There are two main aspects to the treatment of gout:
- treating the acute attack of inflammation when one or more joints are very inflamed and painful
- ongoing treatment to reduce the level of urate in your blood and to get rid of urate crystals.
Treatments for acute attacks
The two most commonly used drug treatments for acute attacks of gout are non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine.
Non-steroidal anti-inflammatory drugs (NSAIDs)
Acute attacks of gout are often treated with oral non-steroidal anti-inflammatory drugs (NSAIDs), which can ease pain and possibly reduce some of the inflammation. Examples include ibuprofen, naproxen and etoricoxib.
Like all drugs, NSAIDs can sometimes have side-effects, but your doctor will take precautions to reduce the risk of these – for example, by prescribing the lowest effective dose for the shortest possible period of time.
NSAIDs are more effective the closer you take them to the onset of an attack of gout.
NSAIDs can cause digestive problems (stomach upsets, indigestion, or damage to the lining of the stomach) so NSAIDs should be prescribed along with a drug called a proton pump inhibitor (PPI), which will help to protect your stomach.
NSAIDs also carry an increased risk of heart attack or stroke. Although the increased risk is small, your doctor will be cautious about prescribing NSAIDs if there are other factors that may increase your overall risk – for example, smoking, circulation problems, high blood pressure, high cholesterol or diabetes.
If you're on some other medication, including water tablets or warfarin, or if you have other medical conditions, such as chronic kidney disease, it may mean that you shouldn't take an NSAID, but your doctor will advise you on this.
Colchicine is made from the crocus plant. It's not a painkiller but it's often very effective at damping down the inflammation caused by the crystals touching the joint lining. As with NSAIDs, colchicine tablets should be taken as close as possible to the beginning of an attack, and certainly within the first 24 hours of the attack starting, otherwise it may not be effective. Your doctor may let you keep a supply so you can start taking them at the first signs.
The recommended dose of colchicine is 0.5 mg two to four times per day, depending on your size, age and whether you have other health problems. Some people are unable to take colchicine because they have side-effects such as nausea, vomiting or diarrhoea. For this reason it's best to start at a low dose and only increase it if there's no upset.
You shouldn't take colchicine at the same time as NSAIDs. Colchicine can interact with many other drugs (including statins for high cholesterol) but your doctor will advise whether this means you should avoid colchicine or temporarily adjust your other medications.
You can also take colchicine in the longer term at a dose of 0.5 mg once or twice a day to reduce your risk of having attacks in the future. However, like NSAIDs, colchicine won't reduce the urate level in your blood, so it won't help to get rid of the urate crystals or prevent long-term joint damage.
If an acute attack of gout doesn't improve with NSAIDs or colchicine or if you're at risk of side-effects from these drugs, your doctor may prescribe a steroid injection into the joint or muscle, or a short course of steroid tablets (usually no more than a few days).
Putting an ice pack on the affected area can reduce some of the swelling, heat and pain. They're very safe, but make sure that you don't put the pack directly onto your skin to avoid burning or irritating your skin. You can buy reusable cooling pads from sports shops and chemists, or you can use a pack of frozen peas, wrapped inside a damp towel. You should always use ice packs alongside any drug treatments your doctor has prescribed.
Resting the painful joint also takes some of the edge off severe pain. A cage over the affected foot or knee to take the weight of the bedclothes at night can help.
Ongoing treatments to reduce urate
The drugs given to ease an acute attack don't get rid of the urate crystals in your joints or reduce the level of urate in your blood. Drugs are available that can lower urate levels and get rid of urate crystals in your body. Traditionally, the use of these urate-lowering therapies was reserved for people with more severe gout, for example if they were having frequent attacks, or if they had tophi, kidney stones, evident signs of joint damage or high urate levels.
Recent guidance advises that when people are first diagnosed with gout that an explanation about urate-lowering therapies is included in the information that they receive about gout. People with gout can then be involved in deciding whether or not they wish to go onto urate-lowering therapy at an earlier stage.
The reasoning for this line of thinking is that urate crystal deposits are very widespread even at the time of someone first experiencing an attack of gout. High urate levels can cause long-term joint damage and can also be bad for other aspects of your general health. The majority of people who suffer from gout will have multiple attacks and the condition is easier to treat the earlier you start.
You may still have acute attacks when you first begin urate-lowering treatment, so you may wish to take daily NSAIDs or colchicine to dampen down inflammation while your urate level is brought down. This tactic is called 'prophylaxis' (preventative treatment) of acute attacks.
