Gout

What is gout?

Gout is a very painful form of arthritis caused by crystals that form in and around the joints.

It’s the most common type of inflammatory arthritis. It’s more common in men and you’re more likely to get it as you get older.

Gout occurs in people who have high levels of urate in their blood, but having urate in your blood doesn’t mean you’ll develop gout. It’s normal and healthy to have some urate in your bloodstream.

Urate is created every day when our bodies break down purines. Purines are chemicals that are naturally created in our body, but they are also present in certain foods.

People used to think that gout was caused by overeating and drinking too much alcohol. While this can make attacks of gout more likely, it’s not the whole story.

In any day, about three-quarters of the urate in our bodies comes from the breakdown of purines produced within our body, while only about a quarter comes from the breakdown of purines in food and drink we consume.

As urate levels build up, your body gets rid of any extra through your kidneys and in your wee. But if your body is making too much urate, or your kidneys are unable to get rid of enough of it, then levels start to rise.

If urate levels stay too high, urate crystals can slowly start forming. They mainly occur in and around firm joint tissues, such as the cartilage. But crystals can also appear under your skin and may even occur in your internal organs, such as the kidneys.

Symptoms

Attacks

When you have gout, urate crystals can build up in your joints for years without you knowing they are there. When there are a lot of crystals in your joints, some of them can spill out from the cartilage into the space between the two bones in a joint.

The tiny, hard, sharp crystals can rub against the soft lining of the joint, called the synovium, causing a lot of pain swelling and inflammation. When this happens, it’s known as an attack or flare of gout.

During an attack of gout the affected joint becomes:

  • very painful
  • tender
  • red
  • hot
  • swollen.

The skin over the joint often appears shiny and may peel off a little as the attack settles.

Attacks usually come on very quickly, often during the night. Doctors describe this sudden development of symptoms as ‘acute’.

The attack usually settles after about five to seven days, but it can go on for longer.

If gout is left untreated, attacks can become more common and may spread to new joints.

Attacks typically affect the joint at the base of the big toe and often start in the early hours of the morning. The symptoms develop quickly and are at their worst within just 12 to 24 hours of first noticing that anything is wrong.

Any light contact with the affected joint is very painful – even the weight of a bedsheet or wearing a sock can be unbearable.

Although gout most often affects the big toe, other joints may also be affected, including:

  • other joints in your feet
  • ankles
  • knees
  • elbows
  • wrists
  • fingers.

It’s possible for several joints to be affected at the same time. It’s not common to have gout in joints towards the centre of your body, such as the spine, shoulders or hips.

Gout attacks are especially common in joints at the ends of your legs and arms, such as in your fingers and toes. This is probably because these parts of the body are cooler, and low temperatures make it more likely for crystals to form.

Similar attacks can be caused by a condition called acute calcium pyrophosphate crystal arthritis. This is also known as acute CPP crystal arthritis, which used to be called ‘pseudogout’.

Tophi

Urate crystals can also collect outside of the joints and can be seen under the skin, forming small, firm lumps called tophi. You can sometimes see the white colour of the urate crystals under the skin.

The most common areas for tophi are:

  • over the top of the toes
  • back of the heel
  • front of the knee
  • backs of the fingers and wrists
  • around the elbow
  • the ears.

Tophi aren’t usually painful, but they can get in the way of normal daily activities. They can sometimes become inflamed, break down and leak pus-like fluid with gritty white material - these are the urate crystals.

Tophi can also grow within your joints and cause damage to your cartilage and bone. This can lead to more regular, daily pain when you use the affected joints.

Causes

There are two different types of gout. When you have it and there’s no single cause, it’s called primary gout. When you have it and it’s caused by something else, it’s known as secondary gout. Secondary gout can be caused by either:

  • chronic kidney disease
  • long-term use of medications that affect how well your kidneys can remove urate from your body.

Risk factors

Family history

Even though your kidneys can be completely healthy, sometimes the genes you’ve inherited make it more likely that your kidneys don’t flush urate out as well as they should. This is the most common cause of primary gout, especially when several family members are affected, such as your parents or grandparents.

Being overweight

Gout is much more common in people who are overweight. The more overweight you are, the more urate your body produces, and this may be more than your kidneys can cope with.

Being overweight also makes it more likely that you’ll have:

  • high blood pressure
  • type 2 diabetes
  • high cholesterol
  • fats in your blood.

These conditions can all lower how much urate is filtered out by your kidneys.

Gender and age

Gout is about four times more common in men than women. It can affect men of any age, but the risk is greater as you get older.

