It’s the middle of the night when you wake to the sensation that your big toe is on fire. The joint is swollen and the pain is excruciating, to the point that you can’t bear any weight on your toe or even tolerate the feel of a sock or a bedsheet on it.
That nightmare scenario describes a hallmark gout flare. Gout is the most common form of inflammatory arthritis. Affecting an estimated 4 percent of the population, gout can cause a sudden onset of pain and swelling in any joint but is typically associated with the big toe.
And it’s not just a short-term problem, says UNC Health rheumatologist Amanda Snyder, MD. “The acute flares come and go, but left untreated, gout can progress to a chronic state and cause long-term damage to the joints.”
Dr. Snyder explains what causes the condition and how it’s treated.
Causes of Gout
Gout is caused by a buildup of urate crystals, which are formed by excess uric acid in the bloodstream. Uric acid is a waste product typically removed from the body in urine.
“You might have too much uric acid because your body either overproduces it, or because your body has trouble removing it,” Dr. Snyder says. “The uric acid causes gout crystals in the joints, which leads to the acute gout symptoms of pain and swelling.”
Your body’s reaction to uric acid may be genetic; if you have a family member with gout, you’re more likely to also have gout.
Kidney disease may affect your ability to process uric acid and increase your risk for gout. Some medications, including diuretics and beta blockers used for high blood pressure, can increase uric acid.
Obesity is a risk factor for gout and diet can affect your levels of uric acid. Red meat, seafood, alcohol, gravies, and food and drinks high in sugar or high fructose corn syrup can increase your body’s uric acid; they contain chemical compounds called purines, and when your body breaks them down, uric acid is a byproduct. Because of this association with a rich diet, gout was once considered “the disease of kings,” but Dr. Snyder says this perception is unfair and may keep people from getting help.
“Gout gets a bad rap because some will point the finger at too much red meat or alcohol and just think that your lifestyle is terrible, so people in pain will feel a degree of guilt,” Dr. Snyder says. “I want to eliminate that stigma for patients. A lot of people experience gout for different reasons. It’s a challenging and painful disease, but we can manage it.”
Managing Gout
The management of gout includes treating the acute flares when they occur and preventing future flares by lowering the amount of uric acid in the blood.
To treat acute flares, your doctor might start with an over-the-counter nonsteroidal anti-inflammatory drug, or NSAID, such as ibuprofen, or they may prescribe a medication called colchicine, Dr. Snyder says. These medications calm inflammation to reduce pain. Less commonly, doctors prescribe a corticosteroid such as prednisone, which also calms inflammation but comes with more side effects than the other options.
“The pain is at its worst for the first four to 12 hours, and it eases over three to four days,” Dr. Snyder says. “Most flares completely resolve in five to seven days, but they can last longer for some patients who have had gout for a long time.”
Even if you manage a gout flare with over-the-counter medications, you still need to talk to your primary care provider about long-term management for this form of arthritis. Without taking steps to manage uric acid, you will likely begin experiencing more frequent flares. When joints are repeatedly inflamed and swollen, it can lead to joint damage and chronic pain. Sometimes, flares lead to tophi, or large bumps that form over the joints; left untreated, tophi can make it difficult to use the joint.
To prevent future flares, your doctor likely will prescribe allopurinol or febuxostat, medications that lower the amount of uric acid in the blood. Your doctor may also recommend making diet and lifestyle modifications.
“Weight loss can help, and we counsel people to avoid foods high in purines, like shellfish, red meat, organ meat and alcohol, especially beer,” Dr. Snyder says. “Low-fat dairy can lower uric acid. It’s good to eat a balanced diet with everything in moderation.”
But lifestyle changes alone can’t prevent the need for medication.
“Most people will need a medication that lowers uric acid, even with diet and exercise,” Dr. Snyder says. “You can also have the best management—medication and a moderate diet—and still have a flare. That’s not a failure, so don’t feel guilty.”
If you continue to have flares despite medication, your primary care provider might refer you to a rheumatologist.
“It’s a chronic disease, so it’s not curable, but it is manageable,” Dr. Snyder says. “We focus on helping patients enjoy the activities they want to do and live the life they want without the devastating pain.”
Have you experienced a gout flare? Talk to your doctor. If you need a doctor, find one near you.