Gout
Gout begins abruptly and nearly always at night: you wake to pain in the joint at the base of the big toe, which within a few hours has turned hot, purple and…
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Medicines commonly prescribed for Gout
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: TABLET, 600 mgActive substance: ibuprofenManufacturer: Farmalider S.A.Prescription requiredDosage form: ORAL SOLUTION/SUSPENSION, 100 mgActive substance: ibuprofenManufacturer: Nutra Essential Otc S.L.Prescription not requiredDosage form: ORAL SOLUTION/SUSPENSION, 100 mg/5mlActive substance: ibuprofenManufacturer: Farmalider S.A.Prescription required
Gout begins abruptly and nearly always at night: you wake to pain in the joint at the base of the big toe, which within a few hours has turned hot, purple and so tender that even the edge of the sheet is unbearable. It is the most painful of the common forms of arthritis and, at the same time, one of the few that can now be not merely settled but stopped altogether. The difference between someone who goes on having attacks for years and someone who stops having them lies neither in diet nor in willpower, but in whether the cause is being treated.
What an attack is like
The pain builds quickly: from the first discomfort to its peak takes a few hours, rarely more than a day. The joint swells, the skin over it stretches tight, reddens and shines; on brown and black skin the redness is harder to see, though the swelling and heat are just as obvious. Touching it is impossible, and so is putting weight on the foot.
The classic target is the joint at the base of the big toe, but gout does not stop there: it also takes the ankle, the midfoot, the knee and, less often, the wrist, elbow and small joints of the hand. Usually one joint at a time; in people who have had it for years, an attack can seize several at once.
Untreated, an attack settles by itself over one to two weeks, and towards the end the skin above the joint peels. That spontaneous fading is what misleads people: the pain has gone, so surely it is over. In fact the crystals are still there, and the next episode is only a matter of time.
When a hot joint is not gout
This deserves saying before anything else, because getting it wrong is expensive. Infection inside a joint, septic arthritis, looks almost identical: one joint, heat, swelling, unbearable pain. The difference is that it destroys cartilage within days and is treated only in hospital, by washing out the joint and giving antibiotics into a vein.
Seek help the same day if joint pain comes with any of the following:
- fever, shivering, a sense of being seriously unwell;
- the joint cannot be bent even slightly, and any movement causes sharp pain;
- redness spreading upwards from the joint along the limb in streaks;
- the affected joint is an artificial one, has recently been injected, or there is a wound nearby;
- you take medicines that suppress the immune system, or have another condition that makes infections run more severely.
The argument "I have gout, I know this attack" offers no protection here: gout and infection can occupy the same joint at once. If there is any doubt, the doctor draws fluid out with a needle, which eases the pain and answers the question in one move.
What to do while the attack lasts
The main rule is to start early: a medicine taken in the first hours works noticeably better than the same medicine two days on.
- Rest the leg and raise it on a pillow.
- Apply something cold wrapped in cloth for fifteen to twenty minutes several times a day.
- Keep the bedclothes off the painful joint by rigging up a frame of pillows over it.
- Drink enough water, unless you have been told to limit fluids.
- Do not press on the joint, rub it, or try to walk it off.
The medicines used are non-steroidal anti-inflammatory drugs, colchicine and corticosteroids, either as tablets or injected straight into the joint. Which one suits you depends not on how bad the pain is but on your other conditions: with a stomach ulcer, reduced kidney function, heart failure or blood-thinning medication, anti-inflammatories sit badly and the doctor will take another route. Improvement usually arrives within a day or two.
Separately: if you already take a medicine that lowers uric acid, it is not stopped during an attack. Sharp swings in the level are themselves a trigger, and a break only drags the story out.
How the diagnosis is confirmed
Gout is a disease of crystals. Uric acid, an ordinary product of the body's metabolism, when present in excess settles in the joint tissues as needle-shaped crystals, and those set off a violent inflammation.
A blood test for uric acid is done, but it cannot be relied on entirely: during an attack the level often comes back normal, because the acid has moved out of the blood and into the joint. A normal result at the height of the pain does not rule gout out, and the test is worth repeating a few weeks after everything has settled. The reverse holds too: a raised figure on its own is not a disease. In many people it stays high for years without a single attack, and treating a number is not the aim.
