What triggers a gout attack?

What happens during a gout attack?

Gout develops when uric acid levels in the blood are high for long enough for crystals to form in and around joints. An attack, or flare, occurs when the immune system reacts to these crystals, causing sudden, severe pain, swelling, redness and warmth, often starting at night.

The joint at the base of the big toe is most commonly affected, but gout can involve the ankle, knee, wrist, fingers and elbow. Without treatment, an attack usually settles over one to two weeks.

Does alcohol trigger gout attacks?

In an internet-based case-crossover study of 724 people with gout, there was a dose-response relationship between alcohol intake over the previous 24 hours and the risk of a recurrent attack 1. The risk was 1.36 times higher after more than one to two drinks and 1.51 times higher after more than two to four drinks, compared with no alcohol 1.

Wine, beer and spirits were each associated with increased risk 1. People with gout are advised to limit all types of alcohol.

Which foods can trigger gout?

Purines are substances broken down into uric acid. In a case-crossover study of 633 people with gout, the risk of an attack increased with total purine intake over the previous two days, with an odds ratio of 4.76 in the highest compared with the lowest intake group 2.

The effect was stronger for purines from animal sources, such as red meat, organ meats and some seafood, than from plant sources 2. Sugary drinks sweetened with fructose can also raise uric acid levels.

What other triggers are there?

Dehydration, sudden illness, surgery, injury to a joint, fasting or crash diets, and some medicines, such as certain diuretics, can trigger gout attacks. Starting urate-lowering treatment can also trigger attacks in the early months as uric acid levels change, which is why preventive medicine is often given at the same time.

Kidney disease, high blood pressure, obesity and diabetes are linked with gout and can affect uric acid levels.

How is a gout attack treated?

A guideline from the American College of Rheumatology strongly recommends colchicine, non-steroidal anti-inflammatory drugs or glucocorticoids, taken by mouth or given by injection, to treat gout flares 3. Treatment works better when started early in the attack.

Resting and raising the affected joint, applying ice packs wrapped in a cloth and avoiding pressure from bedclothes can ease symptoms.

How can future attacks be prevented?

The same guideline strongly recommends urate-lowering therapy for people with frequent flares, tophi (deposits of crystals under the skin) or joint damage from gout, with allopurinol as the preferred first-line medicine, started at a low dose and adjusted to reach a blood urate target below 6 mg/dl 3. UK guidance also covers offering urate-lowering therapy and lifestyle advice 4.

Limiting alcohol, reducing purine-rich foods and sugary drinks, staying hydrated, maintaining a healthy weight and reviewing medicines with a doctor support treatment. Diet alone is rarely enough to control gout.

How is gout diagnosed?

Gout is often suspected from a sudden, very painful, red and swollen joint, particularly at the base of the big toe. The most reliable way to confirm gout is to take fluid from the joint and look for urate crystals under a microscope, which also helps rule out infection.

Blood tests measure uric acid levels, although levels can be normal during an attack, so tests are often repeated later. Ultrasound or specialised scans may show crystal deposits in some cases.

When is a painful joint an emergency?

A hot, swollen joint with fever or feeling unwell may indicate joint infection, which can look like gout and needs urgent assessment.

Seek medical advice for a first suspected gout attack to confirm the diagnosis, and for attacks that do not settle with treatment.

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