Gout

When the urate (uric acid) level in the blood stays high for long enough, sharp crystals shaped like needles can start to settle in and around a joint, and gout can follow. Everyone makes urate as waste. The level climbs if the body makes more than it needs, or, as happens more often, if the kidneys pass too little of it out. Over time the crystals accumulate, and an attack is the body's inflammatory reaction to them.

Your urate level, and with it your risk, is pushed up by:

• Being a man, or, for a woman, being past the menopause
• Gout in your family
• Kidneys that work less well, high blood pressure, diabetes or raised cholesterol
• Certain medicines, diuretics (water tablets) especially
• What you eat and drink, red meat, shellfish, sugary drinks and beer in particular

So gout is best seen as a treatable fault in how the body handles urate, not simply the result of how someone lives.

Gout matters for the heart, too. Across the years it makes a heart attack or a stroke somewhat likelier, a link it shares with other inflammatory rheumatic conditions. High blood pressure, raised cholesterol and diabetes are so often found with it that being told you have gout is a good moment to have your heart health checked, however well you feel. Our inflammation and your heart guide explains the link and how far the risk can be brought down.

An attack often arrives with little warning, sometimes overnight. The usual features are:

• Sudden, severe pain in one joint, most often where the big toe meets the foot, though others can be affected
• Redness and warmth across a swollen joint
• Skin so tender that even a light touch is hard to bear
• Attacks that settle over days but tend to come back while the cause goes untreated

Rarely, the cause turns out to be an infected joint (septic arthritis), which can mimic an attack of gout closely. A fever, or feeling more and more unwell, with a hot, swollen joint means going the same day, either at A&E or by calling NHS 111, not waiting for a routine appointment, and with shaking, confusion, rapid breathing, or feeling dramatically worse over hours it is a 999 or A&E emergency instead, as the first list in "When to seek help" sets out; a joint worsening faster than your attacks usually do, even without these, needs to be seen that day by a route from the second list.

The pattern of the attacks is usually enough to recognise gout, with blood tests to support it and, if needed, a sample of fluid from the joint to examine. Confirming it is worthwhile, since other conditions can look much the same: pseudogout (CPPD), an infected joint and, where attacks come and go from joint to joint, palindromic rheumatism.

Dr Borukhson puts ultrasound at the centre of her assessment, since in gout it is especially telling. On the scan, urate crystals can betray themselves: a bright line lying over the cartilage, known as the double contour sign, clumps of crystal, and early tophi, signs that point to urate as the cause of the inflammation. A scan cannot rule out an infected joint, though, since infection and gout can occur together; fluid drawn from the joint is what settles that question. Point-of-care ultrasound is part of the consultation with Dr Borukhson, so the scan seldom needs a separate visit; what it involves is on our ultrasound clinic page. These marks of urate crystals often remain between attacks, when the joint has stopped hurting and the swelling has gone, which matters: a flare is not needed before you ask for an assessment.

Treatment aims at two things: settling an attack, and, where it is right for you, bringing the urate level down over the long term so that attacks stop and the joints are protected. For the attack itself, a short spell of medicine to damp down the inflammation usually brings it under control: an anti-inflammatory tablet (an NSAID), colchicine, or a steroid such as prednisolone, taken as tablets for a short time. Which suits you depends on your other conditions and medicines, since NSAIDs and colchicine need particular care when the kidneys work less well, and alongside an NSAID a medicine to protect the stomach may be added. Each part is explained in full and fitted to you.

Changes to how you live can help, and when a long-term medicine to lower urate is needed, it often works very well. Allopurinol and febuxostat are the two tablets most used to bring urate down; each is a daily tablet, and either can reasonably be tried first. In the UK allopurinol is the usual starting choice, and it is the one to prefer after a heart attack or stroke, or with significant heart disease. The tablet is begun once an attack has settled and the dose raised gradually, with the urate checked along the way, until it falls below the target of 360 micromol per litre, and sometimes lower. Beginning the medicine can itself bring on attacks in the first months, so a second medicine to prevent them is usually taken alongside it at first. An ultrasound-guided injection may help to settle one badly inflamed joint. You and Dr Borukhson settle the plan together.