Women rarely develop gout before the menopause. This is because the female hormone oestrogen increases how much urate is filtered out by the kidneys. But after the menopause, oestrogen levels go down and urate levels go up.

Taking certain medications

Some medications can reduce your kidneys’ ability to get rid of urate properly. These include diuretics, also known as water tablets, and several tablets for high blood pressure, including beta-blockers and ACE inhibitors.

Other conditions

Several different conditions are linked to raised urate levels. This could be because they affect the way the kidneys filter urate, or because they cause more urate to be produced in the first place.

For some conditions, the link with gout is less clear, and may be due to many different factors.

Common conditions associated with gout include:

  • chronic kidney disease
  • high cholesterol and fats in the blood
  • high blood pressure
  • type 2 diabetes
  • osteoarthritis.

What can trigger a gout attack?

Several things can cause the crystals to shake loose into your joint cavity, triggering an attack. These include:

  • a knock or injury to the joint
  • an illness that may make you feverish
  • having an operation
  • having an unusually large meal, especially a fatty meal
  • drinking too much alcohol
  • dehydration
  • starting urate lowering therapy, especially at a high dose, or not taking your treatment regularly each day.

Diagnosis

Diagnosing gout is usually straightforward, especially if you have typical symptoms of the condition - for example, if you have an attack in your big toe.

But gout can sometimes be more difficult to diagnose. Your doctor will need to know about the symptoms you’ve been having and will probably need to perform some tests.

Blood tests

Blood tests to measure your urate levels can be helpful to support a diagnosis of gout, but aren’t enough on their own to confirm it.

High urate levels in blood tests can suggest that you have gout, but this will need to be considered alongside your symptoms. It’s possible to have high levels of urate, but not have any other symptoms of the condition.

Imaging tests

Ultrasound and CT scans can be good at spotting joint damage, crystals in the joints and early signs of gout. X-rays are generally used to pick up the bone and joint damage caused by having gout for a long time.

Synovial fluid examinations

These are a good way to rule out other crystal conditions and make a diagnosis.

They’re done by taking a sample of your synovial fluid through a needle inserted into one of your joints. The fluid is then examined under a microscope for urate crystals. If you have tophi, doctors can take a sample from one of those instead.

How will gout affect me?

Attacks can vary from person to person. Some people only have an attack every few years, while others have attacks every few months.

Without medication attacks tend to happen more often and other joints can become affected.

Having high urate levels and gout for a long time can lead to other health problems, including:

  • narrowing of the arteries - which can lead to an increased risk of stroke or heart attacks or other heart problems
  • osteoarthritis, which occurs when the urate crystals and hard tophi cause joint damage.
  • an increased risk of developing kidney disease or worsening of the condition if you already have it
  • kidney stones
  • an increased risk of some cancers, especially prostate cancer
  • mental health problems, including depression
  • underactive thyroid
  • erectile dysfunction in men.

If you take medication to lower your urate levels, and have a healthy diet and lifestyle, most of the damage and complications caused by gout can be stopped.

Treatments

Treatments for gout are incredibly successful. There are two main parts to treating gout, which are:

  • treating the acute attack
  • treatments to prevent future attacks.

Treating a gout attack

Treating an attack of gout doesn’t lower your urate levels or stop future attacks. The treatment helps you to manage your symptoms when an attack happens.

The most commonly used drug treatments for attacks of gout are:

Some people will be better suited to NSAIDS, while others will be suited to colchicine. But your preference is also taken into consideration – many people with gout quickly learn what works best for them.

In cases where one drug doesn’t seem to be working on its own, your doctor might suggest a combination of NSAIDs with either colchicine or steroids.

Non-steroidal anti-inflammatory drugs (NSAIDs)

Attacks of gout are often treated with NSAID tablets, which can help with pain and reduce some of your inflammation. Ibuprofen, Naproxen and diclofenac are three NSAIDs you could be given.

If you’ve been prescribed NSAIDs to treat an attack, you should start taking them as soon as you notice signs of one coming on. Your doctor may let you keep a supply so you can start taking them at the first signs of an attack.

The earlier you start treatment, the better.

NSAIDs aren’t suitable for everyone, so talk to your doctor about them first if you have any other conditions. They can also interact with other drugs, so make sure you talk to a doctor before starting on any new medication.

NSAIDs aren’t usually prescribed for a long period of time, as they can cause problems with your digestive system. To reduce the risk of this happening and to protect your stomach, your doctor will also prescribe a proton pump inhibitor.

