Gout is the most common form of inflammatory arthritis in the UK, affecting around 2.5% of the adult population — approximately 1.7 million people. It is caused by the build-up of uric acid in the blood, which eventually forms needle-sharp monosodium urate crystals that deposit in joints, causing attacks of extreme pain. Gout is highly treatable — both acute attacks and long-term prevention can be effectively managed with the right approach.
Gout Symptoms: The Acute Attack
A gout attack (flare) develops rapidly — often reaching peak intensity within 6–12 hours. The pain is typically described as one of the most severe experienced. Symptoms include:
- Sudden, severe joint pain — often starting at night; excruciating, knife-like or crushing in character
- Swelling — the affected joint becomes markedly swollen
- Redness and warmth — the joint turns red, hot, and shiny-looking
- Extreme tenderness — even the weight of a bed sheet can be intolerable
- Limited movement — joint becomes very stiff during an attack
Which Joints Are Affected?
- Big toe (metatarsophalangeal joint) — affected in ~70% of first gout attacks; the classic “podagra” presentation
- Ankle — second most common site
- Knee
- Wrist, fingers, and elbow — more common in chronic/tophaceous gout
- Tophi — visible deposits of urate crystals under the skin; appear in chronic untreated gout; commonly over the ears, elbows, and fingers
Without treatment, attacks typically resolve spontaneously in 1–2 weeks. However, untreated gout becomes progressively more frequent, and attacks last longer and affect more joints over time.
What Causes Gout?
Gout is caused by hyperuricaemia — chronically elevated uric acid levels in the blood (above 360 µmol/L). Uric acid is the breakdown product of purines (found in many foods and produced naturally by the body). When uric acid levels remain high for years, urate crystals slowly accumulate in joints and surrounding tissue.
Risk Factors
- Diet high in purines — red meat, offal (liver, kidneys), shellfish, oily fish (sardines, anchovies, mackerel)
- Alcohol — especially beer; alcohol both increases uric acid production and decreases excretion; wine is less problematic but still increases risk
- Sugary drinks and fructose — fructose drives uric acid production; sugary soft drinks strongly associated with gout
- Obesity — adipose tissue produces purines; obesity is independently associated with hyperuricaemia
- Medications — diuretics (thiazides, furosemide) are a major cause of secondary gout; low-dose aspirin, ciclosporin, tacrolimus also raise uric acid
- Chronic kidney disease — kidneys excrete uric acid; impaired kidneys cause accumulation
- Male sex — men have higher baseline uric acid levels; women’s risk increases after menopause
- Genetics — gout has a strong hereditary component; variants in SLC2A9 and ABCG2 genes affect uric acid excretion
- High blood pressure (hypertension)
Diagnosing Gout
Gout can often be diagnosed clinically from the characteristic presentation (sudden severe big toe pain in a middle-aged man who drinks beer). Your GP may arrange:
- Serum uric acid — note: during an acute attack, uric acid levels may paradoxically fall (inflammation redistributes urate), so a normal level does not exclude gout; retest 4–6 weeks after an attack
- Blood tests — FBC, CRP, ESR, renal function, LFTs, glucose, lipids (to check for associated conditions)
- Joint aspiration (gold standard) — examination of joint fluid under polarised light microscopy; needle-shaped, negatively birefringent urate crystals confirm gout; also excludes septic arthritis
- Ultrasound — can detect urate crystal deposits (double contour sign) and tophi; increasingly used by rheumatologists
- DECT (dual-energy CT) — highly accurate at detecting urate crystal deposits; specialist use
Treating a Gout Attack
Acute gout attacks are intensely painful and require prompt treatment. Start treatment as soon as an attack begins — early treatment is much more effective:
- NSAIDs — naproxen (500mg twice daily), indomethacin, or etoricoxib; first-line if no contraindications; take with a stomach protector (omeprazole) if at risk; avoid in renal impairment, heart failure, or if on anticoagulants
