Gout

Overview

Gout is a common and complex form of arthritis that can affect anyone. It's characterized by sudden, severe attacks of pain, swelling, redness and tenderness in the joints, often the joint at the base of the big toe.

An attack of gout can occur suddenly, often waking you up in the middle of the night with the sensation that your big toe is on fire. The affected joint is hot, swollen and so tender that even the weight of the sheet on it may seem intolerable.

Gout symptoms may come and go, but there are ways to manage symptoms and prevent flares.

Symptoms

The signs and symptoms of gout almost always occur suddenly, and often at night. They include:

  • Intense joint pain. Gout usually affects the large joint of your big toe, but it can occur in any joint. Other commonly affected joints include the ankles, knees, elbows, wrists and fingers. The pain is likely to be most severe within the first four to 12 hours after it begins.
  • Lingering discomfort. After the most severe pain subsides, some joint discomfort may last from a few days to a few weeks. Later attacks are likely to last longer and affect more joints.
  • Inflammation and redness. The affected joint or joints become swollen, tender, warm and red.
  • Limited range of motion. As gout progresses, you may not be able to move your joints normally.

When to see a doctor

If you experience sudden, intense pain in a joint, call your doctor. Gout that goes untreated can lead to worsening pain and joint damage.

Seek medical care immediately if you have a fever and a joint is hot and inflamed, which can be a sign of infection.

Illustration showing gout in the big toe

Gout causes intense pain and swelling around one or more joints. Gout most commonly affects the joint at the base of the big toe.

Causes

Gout occurs when urate crystals accumulate in your joint, causing the inflammation and intense pain of a gout attack. Urate crystals can form when you have high levels of uric acid in your blood.

Your body produces uric acid when it breaks down purines — substances that are found naturally in your body.

Purines are also found in certain foods, such as steak, organ meats and seafood. Other foods also promote higher levels of uric acid, such as alcoholic beverages, especially beer, and drinks sweetened with fruit sugar (fructose).

Normally, uric acid dissolves in your blood and passes through your kidneys into your urine. But sometimes either your body produces too much uric acid or your kidneys excrete too little uric acid. When this happens, uric acid can build up, forming sharp, needlelike urate crystals in a joint or surrounding tissue that cause pain, inflammation and swelling.

Risk factors

You're more likely to develop gout if you have high levels of uric acid in your body. Factors that increase the uric acid level in your body include:

  • Diet. Eating a diet rich in meat and seafood and drinking beverages sweetened with fruit sugar (fructose) increase levels of uric acid, which increase your risk of gout. Alcohol consumption, especially of beer, also increases the risk of gout.
  • Obesity. If you're overweight, your body produces more uric acid and your kidneys have a more difficult time eliminating uric acid.
  • Medical conditions. Certain diseases and conditions increase your risk of gout. These include untreated high blood pressure and chronic conditions such as diabetes, metabolic syndrome, and heart and kidney diseases.
  • Certain medications. The use of thiazide diuretics — commonly used to treat hypertension — and low-dose aspirin also can increase uric acid levels. So can the use of anti-rejection drugs prescribed for people who have undergone an organ transplant.
  • Family history of gout. If other members of your family have had gout, you're more likely to develop the disease.
  • Age and sex. Gout occurs more often in men, primarily because women tend to have lower uric acid levels. After menopause, however, women's uric acid levels approach those of men. Men are also more likely to develop gout earlier — usually between the ages of 30 and 50 — whereas women generally develop signs and symptoms after menopause.
  • Recent surgery or trauma. Experiencing recent surgery or trauma has been associated with an increased risk of developing a gout attack.

Complications

People with gout can develop more-severe conditions, such as:

  • Recurrent gout. Some people may never experience gout signs and symptoms again. Others may experience gout several times each year. Medications may help prevent gout attacks in people with recurrent gout. If left untreated, gout can cause erosion and destruction of a joint.
  • Advanced gout. Untreated gout may cause deposits of urate crystals to form under the skin in nodules called tophi (TOE-fie). Tophi can develop in several areas such as your fingers, hands, feet, elbows or Achilles tendons along the backs of your ankles. Tophi usually aren't painful, but they can become swollen and tender during gout attacks.
  • Kidney stones. Urate crystals may collect in the urinary tract of people with gout, causing kidney stones. Medications can help reduce the risk of kidney stones.