Colchicine

Colchicine isn’t a painkiller, but can be very effective at reducing the inflammation caused by urate crystals.

As with NSAIDs, colchicine tablets should be taken as soon as you notice an attack coming on, or it may not work as well. Your doctor will probably recommend keeping a supply at home.

Colchicine can interact with several other drugs, including statins taken for high cholesterol. Your doctor will advise whether you’d be better off using an NSAID instead, or adjusting your other medications while you’re taking colchicine.

You should avoid taking colchicine if you have chronic kidney disease.

Colchicine tablets can cause diarrhoea or stomach aches.

Steroids

If colchicine or NSAIDs haven’t worked for you, or if you’re at risk of side effects from these drugs, your doctor may prescribe steroids.

They are usually taken as a short course of tablets, lasting a few days.

However, they can also be taken as an injection into a muscle or joint affected by gout. This can be particularly helpful if gout is affecting only one joint.

Check out our steroids and steroid injection pages for more information.

Tips for managing an attack at home

  • Keep the area cool – an ice pack, or a bag of frozen peas wrapped in a tea towel, can be particularly good at reducing some of the pain and swelling.
  • Rest the affected joint.
  • Think about getting yourself a bed cage. These support the bedsheets above your feet so that your affected joint can rest without the strain of the sheets.

Treatments to prevent gout attacks

There are drugs available that can lower urate levels, prevent new crystals from forming and dissolve away the crystals in your joints. They are called urate lowering therapies or ULTs for short.

Treatment with ULTs is generally started after an attack of gout has completely gone.

There’s no single fixed dose of a ULT, and different people need different doses to get to the right blood urate level.

It can take a few months or years for the drugs to completely clear your body of urate crystals. But once they’re gone, you will no longer have attacks of gout, tophi or risk of joint damage due to gout.

It’s important to remember that ULTs won’t stop attacks of gout straight away. You could actually have more attacks within the first six months of starting them.

Don’t stop taking your ULTs if this happens to you, as this is actually a sign that the drugs are working. As the drugs start dissolving the crystals, they become smaller and are more likely to get into the joint cavity, triggering an attack.

Your doctor might suggest taking a low dose of colchicine or NSAID as a precaution against attacks during the first six months of starting ULTs.

ULTs are usually life-long treatments and require yearly check-ups to monitor your urate levels. If your symptoms aren’t getting under control, talk to your doctor about your urate level, as you might need to be on a higher dose.

Try not to miss or skip any of your doses, especially in the first year or two of starting treatment. This could cause your urate levels to go up and down, which could trigger an attack.

Allopurinol

Allopurinol is the most commonly used ULT. It’s a very effective treatment for most people with gout.

It works by reducing the amount of urate that your body makes.

You’ll start on a low dose of allopurinol, which can be gradually increased until you are on the right dose.

Gradually building up the dose means it’s less likely to trigger an attack and also makes sure you’ll have the lowest dose needed to get your gout under control.

Allopurinol is broken down and removed from the body through your kidneys, so if you have a problem with your kidneys, it may not be suitable for you. Your doctor might decide to start you on an even lower dose and increase slowly, or suggest that you try febuxostat instead.

Febuxostat

Febuxostat is a newer drug that reduces the amount of urate made in the body in the same way that allopurinol does.

You won’t be prescribed febuxostat as your first ULT, unless your doctor has said that you can’t take allopurinol.

It works in a similar way to allopurinol but, instead of being broken down by the kidneys, it’s broken down by your liver. It’s useful if you have kidney problems and can’t take a high enough dose of allopurinol.

Febuxostat is more likely to trigger gout attacks than allopurinol when you first start treatment. So, as a precaution, it’s likely you’ll be prescribed a low-dose NSAID or colchicine to take on a daily basis for the first six months of starting febuxostat.

There are just two doses of febuxostat, so if your urate levels haven’t lowered enough after a month on the low dose, you may need to go on to the higher dose.

Uricosuric drugs

Uricosuric drugs, which include sulfinpyrazone, benzbromarone and probenecid, work by flushing out more urate than normal through your kidneys.

They’re not used much in the UK, as they’re not widely available. They’ll only be prescribed by a rheumatologist if allopurinol and febuxostat haven’t worked or aren’t suitable for you.

It’s unlikely you’ll be able to take these drugs if you’ve had severe problems with your kidneys or had kidney stones. This is because, by encouraging your kidneys to filter more urate, they also increase the risk of developing kidney stones.

