Gout is a disease that can be effectively treated and managed. Prompt diagnosis and initiation of treatment can, in most cases, alleviate your acute gout symptoms: pain, swelling and inflammation in the affected joint. You may start to feel better quickly, even within a day or two. You may be able to quickly return to work and other daily activities. Controlling those acute symptoms is the first, immediate goal for gout treatment.
What about after that? Once you get the acute, painful attack under control, don’t consider gout to be out of sight, out of mind. Your doctor can prescribe treatments for you with these long-term goals in mind:
- Prevent future gout attacks of pain and inflammation
- Prevent tophi from developing, as these could damage your joint
- Lowering your uric acid levels and controlling hyperuricemia over the long term to prevent not just gout, but also kidney problems such as kidney stones
- Addressing any lifestyle factors, like diet, obesity or alcohol consumption, that may contribute to high uric acid levels and/or gout
Treatments for Acute Gout Flares
Your first warning sign that you have gout is likely a sudden, acute flare of gouty arthritis. This is also called synovitis. It’s the inflammation of tissue in your joint caused when your body’s immune system triggers white blood cells to attack the crystals that have settled in your joint.
The first, immediate step in your treatment plan is to treat that inflammation. This should quickly ease your symptoms. Current treatment guidelines for gout suggest that your doctor prescribe treatment to control your inflammation within 24 hours if possible. So don’t delay contacting your doctor’s office when you have signs of a gout attack! Toughing it out is generally a very bad strategy for managing gout, since this gives more time for the inflammatory process to build up a head of steam. It is also a good idea to keep a supply of anti- inflammatory medications at home for immediate treatment.
Medications used to treat inflammation in an acute gout flare include:
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Corticosteroids (also called glucocorticoids or “steroids” for short) by mouth, by intramuscular injection or injected directly into a joint
- Oral colchicine
If your gout attack is limited to one or two joints, and your pain is mild to moderate, you may only need one of these medications to control the inflammation. However, if your pain is severe, and if one or more of your larger joints (not just a toe) are involved, you may need a combination of treatments to get it under control.
Also, if one drug doesn’t work well enough to treat your gout attack symptoms, your doctor may either switch you to a different medication or try a combination of medications. There are several options for treating gout attacks, so your doctor will decide which one is best for you. An inadequate response to your first medication is:
- About less than 20 percent improvement in your pain (measured and scored on a standard questionnaire) within 24 hours, or
- Less than 50 percent improvement in your pain after 24 hours or later.
Colchicine (Colcrys® or Mitigare®) is a prescription, oral anti-inflammatory medication that’s prescribed to treat gout and other types of crystal-related arthritis. There are some unusual conditions that colchicine also treats, but it’s not an anti-inflammatory medication that works for things like headaches or joint injury. Colchicine may be the first choice to treat your acute gout flare and ease your symptoms if it’s within 36 hours of the onset of your symptoms.
Colchicine may also be prescribed at lower doses as a preventive medicine to reduce your likelihood of a future flare. This lower-dose strategy is often used during the first six months of treatment with a medication that lowers the urate level, when we know that “mobilization flares” are common and a person can actually have more gout flares than previously thought. Colchicine does not lower the urate level in the body, so it really isn’t a long-term solution to gouty arthritis.
Nonsteroidal anti-inflammatory drugs, or NSAIDs, are the most commonly used treatments for inflammation and pain in conditions like gout or other types of arthritis. NSAIDs are generally safe to use for acute flares of pain and inflammation. For a gout attack, you may need a short-term, high-dose prescription NSAID.
It’s not ideal to take NSAIDs regularly for pain that persists, as they can cause serious side effects, including ulcers, diarrhea or stomach pain.
Common NSAIDs your doctor may prescribe for gout attacks and symptom relief:
- Indomethacin (Indocin®)
- Naproxen (Naprosyn®)
- Sulindac (Clinoril®)
- Naproxen sodium (Aleve®)
- Celecoxib (Celebrex®)
- Ibuprofen (Advil®, Motrin®)
- Diclofenac sodium (Voltaren®) u Ketoprofen (Actron®, Orudis®)
- Piroxicam (Feldene®)
- Meloxicam (Mobic®)
Corticosteroids are also called glucocorticoids or “steroids” for short. They may be a good choice to treat your acute gout symptoms if you can’t take NSAIDs for any reason. Corticosteroids for gout treatment may be oral (pills you swallow) or injected (into a muscle or into the affected joint). Prednisone, methylprednisolone and triamcinolone acetonide are corticosteroids used to treat gout.
Corticotropin or Adrenocorticotrophic Hormone (Acthar®, H.P. Acthar Gel®)
Another possible first-line therapy for an acute gout attack is adrenocorticotropic hormone, or corticotropin or ACTH (Acthar®, H.P. Acthar Gel®). It’s not a common first-line treatment for a gout attack, but it’s a possible option for some people, particularly those who cannot take oral NSAIDs, colchicine or corticosteroids for some reason, or who are hospitalized.
