Gout: what to do in a flare and how to keep it under control

Gout is a common type of inflammatory arthritis. It happens when the body builds up too much uric acid over time and needle-like crystals form inside a joint. It usually affects one joint at a time, most often the big toe. If several joints hurt at once, see joint pain; if it is the bottom of the heel, see plantar fasciitis.

Flares alternate with periods without symptoms. Without treatment, flares tend to come more often and last longer. Not everyone with high uric acid develops gout.

The risk is higher in men, in people with a family history of gout, and with overweight, high blood pressure, diabetes, heart failure or kidney problems. Food and drink matter too: alcohol (especially beer), sugary drinks and snacks, red meat, organ meats and some seafood can set off a flare.

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A gout flare is handled in a doctor visit, the same price for every age, with no membership. If you already have a diagnosis and only need a refill of a non-controlled gout medicine you already take, choose the follow-up visit on prescription refills.

You pay by card when you request the visit, and you get a full refund if the clinic can’t see you. We do not bill insurance; the lab and the pharmacy charge separately. See all prices. The service is run by The Health Initiative, a nonprofit.

According to the NIH, a flare usually starts suddenly, often at night, and the pain can be bad enough to wake you up. The most common signs are:

• Sudden, intense pain in one joint
• Swelling of the joint
• Redness of the skin over the joint
• Warmth in the joint
• Pain in the big toe, the most common site

Treatment has two parts. During a flare, the goal is to bring down pain and inflammation: the NIH lists anti-inflammatory medicines (NSAIDs), colchicine and oral corticosteroids. The doctor chooses based on your case, your kidneys, your stomach and your other medicines. Rest the joint, keep it raised and put ice wrapped in a cloth on it.

Colchicine. According to MedlinePlus, it is used to relieve the pain of a gout flare and also to prevent flares; it is not a general painkiller. It may not be appropriate with kidney or liver disease, several medicines should not be taken with it, and grapefruit should be avoided. Tell your doctor if you get muscle pain or weakness, or numbness in your fingers or toes.

Allopurinol. It lowers how much uric acid your body makes. MedlinePlus explains that it prevents flares rather than treating one that has already started, and that flares can increase in the first months. That is why the 2020 American College of Rheumatology (ACR) guideline recommends pairing it with a preventive medicine, such as colchicine or an NSAID, for 3 to 6 months. The same guideline says that when uric acid-lowering treatment is indicated, it can be started during a flare.

Who needs to lower uric acid. According to the ACR, treatment is indicated if you have tophi (hard lumps of crystals under the skin), joint damage from gout on an X-ray or other imaging, or 2 or more flares a year. Allopurinol is the first choice for most people, and the goal is to keep uric acid below 6 mg/dL. It is taken every day long term, starting at a low dose that is raised gradually.

Before starting allopurinol. The starting dose is lower if you have kidney disease, which is why the doctor checks your creatinine; see high creatinine. The ACR suggests a genetic test, HLA-B*5801, before starting in people of Southeast Asian descent and in African American patients, because that gene raises the risk of a severe skin reaction. If you get any rash, itching or hives, stop the medicine and call your doctor right away or get emergency care.

Uncontrolled gout can form tophi and kidney stones. With early diagnosis, treatment and lifestyle changes, gout is one of the most controllable forms of arthritis. Book an evaluation; the doctor decides whether a treatment is right for you.

According to MedlinePlus, a uric acid test measures how much is in your blood or urine; for gout the blood test is used, often together with an analysis of fluid from the joint. Some medicines, such as aspirin and niacin, can change the result: tell the doctor, but don’t stop them on your own.

The doctor gives you a lab order online for uric acid and kidney tests when gout is suspected, before starting or adjusting a uric acid-lowering medicine, and to follow it over time. We go over those results with you in a follow-up visit. What helps most at home: avoid alcohol and sugary drinks, eat less red meat and organ meat, keep a healthy weight and get about 150 minutes of activity a week.

A high uric acid result does not always mean gout. MedlinePlus explains that many people have high uric acid without health problems, and that a high result does not always mean there is something that needs treatment.

It rises when the kidneys do not remove it well, with high-purine foods (red meat, organ meats, shellfish), high-fructose corn syrup in soda and sweets, alcohol, and some medicines such as diuretics. Over time, high uric acid can also cause kidney stones or kidney damage. If the same lab showed high creatinine, the doctor reviews both results together in an online follow-up visit.

For your safety, go to the emergency room or call 911 if you notice any of these signs. An infected joint can be damaged quickly without prompt treatment. See when to go to the ER.

• A hot, swollen joint with fever or chills, especially the first time
• You can’t move the joint or put weight on your foot
• Several swollen joints at once with fever
• Redness spreading across the skin, or a wound near the joint
• A child with a swollen joint, fever, or who won’t walk or move an arm or leg