Once an attack begins, take the treatment you have agreed at its very start, and rest the joint, raised and kept cool; tackled early, attacks settle faster. Having some doses at home means you can respond to the very first twinge.

Between attacks the goal is a urate level held steady. These help:

• Drinking plenty of fluids, and keeping to a healthy weight, losing any excess gradually rather than by crash dieting
• Cutting down on alcohol, beer especially, and on sugary drinks
• A sensible look at your diet, which our gout and diet guide covers
• Staying active, since it lowers the chance of an attack as well as helping your health in general

The outlook is good. With the urate held at target, most people stop having attacks, tophi slowly shrink and further damage to the joints is prevented. Taking the urate-lowering tablet every day and keeping your reviews are what keep gout away over the long term.

Most attacks of gout can wait for a planned appointment. The exceptions follow in two lists, starting with the most dangerous; the hot-joint signs among them are there because infection in a joint can look like gout. The paragraph beneath the lists says which attacks can wait.

Treat any of these as a 999 or A&E emergency: call 999 and do not drive yourself to A&E.

• Severe illness with suspected sepsis: a high fever with shaking, confusion, rapid breathing, or feeling dramatically worse over hours
• With a fever or feeling unwell, a rash that does not fade when you press it, a stiff neck with eyes that cannot bear bright light, or skin, lips or tongue turning blue, grey, pale or blotchy, since these can be signs of meningitis or sepsis; on black or brown skin the rash and the change of colour may be easier to see on the palms of the hands or the soles of the feet
• A joint you cannot put weight on or move, or that has moved out of place, or, after a fall or injury, very bad pain or any tingling or numbness
• Chest pain that is crushing, tight or like a pressure, that spreads to an arm, the jaw, the neck, the stomach or the back, that comes with breathlessness, sweating, feeling sick or feeling light-headed, or that came on suddenly and does not go away
• Sudden weakness or numbness on one side, a drooping face or difficulty speaking, a sudden severe headache, sudden confusion or a seizure, or sudden loss of vision, any of which can be a stroke, even if it stops after a short time, and gout makes a stroke somewhat likelier
• An eye that suddenly and completely loses its sight
• Vomiting blood, or bleeding from the back passage that is heavy or will not stop, most of all with faintness, confusion or pain in the abdomen, or vomit that is black or dark brown, since anti-inflammatory tablets, a common treatment for an attack, can make the stomach bleed
• Lips, mouth, throat or tongue that suddenly swell, a throat that feels tight, very fast breathing or a struggle to breathe or to swallow, skin, tongue or lips turning blue, grey or pale (on black or brown skin this may be easier to see on the palms of the hands or the soles of the feet), becoming suddenly very confused, drowsy or dizzy, or fainting and not being able to be woken, since this can be a severe allergic reaction, anaphylaxis, which can follow a dose of any medicine

Any of these needs an assessment that is urgent, on the same day, from your GP or NHS 111:

• A joint that is hot and swollen, with a fever or feeling unwell, since an infected joint has to be ruled out at once, at A&E or through NHS 111
• The first attack in a joint, before gout has been confirmed; a joint worsening faster than your attacks usually do; or severe pain that your usual attack treatment does not control, even without a fever and even if you feel well, since infection can mimic gout and has to be excluded that day: an urgent GP appointment, NHS 111 or a specialist clinic that can see you that day
• Joint pain with a fever, or feeling hot, cold or shivery, or generally unwell, since an infection in or around a joint has to be found the same day
• A rash or other skin reaction on its own, or bruising that comes easily, feeling very tired, a sudden sore throat or a high temperature, while you take allopurinol, since a rash or other skin reaction means stopping the tablet and telling your doctor straight away, and the others can, rarely, mean a problem with the white blood cells; a rash that comes with a high temperature or other flu-like symptoms, or with blisters or sores, on allopurinol or febuxostat, a swollen throat or tongue or difficulty breathing on either tablet, or a stiff neck with a severe headache, feeling sick or confusion on allopurinol, is a 999 or A&E emergency: call 999 and do not drive yourself to A&E
• While you take colchicine: diarrhoea, feeling or being sick, or pain in the stomach; a high temperature, bruising, or bleeding that goes on for a long time after an injury; muscle pain or weakness, or dark red or brown pee; or pain, tingling, loss of feeling or weakness, since these can mean that too much of the medicine has built up in the body or that it is affecting the bone marrow, the muscles and kidneys or the nerves; NHS 111 can tell you what to do that day, and a swollen throat or tongue, or difficulty breathing, is a 999 or A&E emergency: call 999 and do not drive yourself to A&E
• Black or dark red stools, on anti-inflammatory tablets, since a bleed in the stomach or gut has to be found that day

Short of the signs in the lists above, a typical attack of gout you already know can be treated as agreed and talked over at a planned appointment. When attacks come more often or spread to new joints, or firm lumps (tophi) appear under the skin, book a routine review with your GP or team rather than seeking urgent care; and if you take a urate-lowering tablet, mention any attacks that keep coming, since the dose may need raising. If you cannot tell how urgent something is, asking is never a mistake.

Repeated attacks of gout should not simply be put up with, and yet too few people are treated for them: by NICE's figures, only about a third of people with gout have a urate-lowering medicine, and only about a third of those who take one bring their urate down to the target. A sure diagnosis followed by the right long-term plan can often bring the attacks to an end and keep the joints safe. Even one hot, swollen joint in the past is reason enough to have the cause found by a specialist, and the plan built from there.

Can I be assessed when I am not having a flare?

Yes. On ultrasound, the signs that point to urate crystals often stay visible after a flare has died down, so the joint need not be sore or swollen on the day you come. Point-of-care ultrasound is part of the consultation with Dr Borukhson, so this can usually be looked at in the same appointment.

Is a urate-lowering medicine something I take for good?

In most cases it is long term, yes, though the choice is always made together with you. The tablet, most often allopurinol, begins once a flare has calmed down, and the dose is raised step by step until the urate reaches its target, which NICE sets below 360 micromol per litre for most people. Holding the urate at that level is what keeps attacks away, which is why the treatment generally carries on, with regular reviews, instead of ending after a short spell.

I have started a urate-lowering medicine. Why do I still get flares?

Flares are common in the first months on a urate-lowering medicine and are no sign that it is failing, which is why a second medicine to prevent them, colchicine as a rule, is usually taken alongside it at the start. Attacks that go on past those early months are a reason to check whether the urate has reached its target, so tell your team about them at your review.

When does gout need help the same day, or sooner?

Anything in the first list under When to seek help is a 999 or A&E emergency, a joint you cannot put weight on or move among them. Call 999 and do not drive yourself to A&E. A hot, swollen joint that comes with a fever, shivering or feeling more and more unwell needs the same day, at A&E or through NHS 111, since infection in a joint can pass for gout and must be excluded without delay. Three more signs call for help that same day, even if you feel well otherwise: a joint getting worse faster than your attacks usually do, severe pain your usual attack treatment does not control, and the very first attack in a joint before gout has been confirmed; for these the route is an urgent GP appointment, NHS 111 or a specialist clinic that can see you that day, as the second list says. A typical attack with none of these features can usually wait for a planned appointment.

Is gout worth treating if the attacks come only now and then?

Yes. Treatment works well for gout, and attacks tend to keep returning while their cause goes unaddressed. NICE notes that only about a third of people with gout have a urate-lowering medicine, so many go under-treated. A specialist review can settle the diagnosis and show whether you would gain from treatment over the longer term.