Uricosuric drugs are usually used on their own. But in rare cases, where you’ve tried several ULTs and none have worked for you, uricosurics can be used in combination with other ULTs, like allopurinol or febuxostat.

If you’re unable to take allopurinol, febuxostat or a uricosuric, or if they don’t work for you, you’ll need to see a rheumatologist for advice.

Treatment for joint damage

If your gout has caused damage to your joints, then the treatments available will be the same as those used for osteoarthritis. They include:

  • exercising regularly
  • reducing the strain on your affected joints
  • staying at a healthy weight
  • taking painkillers
  • in more severe cases, joint replacement surgery.

Visit our osteoarthritis page to find out more about treatments available for joint damage.

Managing your symptoms

Lifestyle choices are not the main reason why most people get gout.

However, if you have a healthy lifestyle and also take prescribed medication, you’ll have the best chance of lowering your urate levels. This will then decrease the chances of you having attacks of gout.

Exercise

Exercise is extremely important, not only to reduce the chances of an attack, but also for your general health and wellbeing.

It doesn’t matter how much exercise you do - a little is better than none at all.

Start off slowly and gradually build up how much you do until you’re doing regular sessions.

As your confidence increases, you can increase the length and intensity of what you’re doing.

Exercises that get you out of breath are particularly good for burning calories. You could try dancing, walking in hilly countryside or doubles tennis.

It helps to find a sport or exercise you enjoy which you enjoy and will keep doing. Some people find joining a leisure centre or sports club to be really fun and motivational. Have a look around and see what’s available in your area.

You should avoid exercising during a flare up of gout, as it could make your pain worse. It’s important to rest and recover and begin exercising after the pain and swelling has gone down.

Diet

You should try to have a well-balanced diet that is low in fats and added sugars, but high in vegetables and fibre.

Extreme weight loss or starvation diets increase cell breakdown in your body, which can raise urate levels. However, you should be OK to do some daytime fasting - for example, during Ramadan.

We don’t recommend Atkins-type weight-loss diets, as they include a lot of meat and are high in purines.

If you’re overweight, weight loss should be gradual combined with daily exercise.

The NHS has a good diet and exercise plan which can help you lose weight in a healthy way over 12 weeks.

Food to have in moderation

You should try to avoid eating large quantities of foods that are high in purines. But there’s no need to remove them completely from your diet.

These include:

  • red meat, game and offal - such as venison, kidneys, rabbit and liver
  • seafood, particularly oily fish and shellfish - such as anchovies, fish roe, herring, mussels, crab and sardines
  • foods rich in yeast extracts - such as Marmite, Bovril and Vegemite
  • processed foods and drinks.

Protein is an important part of your diet, but you can get it from sources other than just meat and fish. You could try replacing a portion of meat with other protein-rich foods like soybeans, eggs, pulses or dairy products.

The UK Gout Society has a detailed food list of foods high in purines. Check out their diet factsheet for more information.

What about drink?

If you have gout and a history of kidney stones, you should try to drink at least two litres of water a day to decrease the chance of stones forming.

Sweetened soft drinks should be avoided, as they contain large amounts of sugar and can increase the risk of getting gout.

While fruit and fresh fruit juices contain sugar, the benefits of eating fruit are likely to far outweigh any negatives. Reducing how much sugar you consume from other sources is a heathier option than cutting out some of your five a day.

Alcohol

Drinking too much alcohol, especially beer and spirits, can increase your urate levels and your chances of triggering a gout attack. Beer is particularly bad, as it contains a lot of purines.

However, drinking a bit of wine doesn’t appear to increase the risk of triggering an attack.

As a rule of thumb, try to stick to the government guidelines of drinking no more than 14 units a week. This is equivalent to about 6 pints of beer or 6 glasses of wine. But don’t save these units up and drink them all in one go - it’s better to spread them out over the course of the week.

Your doctor might also advise a lower limit.

You can find out more about government drinking guidelines at drinkaware.

Vitamin C

Research has shown that vitamin C may slightly reduce uric acid levels in people with gout. This is another reason to make sure your diet includes plenty of fruit and vegetables. But if you’re considering taking vitamin C supplements, talk to your doctor first, as there’s a very slight risk that vitamin C supplements could interact with other medications.

Cherries

Research has shown that cherries may reduce the risk of having an acute attack of gout, particularly when taken with allopurinol.

Skimmed milk and low-fat yoghurt

Research suggests drinking skimmed milk and eating low-fat yoghurt may help to prevent attacks of gout.

Complementary and alternative treatments

If you decide to try complementary and alternative treatments, you should be critical of whether they are making a difference to your condition.

