Gout often announces itself overnight: a big toe that was fine at dinner is hot, red and too painful to touch by morning. It is one of the most painful forms of arthritis, and also one of the most treatable. Many people live with repeated flares for years without learning that a long-term plan can usually prevent them.

What gout is

Gout is caused by uric acid, a waste product the body makes when it breaks down purines, which are found in our own cells and in some foods. When uric acid builds up in the blood, the CDC explains, it can form painful crystals in and around a joint. Over time, uncontrolled levels can also form lumps called tophi, which can damage joints.

Gout is common. National survey data from 2015 to 2016 put it at 3.9 percent of US adults, about 9.2 million people, more often in men. The same study found that only about a third of people with gout were taking medicine to lower uric acid.

The CDC lists the main risk factors: being male, a family history of gout, obesity, heart failure, high blood pressure, insulin resistance, diabetes, poor kidney function, and certain medicines such as diuretics (water pills). Not everyone with a high uric acid level develops gout.

What a flare looks like

The CDC describes a flare as sudden pain, swelling, redness and heat, usually in one joint at a time and often the big toe. A flare can last days or weeks, followed by quiet periods. Without treatment, flares tend to become more frequent and last longer.

Because other conditions can look similar, the CDC advises that a doctor make the diagnosis, ideally during a flare, when uric acid crystals are easiest to spot in the affected joint. Doctors combine an exam, lab tests, X-rays and your history.

Treating a flare

The 2020 American College of Rheumatology gout guideline strongly recommends three options for a flare: colchicine, NSAIDs, or glucocorticoids (steroids) taken by mouth or injected into the joint or muscle.

The choice matters if your kidneys are involved. The 2024 KDIGO guideline says that for people with chronic kidney disease, low-dose colchicine or steroids are preferable to NSAIDs, and the National Kidney Foundation notes that colchicine doses are lowered in CKD. Our article on NSAIDs: risks and side effects explains why those pain relievers are hard on the kidneys.

Preventing the next flare

Long-term treatment aims to lower uric acid enough that crystals dissolve. The ACR guideline strongly recommends urate-lowering therapy for people with tophi, joint damage on X-ray, or frequent flares, and it sets a clear goal:

  • Treat to target. The dose is adjusted using repeated blood tests until uric acid is below 6 mg/dL.
  • Allopurinol first. The ACR names allopurinol as the preferred first medicine, including for people with moderate to severe CKD, starting at a low dose (100 mg a day or less, and lower in CKD) and increasing slowly.
  • Prevent flares while starting. Because lowering uric acid can trigger flares at first, the ACR strongly recommends anti-inflammatory protection, such as low-dose colchicine, for at least three to six months.

Patience matters here. Some flares in the first months of treatment are expected, which is why the protective medicine is part of the plan, and they are not a sign the treatment has failed.

Food and drink play a supporting role. The CDC suggests limiting beer and liquor, sugary foods and drinks, red and organ meats, and some seafood, along with at least 150 minutes a week of moderate activity. The National Kidney Foundation adds drinking plenty of water unless your doctor has limited fluids.

Gout and the kidneys

Gout and kidney disease are closely tied. The National Kidney Foundation notes that gout can be a sign of kidney disease, so people with gout should have their kidneys checked, and that uric acid crystals can also form kidney stones. Reduced kidney function, in turn, makes it harder to clear uric acid. KDIGO recommends offering uric acid-lowering treatment to people with CKD who have symptoms, and suggests considering it after a first flare, especially when uric acid is above 9 mg/dL. For a high uric acid level with no symptoms, the ACR guideline advises against starting medicine in most people.

If you have gout, ask for an eGFR and a urine albumin test. Our article on kidney stones covers uric acid stones.

Call your doctor for a first episode of a hot, swollen joint, or for a flare that is not settling after a few days of treatment. A hot, swollen joint together with fever or chills needs same-day care, because infection can look like gout.

Dr. Yana Shtern is board-certified in Internal Medicine and Nephrology, so gout and kidney function can be managed together. Same or next business day visits are available for members when a flare starts, and you can read more on our chronic care page. A complimentary meet and greet with Dr. Shtern is an easy way to talk it through.

This article is general information, not advice for your situation. Members can call the office with questions about their own care.