your immune system reacts to those crystals, and the result is a gout flare.

Between flares, many people feel completely fine. That is the trap. The crystals are still there, and without treatment flares tend to come more often and last longer. Over the years they can also form firm lumps of crystals under the skin, called tophi, which can damage joints and nearby tissue.

Signs of a gout flare

  • Sudden, severe pain in a joint, often starting at night
  • A joint that looks red and swollen and feels warm and very tender
  • Usually one joint at a time, often the big toe or another joint in the foot, ankle or knee
  • Flares that settle within one to two weeks, then come back later

Who gets gout

Gout becomes more common with age, rising from under 1% of adults in their 20s and 30s to almost 9% of adults 80 and older. Men are affected about twice as often as women. Your risk is higher if you have:

  • A family history of gout, or you are past menopause
  • Overweight or obesity, or metabolic syndrome
  • High blood pressure, chronic kidney disease, heart failure, insulin resistance or diabetes
  • Medicines that raise urate, such as diuretics (water pills), low-dose aspirin, high-dose niacin or cyclosporine

Never stop a prescribed medicine on your own because of gout. Ask your doctor whether a change makes sense for you.

Common triggers, and what helps

Food and drink do not cause gout by themselves, but some of them push urate higher and can set off a flare in someone who already has it.

Cut back on

  • Alcohol, especially beer and hard liquor (nonalcoholic beer counts too)
  • Sugar-sweetened drinks such as soda
  • Red meat and organ meats
  • Shellfish, sardines and anchovies

What helps

  • Reaching and keeping a healthy weight
  • An eating pattern like DASH: vegetables, fruit, whole grains and low-fat dairy
  • At least 150 minutes a week of moderate activity
  • During a flare: ice, raise the limb, and rest the joint

Diet changes help, but they are rarely enough on their own. If you have frequent flares or tophi, the real fix is urate-lowering medicine taken every day.

How gout is diagnosed

Gout can look like other problems, including an infection inside the joint, so a first flare deserves a proper diagnosis. A doctor may use:

Joint fluid test
A small sample of fluid is drawn from the painful joint (or from a tophus) and checked under a special microscope for urate crystals. Seeing the crystals is the most reliable way to confirm gout.
Blood test
Measures your urate level. It also sets the baseline for treatment, since the goal is to bring that number down and keep it down.
Imaging
An ultrasound or a special CT scan can show urate crystal buildup in and around a joint.

Treatment: calm the flare, then lower the urate

Gout treatment has two separate jobs. One stops the pain of a flare. The other removes the cause, so flares stop coming back.

Step 1

Treating a flare

  • Anti-inflammatory medicines, over the counter or prescription
  • Colchicine, which works best when started at the first sign of a flare
  • Corticosteroids, taken by mouth or injected into the joint

Starting early matters. Ask your doctor for a plan you can begin at the first twinge.

Step 2

Preventing the next one

  • Xanthine oxidase inhibitors (allopurinol, febuxostat) lower how much urate your body makes
  • Uricosurics (such as probenecid) help your kidneys clear more urate
  • Uricase (pegloticase) breaks urate down, for gout that has not responded to other medicines

Treat to target

The 2020 American College of Rheumatology guideline recommends allopurinol as the first choice for most people, including people with chronic kidney disease. It recommends starting at a low dose and raising it step by step until blood urate stays below 6 mg/dL, rather than staying on one fixed dose. Because flares can pick up when urate-lowering treatment begins, it also recommends anti-inflammatory protection for at least 3 to 6 months after starting.

This is the step many people miss. In U.S. national survey data, only about one in three people with gout were taking urate-lowering medicine.

When to see a doctor

Get urgent care the same day if a painful, swollen joint comes with a fever, chills or feeling shivery, if you feel sick or cannot eat, or if the pain keeps getting worse. These can be signs of an infection inside the joint, which needs prompt treatment.

Book a regular appointment if:

  • You have symptoms of gout for the first time
  • Your usual treatment is not helping
  • Flares are coming more often
  • You notice firm lumps near your joints

Questions to bring to your appointment

  1. What is my blood urate level, and what number are we aiming for?
  2. Should I be on daily urate-lowering medicine?
  3. What should I take at the first sign of a flare, and how soon?
  4. Do any of my current medicines raise my urate?
  5. How long should I take flare protection after starting treatment?
  6. When should we recheck my urate level?

Contact

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Sources

  1. Centers for Disease Control and Prevention. Gout.
  2. National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIH). Gout.
  3. National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIH). Gout: Diagnosis, Treatment, and Steps to Take.
  4. FitzGerald JD, et al. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis & Rheumatology. 2020;72(6):879-895.
  5. Chen-Xu M, et al. Contemporary Prevalence of Gout and Hyperuricemia in the United States and Decadal Trends: NHANES 2007-2016. Arthritis & Rheumatology. 2019;71(6):991-999.
  6. NHS. Gout.