They should never replace your prescribed gout medication.

Don’t worry about fish oil supplements raising your urate levels. While some may contain purines, the amount is likely to be so small that it won’t make a difference to your condition.

Similarly, even though the supplement glucosamine is made from the outer shells of shellfish, it doesn’t contain purines. However, there’s no evidence that glucosamine can prevent or treat gout.

Caring for yourself

The emotional effects of gout can have just as much impact as the physical symptoms. Long term damage and severe pain from the attacks of gout can affect your daily life, disturb your sleep and affect your mood. From time to time, your gout may get on top of you. If you’re feeling low, talk to your GP, who can signpost you to the appropriate services. You can also call our helpline on 0800 5200 520, who will listen and offer emotional support.

Work

Work can provide a sense of purpose, a supportive social network, and help you financially. Most people with gout can continue working, but you may need some time off when you have an attack.

If gout is affecting your ability to work, speak to your employer’s occupational health service if they have one. Your employer has a duty to make reasonable adjustments so that you can do your job.

Your local Jobcentre Plus can also put you in touch with Disability Employment Advisors, who can arrange workplace assessments.

Access to Work is a scheme in Scotland, England and Wales that gives extra help to people with disabilities or physical and mental health conditions. There is a separate scheme available in Northern Ireland.

Access to Work provides funded or partly-funded grants to help people start work, stay in work, or move into self-employment, and can be used to pay for equipment, support workers, or transport, among other things.

Research and new developments

Research is greatly increasing our understanding of what triggers gout and how new therapies may be developed to treat it.

Our research has found a more successful way of treating people with gout. We funded a clinical trial in which nurses, trained in gout and its management, delivered a package of care tailored to patients. It provided information on gout and its treatment options, and involved patients in decision making.

The results proved that:

  • when fully informed almost 100% of people with gout want ULTs
  • 95% of patients were still continuing with their treatment after two years
  • after two years, more than 9 out of 10 patients were having fewer gout attacks, tophi were greatly reduced and quality of life was improved compared to patients who continued with their standard treatment.

Versus Arthritis is also currently funding a research project to help design a full-scale clinical trial looking at whether omega-3 fatty acids, which are found in fish oils, can be used alongside ULTs to prevent gout attacks.

The results could reduce gout attacks and overcome the unwanted side effects that some people experience when starting on ULTs.

Neil’s story

Neil in his kitchen, drying pots, with his cat

At its worst, my gout was so bad I couldn’t walk for three months.

I couldn’t even play with my daughter Hannah, who was toddling at the time. The only way I could get around was on all fours and crawl. I was only a year into my thirties.

When I was diagnosed with gout my doctor didn’t prescribe me anything for it. And to be honest, I didn’t take much notice. I put it to the back of my mind and carried on as I always had.

Everything changed about a year later, when I had my first proper experience of a gout attack.

It happened after a game of football. I couldn’t believe how painful and swollen my foot had become.

My ankle was so puffy that my foot looked like a joint of meat. Even the weight of the bed sheets was enough to keep me up at night.

The worst part was not being able to sleep.

The next morning, exhausted, I’d dose up on painkillers before going to work.

At the time I was on my 12th year of doing deliveries for the Royal Mail. Getting my round done every morning was becoming a struggle. To my colleagues it was all a big joke.

I tried ibuprofen but it wasn’t touching it. So, I went back to my doctor.

He said that drugs like allopurinol can be bad for you and that I’d be better off controlling it with my diet.

He gave me the impression that having gout was my fault.

I was prescribed a high dose of ibuprofen and sent on my way.

I followed his advice, changed my diet and gave up alcohol completely.

But nothing changed. In fact, it got worse. It spread to my hands, wrists and elbows.

On bad days the pain was so excruciating I couldn’t touch the gearstick of my car. It’s scary how you take these things for granted.

After another 10 years of walking the beat for the Royal Mail, I decided It was time to get a desk job.

Soon after this I had to make another trip to the doctors for my hands. They thought I’d developed arthritis, so I was being referred to a specialist.

When I met them, they couldn’t hold back their shock. They were appalled that I’d never been on any gout medication.

They said I’d be fine once I was on allopurinol. I’ll be honest - I was sceptical as I’d been in so much pain for so long. But fuck, it was pretty much miraculous how quickly it all stopped. The last four years have been fantastic.

If you have gout, my advice would be don’t panic, do your research and find out everything you can. And if you’re not getting the help you need, go somewhere else. You can always find someone who’ll help.