- Colchicine — 500mcg 2–4 times daily; very effective for gout; specific anti-gout mechanism; can cause diarrhoea at higher doses; not recommended with clarithromycin or ciclosporin
- Corticosteroids — oral prednisolone (30mg daily for 5 days) or intra-articular steroid injection; used when NSAIDs and colchicine are contraindicated (e.g., in severe renal disease)
- Rest and elevate the affected joint; ice packs (wrapped in a cloth) can reduce pain; keep the joint cool and uncovered if possible
- Stay well hydrated — drink plenty of water during an attack
Long-Term Prevention: Urate-Lowering Therapy (ULT)
The only way to prevent recurrent gout attacks and reverse joint damage is to lower serum uric acid below 360 µmol/L (or below 300 µmol/L in severe/tophaceous gout) long-term. NICE and BSR guidelines recommend ULT for:
- Two or more gout attacks per year
- Tophi or joint damage
- Renal impairment or urate kidney stones
- Gout associated with diuretic use that cannot be changed
Allopurinol — First-Line ULT
Allopurinol is the most widely prescribed urate-lowering drug in the UK. It reduces uric acid production by inhibiting xanthine oxidase. Key points:
- Start at 100mg daily (50mg in renal impairment); increase by 100mg every 4 weeks
- Target: serum urate <360 µmol/L; check levels every 4 weeks while titrating
- Do NOT start allopurinol during an acute attack — wait at least 2–4 weeks after the attack resolves, with prophylaxis cover
- Prophylaxis: colchicine 500mcg once or twice daily (or an NSAID) for the first 6 months of ULT to prevent attack flares as crystals dissolve
- Allopurinol must be taken lifelong — stopping leads to urate re-accumulation and attacks
- Rare but serious: allopurinol hypersensitivity syndrome — rash, fever, and organ damage; HLA-B*5801 screening before starting recommended in Han Chinese, Thai, Korean, and other South/South-East Asian patients
Febuxostat (Adenuric) — Alternative ULT
Febuxostat (80–120mg daily) is an alternative for patients who cannot tolerate allopurinol. It is more potent than standard allopurinol doses. MHRA advises caution in patients with established cardiovascular disease — discuss with your GP.
Dietary Advice for Gout
- Reduce high-purine foods — limit offal, game, and shellfish; moderate red meat consumption
- Reduce alcohol — especially beer; alcohol is one of the biggest modifiable risk factors
- Avoid sugary drinks — fructose-sweetened drinks and fruit juice significantly raise uric acid
- Stay well hydrated — 2–3 litres of water daily helps kidneys excrete uric acid
- Eat more cherries — tart cherry juice/concentrate has modest evidence for reducing gout attack frequency (lowers uric acid and inflammation)
- Low-fat dairy — skimmed milk, low-fat yoghurt can modestly lower uric acid
- Coffee — regular coffee consumption is associated with lower uric acid levels
- Lose weight gradually — obesity drives hyperuricaemia; avoid crash dieting (rapid weight loss releases purines and can trigger attacks)
This article is for informational purposes only and does not constitute medical advice. See your GP if you experience sudden severe joint pain. If you have a hot, swollen joint with fever, go to A&E to rule out septic arthritis — a joint infection is a medical emergency.
Related Health Guides on YourHealthXpert
Explore these related NHS-aligned health guides:
- Rheumatoid Arthritis Guide — Both gout and RA cause painful joint inflammation; learn the key differences and NHS treatment pathways.
- High Blood Pressure Guide — Hypertension shares risk factors with gout and certain medications can affect uric acid levels.
- Type 2 Diabetes Guide — Insulin resistance raises uric acid levels; understand how managing diabetes helps gout control.
- Chronic Kidney Disease Guide — Reduced kidney function impairs uric acid excretion, worsening gout; learn about NHS kidney care.
- Kidney Stones Guide — Uric acid kidney stones are a serious complication of gout; understand prevention and NHS treatment.
- Osteoporosis Guide — Gout medications and joint damage can affect bone health; learn about NHS bone protection strategies.