Gout: Uric Acid, Flares, and Long Term Treatment

You woke up with a hot, swollen, very painful big toe. Even a bedsheet touching it hurt. Your clinician said "gout", and you may wonder if it will come back and whether you need pills for life. This guide explains how gout works, how flares are treated, and when long-term treatment makes sense.

What gout is

Gout is a type of arthritis caused by uric acid [4]. Uric acid is a waste product made when the body breaks down substances called purines. Purines are found in your own cells and in some foods and drinks.

When uric acid in the blood gets too high, it can form needle-shaped crystals in and around joints. The immune system attacks these crystals, causing a flare [4].

What a flare feels like

• Sudden, severe pain, often starting at night
• Redness, warmth, and swelling
• Often in the big toe, but also the ankle, foot, knee, wrist, or fingers
• Pain that peaks within a day and settles over 1 to 2 weeks

What raises the risk

• Older age and male sex
• Overweight or obesity
• High blood pressure, diabetes, and kidney disease
• Some medicines, such as some water pills (diuretics)
• Alcohol, especially beer and spirits
• Sugary drinks and large amounts of red meat, organ meats, and some seafood
• Family history

What your doctor looks at

Making the diagnosis

• The pattern of symptoms and which joint is affected
• A uric acid blood test. It can be normal during a flare, so it may be repeated later.
• Joint fluid testing. Finding uric acid crystals under a microscope confirms gout.
• Sometimes ultrasound or a special CT scan to look for crystals

Treating a flare

The American College of Rheumatology (ACR) 2020 guideline recommends treating a flare as early as possible with one of these [1]:

• Colchicine. Low-dose colchicine is preferred, because it works as well as high doses with fewer stomach side effects.
• An NSAID (non-steroidal anti-inflammatory drug), such as naproxen
• A steroid, taken by mouth or injected into the joint

The choice depends on your kidneys, stomach, heart, other medicines, and past response. Ice and rest can also help.

When to start long-term uric acid lowering

The ACR strongly recommends long-term uric acid lowering therapy if you have any of these [1]:

• One or more tophi (lumps of crystals under the skin)
• Joint damage on X-ray caused by gout
• Two or more flares a year

It is usually not started after a first flare, unless you also have moderate or worse kidney disease, a very high uric acid level, or kidney stones [1].

The medicines

• Allopurinol is the preferred first medicine [1]. It is started at a low dose and raised slowly.
• Febuxostat is another option.
• Probenecid helps the kidneys remove more uric acid.

When starting, the ACR recommends taking a low-dose anti-inflammatory medicine, often colchicine, for 3 to 6 months. This lowers the risk of flares as crystals dissolve [1]. The ACR also recommends continuing uric acid lowering medicine during a flare [1].

Before allopurinol, the ACR suggests a genetic test called HLA-B*5801 for people of Southeast Asian descent, such as Han Chinese, Korean, or Thai, and for African American people [1]. This gene raises the risk of a rare but severe skin reaction.

The target level

Guidelines differ on whether to aim for a set number:

• The ACR recommends a treat-to-target approach, with a uric acid goal below 6 mg/dL (about 360 µmol/L) [1].
• The UK's NICE also recommends treat-to-target, with a goal below 360 µmol/L, and below 300 µmol/L for people with tophi, ongoing flares, or chronic gouty arthritis [3].
• The American College of Physicians (ACP) 2017 guideline found the evidence was not strong enough to support a fixed target level [2]. It advised discussing the benefits, harms, and costs of long-term treatment with people who have frequent flares [2].

Practice varies in both Canada and the US. Ask your clinician which approach they use and why.

Lifestyle steps that help

• Limit alcohol, especially beer and spirits.
• Cut back on sugary drinks.
• Limit organ meats and large portions of red meat and some seafood.
• Lose weight if you have extra weight.
• Drink enough water.

These steps can lower uric acid somewhat, but most people with frequent flares also need medicine [1].

Questions to ask your clinician

• How sure are we that this is gout? Should the joint fluid be tested?
• What is my uric acid level, and when should it be rechecked?
• Which flare treatment is safest for me?
• Do I meet the criteria for long-term uric acid lowering?
• What uric acid goal are we aiming for?
• Should I have the HLA-B*5801 test before allopurinol?
• Do any of my current medicines raise my uric acid?

When to get care quickly

Get same-day care for a hot, swollen joint with fever or chills. A joint infection can look like gout and needs urgent treatment. Get urgent care for a new skin rash with blisters, peeling, mouth sores, or fever after starting allopurinol.

Bottom line

Gout flares are caused by uric acid crystals and are treated with anti-inflammatory medicines started early. For frequent flares, tophi, or joint damage, long-term uric acid lowering can prevent future attacks. Most guidelines aim for a uric acid level below 6 mg/dL (360 µmol/L), though the ACP did not endorse a fixed target.

Primary AI can show you the guideline and study sources behind this topic in plain language, so you can bring better questions to your appointment.