Gout

Gout develops when the level of urate (uric acid) in the blood stays high enough for needle-shaped crystals to form in and around a joint. Urate is a normal waste product, but problems arise when the body either makes too much or, more often, when the kidneys clear too little. Over time these crystals build up, and a flare is the inflammation triggered when the immune system reacts to them.

Several things raise your urate level and your risk:

• Being male, and, in women, being past the menopause
• A family history of gout
• Reduced kidney function, high blood pressure, diabetes or raised cholesterol
• Some medicines, particularly diuretics (water tablets)
• Diet and alcohol, especially red meat, shellfish, sugary drinks and beer

Gout is therefore best understood as a treatable problem with urate handling, not simply a consequence of lifestyle.

Gout also has a bearing on the heart. Like other forms of inflammatory arthritis, it carries a somewhat higher risk of heart attack and stroke over the years. And it rarely arrives alone: it travels so often with high blood pressure, raised cholesterol and diabetes that a diagnosis of gout is a sensible prompt to have your heart health checked, even if you feel well. Our guide to inflammation and your heart explains why, and how much of that risk can be lowered.

A gout flare often comes on quickly, sometimes overnight. Typical features include:

• Sudden, severe pain in a joint, classically the base of the big toe, though other joints can be affected
• Redness, warmth and swelling over the joint
• Skin that is so tender even light touch is uncomfortable
• Flares that settle over days but tend to return if the underlying cause is not addressed

Rarely, an infected joint (septic arthritis) can closely resemble a gout flare. If you have a fever, feel increasingly unwell or the joint is rapidly worsening, seek same-day urgent care, for example via NHS 111 or your nearest emergency department, rather than waiting for a routine appointment.

Gout can usually be recognised from the pattern of symptoms, supported by blood tests and, where needed, examination of fluid from the joint. It is worth confirming the diagnosis, because several other conditions can look similar.

Ultrasound is especially valuable in gout, and is central to how Dr Borukhson assesses it. It can reveal features that point to urate crystals in and around the joint, such as a bright line over the joint cartilage known as the double contour sign, along with crystal deposits and early tophi, helping distinguish gout from other causes of a hot, swollen joint. Because she uses point-of-care ultrasound during the consultation, this can often be assessed in the same visit, and you can read more on our ultrasound clinic page. Importantly, these crystal features can often be seen on ultrasound even between attacks, when the joint is no longer painful or swollen, so there is no need to wait for a flare before seeking assessment.

Treatment has two parts: settling an acute flare, and, where appropriate, reducing the urate level over the longer term to prevent further attacks and protect the joints. A flare is usually settled with a short course of an anti-inflammatory medicine: a non-steroidal anti-inflammatory drug (NSAID), colchicine, or a corticosteroid such as prednisolone. Which of these suits you best depends on your other conditions and medicines, as NSAIDs and colchicine need particular care if kidney function is reduced. Both parts of treatment are discussed fully with you and tailored to your circumstances.

Lifestyle factors can play a part, and longer-term medication to lower urate is often very effective when it is needed. The usual first choice is allopurinol, a daily tablet that lowers the urate level, with febuxostat as an alternative if allopurinol does not suit. It is started once a flare has settled and adjusted gradually, under specialist supervision, towards a target urate level: treatment aims to bring the urate level below 360 micromol/L, and sometimes lower. Starting urate-lowering treatment can itself trigger a flare in the early months, so a preventative medicine is usually taken alongside it at first. Where a single joint is severely inflamed, an ultrasound-guided injection may help bring it under control. The right plan depends on your individual situation and is agreed together.

During a flare, rest the joint, keep it cool and raised, and start the treatment agreed with you promptly, as flares settle faster when tackled early. Keeping a few doses to hand means you can act at the first twinge.

Between attacks, the aim is steady control of your urate level. Helpful measures include:

• Staying well hydrated and keeping to a healthy weight, losing weight gradually rather than crash dieting
• Moderating alcohol, especially beer, and sugary drinks
• Reviewing diet sensibly, covered in our gout and diet guide
• Staying active, as gentle movement helps the joints

The outlook is genuinely good. With urate kept at target, most people become flare-free, tophi gradually shrink and further joint damage is prevented. Take urate-lowering tablets daily and attend your reviews, as this is what keeps gout away long term.

Most flares can wait for a planned appointment, but some features need prompt attention because a joint infection can look very like gout and must be ruled out without delay.

Seek same-day medical help, through NHS 111 or an emergency department, if a hot, swollen joint comes with any of these:

• A fever, shivering or feeling increasingly unwell
• A joint that is worsening rapidly rather than over the usual day or two
• Your first ever episode in a joint, before a diagnosis is established
• Severe pain you cannot control with your usual flare treatment

Arrange a routine review, rather than urgent care, if flares are becoming more frequent, are affecting new joints, or you notice firm lumps (tophi) under the skin. If you take urate-lowering medication, do mention any ongoing flares, as it may mean the dose needs adjusting.

Recurrent gout is not something to simply endure, yet it is often under-treated: NICE notes that only around one in three people with gout receive urate-lowering medicines, and that only around a third of those who take them reach the target urate level. With an accurate diagnosis and the right long-term approach, attacks can often be prevented and the joints protected. If you have had a hot, painful, swollen joint, a specialist review can confirm the cause and set out a clear plan.

Do I need to wait for a flare before booking an assessment?

No. The ultrasound appearances that suggest urate crystals often remain visible once a flare has settled, so the joint does not need to be painful or swollen on the day. Because Dr Borukhson uses point-of-care ultrasound, this can usually be checked during the consultation itself.

Will I need to take urate-lowering medication for life?

Usually long term, yes, although the decision is always made with you. Allopurinol, the usual first choice, is started once a flare has settled and adjusted in stages towards a target urate level; NICE recommends a level below 360 micromol per litre for most people. Keeping the urate at target is what prevents future attacks, so treatment is generally continued and reviewed regularly rather than stopped after a short course.

Why am I still getting flares after starting urate-lowering treatment?

Flares in the early months after starting urate-lowering treatment are common and do not mean the medicine is failing. This is the reason a preventative medicine is usually taken alongside it at first. If attacks continue beyond this period, it is worth checking that the urate level has reached its target, so do mention ongoing flares at your review.

When does a gout flare need urgent medical attention?

Seek same-day help, for example through NHS 111 or an emergency department, if you have a fever, feel increasingly unwell or the joint is worsening quickly. An infected joint can look very similar to a gout flare and needs to be ruled out without delay. A typical flare without these features can usually be assessed at a planned appointment.

Is it worth treating gout if attacks are only occasional?

Yes. Gout is very treatable, attacks tend to return if the underlying cause is not addressed, and NICE notes that only around one in three people with gout receive urate-lowering medicines, so under-treatment is common. A specialist review can confirm the diagnosis and establish whether longer-term treatment would help in your case.