Gout

Gout is a common and treatable form of inflammatory arthritis caused by deposition of monosodium urate crystals in joints and soft tissues. It results from sustained high levels of uric acid in the blood (hyperuricemia). Attacks often begin suddenly, frequently at night, with severe pain, redness, and swelling—classically in the big toe, though any joint can be affected.

Without treatment, attacks tend to recur and can lead to chronic arthritis and tophi (urate deposits under the skin). Lowering uric acid with medicine and lifestyle measures prevents attacks and long-term joint damage for most people.

Symptoms of a gout attack include:

• Intense joint pain — often the large joint of the big toe, but also feet, ankles, knees, hands, and wrists
• Lingering discomfort after the most severe pain eases
• Inflammation and redness — the joint becomes swollen, tender, warm, and red
• Limited range of motion as the attack progresses

Attacks often start suddenly and reach maximum intensity within 12–24 hours. Between attacks there may be no symptoms (intercritical period). Chronic tophaceous gout produces firm nodules (tophi) and persistent joint disease.

Gout occurs when urate crystals accumulate in the joint, triggering intense inflammation. Urate forms when the body breaks down purines. Hyperuricemia can result from:

• Overproduction of uric acid
• Under-excretion by the kidneys (more common)
• A combination of both

Not everyone with high uric acid develops gout; genetic factors, local joint conditions, and triggers influence crystal formation and attacks. Common triggers for acute attacks include alcohol (especially beer), red meat and seafood, sugar-sweetened drinks, dehydration, surgery or acute illness, and starting or stopping certain medicines.

Risk factors include:

• Diet high in purines (red meat, organ meats, some seafood) and fructose-sweetened beverages
• Alcohol use, particularly beer and spirits
• Obesity
• Medical conditions — untreated high blood pressure, diabetes, metabolic syndrome, heart failure, and kidney disease
• Certain medicines — thiazide and loop diuretics, low-dose aspirin, tacrolimus, cyclosporine
• Family history of gout
• Age and sex — more common in men; risk in women rises after menopause
• Recent surgery or trauma

Untreated or undertreated gout can lead to:

• Recurrent and increasingly frequent attacks
• Chronic arthritis with joint damage and deformity
• Tophi that can become inflamed or ulcerate
• Kidney stones (urate)
• Chronic kidney disease (association and possible contribution)

To reduce attacks and complications:

• Take uric-acid-lowering medicine as prescribed if indicated (do not stop during an attack without advice)
• Maintain a healthy weight
• Limit alcohol, especially beer
• Limit purine-rich foods and sugar-sweetened beverages
• Stay well hydrated
• Review medicines that raise uric acid with a clinician
• Treat related conditions (hypertension, metabolic syndrome)

The gold standard is identification of urate crystals in joint fluid under polarized light microscopy. In practice, diagnosis often combines:

• Classic clinical pattern (sudden monoarthritis, especially first MTP joint)
• Elevated serum uric acid (supportive but not diagnostic; can be normal during an attack)
• Joint ultrasound or dual-energy CT showing urate deposits in selected cases
• Exclusion of septic arthritis and other crystal or inflammatory arthritides

Aspiration of the joint is recommended when the diagnosis is uncertain or infection must be ruled out.

See a healthcare professional for sudden, severe joint pain. Seek urgent care if the pain is accompanied by fever, because an infected joint (septic arthritis) needs immediate treatment and can look similar to gout.

People with recurrent attacks, tophi, kidney stones, or chronic joint symptoms should discuss long-term uric-acid-lowering therapy.

Treatment has two phases:

Acute attack

• NSAIDs at full anti-inflammatory doses
• Colchicine (early use is most effective)
• Corticosteroids (oral, intramuscular, or intra-articular)
• Rest, ice, and elevation of the affected joint
• IL-1 inhibitors in refractory cases

Long-term urate-lowering therapy (ULT) for people with recurrent attacks, tophi, CKD, or stones:

• Allopurinol (first-line for most) — start low and titrate to target uric acid (usually <6 mg/dL)
• Febuxostat — alternative when allopurinol is not tolerated or effective
• Probenecid or other uricosurics in selected patients
• Pegloticase for severe refractory tophaceous gout
• Anti-inflammatory prophylaxis (colchicine or low-dose NSAID) when starting ULT to prevent mobilization attacks

Helpful measures:

• Start anti-inflammatory treatment at the first sign of an attack as advised by your clinician
• Take ULT consistently once it is indicated; do not stop it during an attack unless told to
• Follow dietary and alcohol guidance
• Stay hydrated
• Maintain a healthy weight with gradual loss if needed
• Keep follow-up appointments so uric acid can be titrated to target

Bring:

• Description of attacks (joints involved, frequency, duration, triggers)
• List of medicines, especially diuretics and aspirin
• Diet and alcohol habits
• Previous uric acid levels or joint-fluid results
• Questions about starting or adjusting urate-lowering therapy and target levels