Prevention

During symptom-free periods, these dietary guidelines may help protect against future gout attacks:

  • Drink plenty of fluids. Stay well-hydrated, including plenty of water. Limit how many sweetened beverages you drink, especially those sweetened with high-fructose corn syrup.
  • Limit or avoid alcohol. Talk with your doctor about whether any amount or type of alcohol is safe for you. Recent evidence suggests that beer may be particularly likely to increase the risk of gout symptoms, especially in men.
  • Get your protein from low-fat dairy products. Low-fat dairy products may actually have a protective effect against gout, so these are your best-bet protein sources.
  • Limit your intake of meat, fish and poultry. A small amount may be tolerable, but pay close attention to what types — and how much — seem to cause problems for you.
  • Maintain a desirable body weight. Choose portions that allow you to maintain a healthy weight. Losing weight may decrease uric acid levels in your body. But avoid fasting or rapid weight loss, since doing so may temporarily raise uric acid levels.

Diagnosis

Tests to help diagnose gout may include:

  • Joint fluid test. Your doctor may use a needle to draw fluid from your affected joint. Urate crystals may be visible when the fluid is examined under a microscope.
  • Blood test. Your doctor may recommend a blood test to measure the levels of uric acid and creatinine in your blood. Blood test results can be misleading, though. Some people have high uric acid levels, but never experience gout. And some people have signs and symptoms of gout, but don't have unusual levels of uric acid in their blood.
  • X-ray imaging. Joint X-rays can be helpful to rule out other causes of joint inflammation.
  • Ultrasound. Musculoskeletal ultrasound can detect urate crystals in a joint or in a tophus. This technique is more widely used in Europe than in the United States.
  • Dual energy CT scan. This type of imaging can detect the presence of urate crystals in a joint, even when it is not acutely inflamed. This test is not used routinely in clinical practice due to the expense and is not widely available.

Treatment

Treatment for gout usually involves medications. What medications you and your doctor choose will be based on your current health and your own preferences.

Gout medications can be used to treat acute attacks and prevent future attacks. Medications can also reduce your risk of complications from gout, such as the development of tophi from urate crystal deposits.

Medications to treat gout attacks

Drugs used to treat acute attacks and prevent future attacks include:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs include over-the-counter options such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve), as well as more-powerful prescription NSAIDs such as indomethacin (Indocin) or celecoxib (Celebrex).

    Your doctor may prescribe a higher dose to stop an acute attack, followed by a lower daily dose to prevent future attacks.

    NSAIDs carry risks of stomach pain, bleeding and ulcers.

  • Colchicine. Your doctor may recommend colchicine (Colcrys, Mitigare), a type of pain reliever that effectively reduces gout pain. The drug's effectiveness may be offset, however, by side effects such as nausea, vomiting and diarrhea, especially if taken in large doses.

    After an acute gout attack resolves, your doctor may prescribe a low daily dose of colchicine to prevent future attacks.

  • Corticosteroids. Corticosteroid medications, such as the drug prednisone, may control gout inflammation and pain. Corticosteroids may be in pill form, or they can be injected into your joint.

    Corticosteroids are generally used only in people with gout who can't take either NSAIDs or colchicine. Side effects of corticosteroids may include mood changes, increased blood sugar levels and elevated blood pressure.

Medications to prevent gout complications

If you experience several gout attacks each year, or if your gout attacks are less frequent but particularly painful, your doctor may recommend medication to reduce your risk of gout-related complications. If you already have evidence of damage from gout on joint X-rays, or you have tophi, chronic kidney disease or kidney stones, medications to lower your body's level of uric acid may be recommended. Options include:

  • Medications that block uric acid production. Drugs called xanthine oxidase inhibitors (XOIs), including allopurinol (Aloprim, Lopurin, Zyloprim) and febuxostat (Uloric), limit the amount of uric acid your body makes. This may lower your blood's uric acid level and reduce your risk of gout.

    Side effects of allopurinol include a rash and low blood counts. Febuxostat side effects include rash, nausea, reduced liver function and an increased risk of heart-related death.