You'll continue to be at risk of acute attacks for at least six months and probably longer, until all the crystals are dissolved away. It can take as long as two to three years to clear your body completely of urate crystals.
Urate-lowering drugs are usually very well tolerated, but you might have to stop using them if you have side-effects such as a rash or indigestion (dyspepsia). Aside from this, you should continue to take them until your doctor tells you to stop. If you miss doses of your urate-lowering medication, especially in the early stages, this can cause your urate level to go up and down, which can trigger acute attacks.
It's also important to consider other ways of reducing your urate levels. For example, it's important:
- to lose weight if you're overweight
- to avoid foods which are high in purines
- not to drink too much alcohol.
If you have other features of metabolic syndrome (high blood pressure, high lipids, diabetes), good control of these will also help to reduce your urate levels.
Allopurinol is the most commonly used urate-lowering drug. It has been available for many years and is normally effective and very well tolerated if taken correctly. It works by reducing the amount of urate that your body makes and is usually taken once a day.
Your doctor will measure the level of urate in your blood and will probably start you on a dose of 100 mg a day. If your urate level hasn't come down enough after a month, your dose will be increased by 100 mg. You may need several dose increases of 100 mg roughly each month until you're at the right dose that keeps your blood urate level well below the saturation point.
The maximum dose of allopurinol is 900 mg but most people reach the target urate level by taking a dose somewhere between 200-500 mg.
Allopurinol is available as 100 mg and 300 mg tablets so you won't need to take a lot of tablets if you need a higher dose. Allopurinol is broken down and excreted through your kidneys, so if your kidney function is impaired you may be started on a lower dose (50 mg) and the dose increased more cautiously.
Once your urate level is well below the saturation point (well under 360 μmol/L or 6 mg/dl), you should continue on that dose of allopurinol and have blood tests every 12 months or so to make sure that your urate level is within the desired range.
The main reason not to start with a large dose is that lowering urate levels quickly can actually trigger an acute attack. This is probably because the crystals in your cartilage become smaller as they start to break down, which allows them to shake loose more easily and shed into the joint cavity.
Bringing urate levels down slowly by gradually increasing the dose of allopurinol is much less likely to trigger an acute attack. Increasing the dose gradually is also less likely to result in side-effects such as a rash, headaches or nausea.
If you do develop any side-effects soon after starting allopurinol, you should stop taking the tablets and see your doctor, who will advise whether you should restart the tablets and what special care you should take. Very rarely some people can develop a severe skin rash, fever and become very unwell (so-called allopurinol hypersensitivity syndrome).
If you're not having any side-effects, it's important to keep taking allopurinol. The most common reason for allopurinol not working is the patient not taking the drug regularly or at the correct dose.
Allopurinol can affect some other tablets, especially warfarin and azathioprine. If you have to take either of these drugs for any reason, you must tell the doctor who prescribes them that you're also taking allopurinol. The dose of the other drug may need to be adjusted.
Febuxostat is a more recently introduced drug that also reduces the amount of urate made in the body. However, unlike allopurinol it's broken down by your liver and is therefore particularly useful if you have kidney problems and can't take a high enough dose of allopurinol.
Febuxostat comes in just two doses. The starting dose is 80 mg, which is quite strong and may trigger acute attacks, so it's recommended that you take a daily NSAID or colchicine for at least six months to help protect against this. If your urate levels haven't lowered after a month, the dose of febuxostat can be increased to a maximum of 120 mg daily.
There have been concerns about people with some heart conditions taking febuxostat. Current research suggests it's probably safe for these people, but more research is being carried out. If you're not sure whether you should be taking febuxostat, talk to your doctor.
Other urate-lowering drugs
Uricosuric drugs, which include benzbromarone and probenecid, work by flushing out more urate than normal through your kidneys. These drugs may not be suitable if you've had kidney stones or similar disorders.
They're not widely used in the UK, but they may be a useful alternative if allopurinol isn't suitable for you. Other drugs for treating acute attacks and for lowering urate are in development now and it's likely that new drugs will become available in the future.
If you're unable to tolerate or be treated successfully with allopurinol, febuxostat or uricosuric drugs you may need to see a hospital specialist (rheumatologist) for further advice.
Treatment of joint damage
If gout has already caused joint damage, the treatment will be the same as for osteoarthritis, including:
losing weight if you're overweight
daily exercise (both muscle strengthening exercise and general aerobic exercise)
reducing strain on the affected joint (for example, by pacing your activities and wearing the right footwear)
- painkillers (for example paracetamol, codeine)
- anti-inflammatory creams and gels
- topical capsaicin cream
- steroid injections into the painful joint
- surgery, including joint replacement.