Acute Gout Flares: What Else You Can Do
While your prescription gout medication should quickly treat your joint pain, swelling and redness, there are things you can do on your own in addition to taking your medicine:
Ice it. Treat your swollen joint with topical ice for a short period of time (no more than 10 minutes at one time) if you need a little extra relief. Ice can ease pain and swelling. Wrap ice or an ice pack in a soft towel or cloth before placing it on your skin. Don’t place ice directly onto your joint, even if it’s inside a plastic bag.
Elevate it. If your big toe or foot is affected, prop it up on pillows while you rest on the sofa. Keep your joint elevated above the level of your heart for the best effect.
Give it a rest. It’s OK to take it easy for a day or two while your symptoms are at their worst. Rest if you can. Try not to use your affected joint until your medications can reduce the inflammation. Gout flares often get worse if you try to ignore them and stress your affected joint.
Treatments for Hyperuricemia
As we mentioned, once your acute gout flare is treated, your doctor will work with you to try to prevent recurrent attacks or the development of tophi, and to lower your urate levels. As we mentioned, many people with gout take colchicine to prevent gout flares.
However, colchicine does not lower your urate.
Not everyone who has one gout flare or receives a gout diagnosis needs to go on long-term medications to manage their gout. In some cases, you may be able to take a short-term treatment for your one gout attack to get the inflammation under control, and make changes to your diet and lifestyle that help you manage your uric acid levels and prevent future attacks. However, if the flares become more frequent, you will likely need to add a medication to control your urate levels.
People who have the following concerns may need to take medications to control their hyperuricemia and gout:
- If you have two or more gout flares each year
- If your gout flares are so severe that you’re not able to work or perform your daily tasks – if so, you may not need to wait until two attacks in a year.
- If your doctor determines that you have damaged your joint(s) on X-ray or other imaging study due to gouty arthritis
- If you have tophi, or the hardened, lumpy uric acid crystals that can damage joints
- If you have kidney damage, kidney stones, or if you excrete high amounts of uric acid in your urine. The American College of Rheumatology recommends medication to lower urate levels after one flare of gout, if the person has abnormal kidney function.
High uric acid or hyperuricemia is what causes gout, and there are several medications used to help you lower these “serum urate” levels. This is also called urate-lowering therapy (ULT). There are two kinds of medications that your doctor can prescribe to try to keep your uric acid at a healthy level:
- Xanthine oxidase inhibitors (XOIs): These drugs are used to lower the uric acid in your blood.
- Uricosuric agents: These drugs work to help your kidneys more efficiently filter out uric acid.
- Enzymes that break down uric acid: This is very effective, but presently available only as an intravenous treatment to be used when other ways to lower urate are unsuccessful or inappropriate.
Treating Gout to Target: Your doctor and you will work as partners in an effort to reach a “target” goal for your serum urate or uric acid levels. Your doctor will create and, if necessary, adjust your treatment plan to reach this target and keep you there. You can take an active part in this effort by taking your medications as prescribed, and following whatever lifestyle recommendations your doctor suggests.
For long-term gout management, your goal is to lower your serum urate level to less than 6 mg/dL at minimum. Some people may need to lower their level to less than 5 mg/dL to control their gout (this lower goal is generally for people with tophi, the “lumps” of urate that can be felt on the body). Make sure you know your goal urate level, and work with your doctor to get there!
What happens if one urate-lowering medication doesn’t work well enough for you? Your doctor can assess your progress, and if one drug isn’t working, you can either increase the dosage, switch to a different medication, or add a uricosuric agent to help your kidneys work more effectively to filter out uric acid, so you can excrete it when you urinate.
These drugs may take many months to achieve full effect and control your gout. So you may have gout attacks during that time. To treat these acute attacks, your doctor can prescribe colchicine or NSAIDs or corticosteroids to take short-term. Don’t stop taking your XOI or uricosoric drug if you have a gout flare. Talk with your doctor to get treatment for the inflammation and ease your pain. When you first start a medication to lower your uric acid, it’s good to plan ahead for possible flares of gout with your doctor. Know ahead of time what medication you should take if a flare occurs. Have that medication with you when you travel and be ready to start quickly if a flare occurs. Rapidly treated gout flares often resolve quickly, while those given time to build up a full level of inflammation can take much longer to get better (and require a lot more medication).
Allopurinol (Aloprim®, Lopurim® and Zyloprim®) is a drug used to treat gout, lower uric acid levels in your blood, and also to prevent kidney stones. It’s one of the recommended, first-line urate-lowering therapies to help you manage your gout. Allopurinol prevents gout flares, but doesn’t treat the symptoms of the flare.