The exact answer comes from joint fluid under the microscope, where the crystals are visible. When fluid cannot be obtained, ultrasound and a special form of computed tomography help. While at it, the doctor checks kidneys, blood sugar, cholesterol and blood pressure: gout hardly ever travels alone.
Why uric acid builds up
In most people the trouble is not that too much acid is made, but that the kidneys clear it less well than they should. That capacity is largely inherited, which explains families where gout skips a generation and the galling mismatch between a strict diet and attacks that keep coming.
The risk is higher if:
- you are a man; in women, oestrogen helps clear uric acid before the menopause, and afterwards the gap narrows;
- there is excess weight, raised blood pressure, raised blood sugar or disturbed blood fats;
- kidney function is reduced;
- you take diuretics, certain blood pressure medicines, ciclosporin or low-dose aspirin: none of these is stopped on your own initiative, but the doctor should be told;
- you have psoriasis or a blood disorder with rapid cell turnover.
An individual attack usually has a trigger: a heavy meal, beer or spirits, dehydration, a crash diet, an injury to the joint, an operation, an illness with a high temperature, and also the first weeks on a uric-acid-lowering medicine.
Treatment measured in years
Ending an attack and curing gout are different jobs. The second is done by medicines that lower uric acid, taken continuously rather than in courses. Your doctor will raise them if attacks recur, if nodules have appeared under the skin, if there are kidney stones, kidney damage or visible changes in the joints.
What matters about this treatment:
- the dose is built up gradually, guided by blood tests, and finding it takes months;
- in the first weeks attacks may become more frequent: this is not a sign the drug is failing but the old deposits dissolving, and for that period the doctor adds anti-inflammatory cover;
- dropping the medicine once the pain has gone is the commonest mistake: the crystals come back and it all starts over;
- taken persistently, the deposits dissolve completely, the nodules shrink away and the attacks stop. It takes years, but the result is genuinely reachable.
What in daily life actually counts
The honest answer is that diet lowers uric acid, but only a little, and on its own it seldom settles matters. That is no reason to neglect it, but equally no reason to blame yourself for an attack after a faultless week.
- Losing weight works better than any single food ban, though crash dieting and fasting bring on attacks in their own right: the pace should be gentle.
- Beer, including the alcohol-free kind, and spirits raise the risk more than anything else; there is no wholly safe amount, and alcohol-free days are worth making a rule.
- Sweetened fizzy drinks and fructose-rich juices act no better than alcohol: water is the sensible swap.
- Offal, meat stocks, small oily fish and shellfish are rich in purines; vegetables, purine-containing on paper, do not raise the risk and need no limiting.
- Low-fat dairy foods and coffee, by contrast, go with fewer attacks.
- Drink enough water, particularly in hot weather and with exertion.
- Keep moving regularly, but spare the damaged joints from impact, and do not train in the middle of an attack.
Where neglected gout ends up
When attacks repeat for years without the cause being treated, crystals accumulate and stop confining themselves to the joint.
- Firm painless lumps appear under the skin, the tophi, most often on the rim of the ear, the fingers, the elbows and the Achilles tendon. In time they get in the way of putting on a shoe or fastening a button, and occasionally they break open and let infection in.
- Cartilage and bone are destroyed, the joint deforms, and the pain becomes constant rather than episodic.
- Uric acid stones form in the kidneys, and the kidneys themselves gradually work less well.
There is one more thing, spoken of less often: gout goes together with a raised cardiovascular risk. Blood pressure, cholesterol, blood sugar and kidney function are not checked as a formality; more often than not it is these, and not the joint, that decide the outlook.
Online consultation
A remote appointment is a good place to work through a first attack: from a description of the pain, how fast it rose and what the joint looks like, the doctor judges whether this fits gout and says which tests to have and exactly when, so that the result means something. Once the diagnosis exists, everyday questions are settled online: why attacks have become more frequent, what to do about the medication if a diuretic has just been added, how to reshape eating without extremes, and whether it is time to move on to continuous treatment. It is also the place to look at how the blood tests are trending. A hot joint with fever and shivering, on the other hand, is not something to sort out through a screen: that needs a doctor in person the same day.
This material is for information only and does not replace medical advice.
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Online doctors for Gout
Discuss your symptoms and possible next steps for Gout with a doctor online.
