Gout
Uric acid crystals in a joint, often the big toe, causing sudden, savage pain. Treat flares fast, then lower the uric acid so the crystals dissolve and attacks stop.
The gout ladder
Steps 1–3 put out the fire. Steps 4–6 stop the house being rebuilt out of matches. Most people with repeat attacks need both.
- Step 1 · Self-careRest, ice and elevate the jointCool pack wrapped in a cloth, foot up, and keep weight off it while it’s hot.
- Works
- Small extra pain relief in one tiny trial; won’t stop the flare on its own
- Cost
- Free
- How long
- Until the flare settles, usually days
- Watch for
- Fever, or a joint that’s hot and you feel unwell: that needs a same-day check.
Bedsheet touching your toe feels like assault? Build a tent with a box at the end of the bed.
- Step 2 · PharmacyAnti-inflammatory tablets (ibuprofen, naproxen)A full-strength short course, started at the first twinge.
- Works
- Pain falls by roughly two-thirds within 4 days in trials, about as well as colchicine or a steroid
- Cost
- About $5–15 a pack
- How long
- Usually 3–5 days
- Watch for
- Stomach upset or bleeding, kidney strain. Avoid with kidney disease, heart failure, stomach ulcers or blood thinners.
Start at the first twinge, not after a night of heroic suffering.
- Step 3 · PrescriptionColchicine (low dose) or a short course of prednisoloneFlare medicines for when anti-inflammatories aren’t safe or aren’t enough.
- Works
- Low-dose colchicine: about 4 in 10 get half their pain gone in 24 hours (vs 1.5 in 10 on a dummy treatment); all three work about equally
- Cost
- Under the $25 PBS co-payment
- How long
- Colchicine: 1 mg, then 0.5 mg an hour later, then stop. Prednisolone: about 5 days.
- Watch for
- Colchicine: diarrhoea, and it’s toxic in overdose or with some other medicines. Prednisolone: raised blood sugar, mood and sleep changes.
With colchicine, more is not better. More is just diarrhoea, or worse.
- Step 4 · PrescriptionAllopurinol, the urate-lowering tabletTaken every day to dissolve the crystals. For repeat attacks, lumps (tophi), kidney stones or kidney disease.
- Works
- Treated to target, about 1 in 12 had a flare in year 2 (vs 1 in 4 with usual care) in a UK trial
- Cost
- Under the $25 PBS co-payment, about $18–25 a script
- How long
- Long term. Start low, raise the dose every few weeks until a blood test shows urate below 0.36 mmol/L.
- Watch for
- Flares in the first months (a flare-preventer is usually given). Stop and seek help for any rash.
Don’t stop it during a flare. Stopping is how you get the next one.
- Step 5 · PrescriptionOther urate-lowering tablets (febuxostat, probenecid)For people who can’t take allopurinol or don’t reach target on it.
- Works
- About 8 in 10 reached target on either febuxostat or allopurinol in a large 2022 trial, with similar flare rates
- Cost
- $25 per script on the PBS ($7.70 concession), when eligible
- How long
- Long term, with regular blood tests
- Watch for
- Febuxostat: not for people with heart disease. Probenecid: kidney stones; drink plenty of water.
Plan B is perfectly respectable. No plan is not.
- Step 6 · SpecialistRheumatologistFor frequent flares despite treatment, big tophi, or kidney problems making medicines tricky.
- Works
- No trials of referral itself; helps get hard cases to target with combinations or specialist-only options
- Cost
- Specialist fees vary; Medicare rebates with a GP referral
- How long
- Until urate is controlled
- Watch for
- Bring your urate results and a list of every medicine you’ve tried.
Gout is very winnable. Sometimes you just need a bigger coach.
Save your money
Popular, heavily marketed or often asked about, but the evidence is weak or says no.
- Cherry juice or extractObservational studies hint at fewer flares, but there are no good trials. Tasty, pricey, unproven.
- Vitamin C supplementsLower uric acid by a trivial amount in trials, not enough to prevent flares. Allopurinol 1, oranges 0.
- Celery seed extractNo trials showing it lowers uric acid or prevents flares. A salad garnish in a capsule.
- Apple cider vinegarNo evidence for gout. Crystals don’t dissolve in salad dressing.
- A strict no-meat, no-seafood dietLowers uric acid only a little and is hard to stick to. Cut beer and sugary drinks first; medicine does the heavy lifting.
What you can do
- Keep a flare kit at home (what your GP has agreed on) and start it at the first twinge.
- Cut back on beer, spirits and sugary drinks. They push uric acid up more than steak ever will.
- Lose weight slowly if you’re above a healthy weight. Crash diets can trigger flares.
- Drink plenty of water, especially in hot weather.
- Ask about your other risks: blood pressure, kidneys, cholesterol and diabetes travel with gout.
See your GP if
- You’ve had more than one attack, or have lumps (tophi) on fingers, ears or elbows
- Flares aren’t settling within a few days of treatment
- You’re on allopurinol and still getting attacks: the dose may need raising
See a doctor the same day for a hot, swollen joint with fever or feeling unwell, a first attack in a joint that isn’t your big toe, or a red joint after surgery or a skin wound. Joint infection can look like gout and needs urgent treatment.
Common questions
What brings on a gout attack?
Uric acid crystals. Common triggers are alcohol (especially beer), sugary drinks, dehydration, big meals, illness, surgery and some medicines such as water tablets (diuretics).
Do I need to give up meat and seafood?
Not completely. Diet changes only lower uric acid a little. Cutting alcohol and sugary drinks and keeping a healthy weight matter more, and medicine does most of the heavy lifting.
Should I stop allopurinol during a flare?
No. Keep taking it and treat the flare separately. Stopping and starting can trigger more attacks.
Why was my uric acid normal during an attack?
Uric acid often drops during a flare, so a normal result then doesn’t rule out gout. It’s best rechecked a few weeks later.
Helpful resources
- Arthritis Australia: Gout information sheetPlain-English guide to flares and long-term prevention, plus the free Arthritis Infoline (1800 011 041). Free, Australia.
- Gout and diet information sheetArthritis Australia’s gout and diet sheet in English and 13 other languages. Free.
Evidence and more information
- Healthdirect: Gout
- Australian Prescriber: The management of gout
- NICE: Gout diagnosis and management (NG219)
- AAFP: Low-dose colchicine for gout flares (AGREE trial)
- Lancet (2018): Nurse-led treat-to-target gout care
- NEJM Evidence (2022): Allopurinol vs febuxostat (STOP Gout)
- Lancet (2008): Prednisolone vs naproxen for gout flares
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