  • Medication that improves uric acid removal. These drugs, called uricosurics, include probenecid (Probalan) and lesinurad (Zurampic). Uricosuric drugs improve your kidneys' ability to remove uric acid from your body. This may lower your uric acid levels and reduce your risk of gout, but the level of uric acid in your urine is increased. Side effects include a rash, stomach pain and kidney stones. Lesinurad can be taken only along with an XOI.

Lifestyle and home remedies

Medications are often the most effective way to treat acute gout and can prevent recurrent attacks of gout. However, making certain lifestyle changes also are important, such as:

  • Limiting alcoholic beverages and drinks sweetened with fruit sugar (fructose). Instead, drink plenty of nonalcoholic beverages, especially water.
  • Limiting intake of foods high in purines, such as red meat, organ meats and seafood.
  • Exercising regularly and losing weight. Keeping your body at a healthy weight reduces your risk of gout.

Alternative medicine

If gout treatments aren't working as well as you'd hoped, you may be interested in trying an alternative approach. Before trying such a treatment on your own, talk with your doctor — to weigh the benefits and risks and learn whether the treatment might interfere with your gout medication.

Because there isn't a lot of research on alternative therapies for gout, however, in some cases the risks aren't known.

Certain foods have been studied for their potential to lower uric acid levels, including:

  • Coffee. Studies have found an association between coffee drinking — both regular and decaffeinated coffee — and lower uric acid levels, though no study has demonstrated how or why coffee may have such an effect.

    The available evidence isn't enough to encourage noncoffee drinkers to start, but it may give researchers clues to new ways of treating gout in the future.

  • Vitamin C. Supplements containing vitamin C may reduce the levels of uric acid in your blood. However, no studies have demonstrated that vitamin C affects the frequency or severity of gout attacks.

    Talk to your doctor about what a reasonable dose of vitamin C may be. And don't forget that you can increase your vitamin C intake by eating more vegetables and fruits, especially oranges.

  • Cherries. Cherries have been reported to lower levels of uric acid, as well as reduce the number of gout attacks. However, more research needs to be done to confirm this. Eating more cherries and drinking cherry extract may be a safe way to supplement your gout treatment, but discuss it with your doctor first.

Other complementary and alternative medicine treatments may help you cope until your gout pain subsides or your medications take effect. For instance, relaxation techniques, such as deep-breathing exercises and meditation, may help take your mind off your pain.

Preparing for an appointment

Make an appointment with your doctor if you have symptoms that are common to gout. After an initial examination, your doctor may refer you to a specialist in the diagnosis and treatment of arthritis and other inflammatory joint conditions (rheumatologist).

Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

  • Write down your symptoms, including when they started and how often they occur.
  • Note important personal information, such as any recent changes or major stressors in your life.
  • Make a list of your key medical information, including any other conditions for which you're being treated and the names of any medications, vitamins or supplements you're taking. Your doctor will also want to know if you have any family history of gout.
  • Take a family member or friend along, if possible. Sometimes it can be difficult to remember all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
  • Write down questions to ask your doctor. Creating your list of questions in advance can help you make the most of your time with your doctor.

Questions to ask the doctor at the initial appointment include:

  • What are the possible causes of my symptoms or condition?
  • What tests do you recommend?
  • Are there any treatments or lifestyle changes that might help my symptoms now?
  • Should I see a specialist?

Questions to ask if you're referred to a rheumatologist include:

  • What are the possible side effects of the drugs you're prescribing?
  • How soon after beginning treatment should my symptoms start to improve?
  • Do I need to take medications long term?
  • I have these other health conditions. How can I best manage them together?
  • Do you recommend any changes to my diet?
  • Is it safe for me to drink alcohol?
  • Are there any handouts or websites that you'd recommend for me to learn more about my condition?

If any additional questions occur to you during your medical appointments, don't hesitate to ask.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to talk about in-depth. Your doctor may ask:

  • What are your symptoms?
  • When did you first experience these symptoms?
  • Do your symptoms come and go? How often?
  • Does anything in particular seem to trigger your symptoms, such as certain foods or physical or emotional stress?
  • Are you being treated for any other medical conditions?
  • What medications are you currently taking, including over-the-counter and prescription drugs as well as vitamins and supplements?
  • Do any of your first-degree relatives — such as a parent or sibling — have a history of gout?
  • What do you eat in a typical day?
  • Do you drink alcohol? If so, how much and how often?

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