Febuxostat (Uloric®) is another, newer xanthine oxidase inhibitor (XOI). It’s used to manage your gout by lowering levels of uric acid. It can prevent gout attacks but not treat an active gout attack or its symptoms.
If your xanthine oxidase inhibitor (XOI) medication does not work well enough for you—to help you achieve a serum urate level of 6 mg/dL or below, your doctor may wish to either increase your dosage or combine your XOI with a uricosuric agent. These drugs are used to help your kidneys flush out or filter out uric acid more effectively.
Probenecid (Benemid®, Probalan®) is a uricosuric agent or drug to treat and manage hyperuricemia. If you can’t take XOIs for any reason or don’t tolerate them well (if they cause severe side effects, for example), it may be an alternative first-line gout management treatment for you. Or, your doctor may prescribe it to you along with an XOI if that drug doesn’t work well enough for you to achieve your serum urate target. Most commonly, probenecid is used as an “add-on” medication to an XOI, such as allopurinol or febuxostat.
Lesinurad (Zurampic®) is another urate-lowering therapy that your doctor may add to yourxanthine oxidase inhibitor (XOI) to help you get your uric acid to a healthy level to prevent gout attacks. Lesinurad is also available in a pill where it’s already combined with allopurinol (Duzallo®).
Pegloticase (Krystexxa®) is a newer medicine. It is an enzyme that rapidly converts uric acid in the blood into a substance easily eliminated by the kidneys, thus lowering the amount of uric acid in your system. Your doctor may prescribe pegloticase if you have uncontrolled gout symptoms and other urate-lowering therapies don’t work well for you or you can’t tolrate them for any reason. Pegloticase is also used in gout patients with visible tophi, since it is the only medication that has been shown to shrink tophi in just months for many patients. Pegloticase will generally not be the first treatment your doctor will prescribe for gout
Off-Label Gout Treatments: Anakinra and Canakinumab
Anakinra (Kineret®) and canakinumab (Ilaris®) are being used by some rheumatologists as an “off label” treatment for severe gout attacks. Anakinra and canakinumab are both interleukin-1 beta antagonists. They are used to treat some forms of inflammatory arthritis. While they are approved by the FDA for use in other types of arthritis, such as rheumatoid arthritis, anti-IL-1 beta drugs are not specifically indicated or approved to treat gout.
What does off label really mean? It means that anakinra and canakinumab have been approved as safe and effective treatments for several conditions, but that the clinical trials necessary to ensure their safety and efficacy for use as gout treatments are not yet sufficient to achieve this “indication” by the FDA. That may happen in the future, as studies of anakinra and canakinumab in gout are ongoing. It’s up to your doctor and you to decide if anakinra, canakinumab or any other off-label treatment is a good option for you.
At this time, anakinra (Kineret®) and canakinumab (Ilaris®) may be prescribed off label for very severe gout attacks. This is not a urate-lowering therapy. They are designed to interrupt the inflammatory process involved in a severe gout attack and treat the attack. These drugs are also called biologics. They lower your immune system’s processes in order to stop inflammation. They may work well for severe gout, but they also lower your body’s ability to fight off infections. So your doctor will have to explain the balance of risks versus benefits of using this type of drug for gout.
Your doctor will not likely prescribe either anakinra (Kineret®) and canakinumab (Ilaris®) as a first-line treatment for gout flares unless you have very severe attacks. These are options for patients for whom other treatments do not work, who cannot tolerate any of the other treatments, or who have very severe gout.
Surgery for Gout
It’s a good idea to consult your primary care physician early, when you first experience a gout attack. If you start medications and lifestyle changes early, you’re more likely to control your gout, treat your hyperuricemia, and prevent additional gout attacks. However, some people do not respond well to treatment, or delay their treatment for various reasons. Their gout may progress to gouty arthritis. They may develop tophi in one or more joints. This can cause damage to the joint.
In those severe cases, surgery may be necessary. Surgery is not a first-line treatment for any joint affected by gout. Surgery is only used for situations when someone has advanced gout and tophi that have led to destructive arthritis. If you haven’t sought medical care or therapy for gout until now, and your pain and joint deformity have progressed so far that you cannot use your joints, your doctor may refer you to an orthopedic surgeon for treatment. It is important to note that aggressive treatment of the urate level can be quite effective, over time, in shrinking tophi. Therefore, surgical removal of tophi may only be necessary in special circumstances.
Surgery for gout-related joint damage may include:
- Your surgeon can remove tophi nodules that have inflamed or damaged toes or fingers, or even your bursae or tendon sheaths. Tophi could become infected in some cases, so they may need to be removed.
- Joint fusion can fuse together two small joints if one joint is badly damaged by gouty arthritis. This procedure does limit the movement of the fused joints, but it can ease the severe pain caused by the damage. It’s very rare that people with gout need this type of surgery.
- Joint replacement or arthroplasty may be used to replace a damaged joint, usually a knee, that’s severely damaged from gout.