Gout

Treating the pain and inflammation of attacks

Once an attack of gout has started, it usually gets better with time – even without treatment – over a few days or weeks. Doctors think that this happens because the cells of the immune system stop reacting to the uric acid crystals, which means that the inflammation gets better*.

Most people need treatment to reduce the pain and inflammation caused by attacks. People who only have occasional attacks, for example every few years, may only need treatment to deal with these attacks. People who have more frequent attacks may need daily medication to reduce the amount of uric acid (urate) in their blood and prevent further attacks or joint damage (see ‘Long-term treatment to lower uric acid and prevent attacks and long-term problems’).

A consultant rheumatologist explains how gout should be treated.

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Gout is usually treated in two phases; the first phase is the treatment of the attack itself, and then the second phase relates to longer term management. The aim of treating an acute attack of gout is to provide rapid relief from the very intense pain and inflammation which people get. And the most commonly used drugs to do this are either anti-inflammatory drugs, or colchicine. And these drugs are usually taken until the pain and inflammation have settled down.

Long-term treatment of gout aims to reduce uric acid levels. The reason for this is that we know that if we can reduce uric acid levels, we can stop acute attacks of gout from happening. We can prevent joint damage from happening in the long term, and we can also cause tophi - which are the deposits of uric acid sometimes found under the skin - we can cause those to shrink and eventually go away. If gout is only treated by treating symptoms that occur during the attack of gout, then we don’t get rid of the crystals and hence those crystals can still go on to cause long term problems.

Most people find that the earlier they recognise the onset of an attack and take their medication, the better it works for them. People we talked to found it useful to keep a supply of medication, prescribed by their GP, at home so that they could take it as soon as they noticed the first signs of an attack.

Alan found it hard to visit his GP during an attack because of the severe pain. He has now been prescribed tablets to keep at home in case he needs them.

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Age at interview: 73

Sex: Male

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Alan: It starts off with a twinge, but basically, within a day it is very difficult to actually walk, you know, the only way you can really walk is with a walking stick so that you don’t actually put any weight on the foot and it’s nearly always the left foot, it’s very occasionally the right but; and the other thing of course, it is very, very painful, it’s, you know, it’s there throbbing and hurting the whole time, but it tends to go after what, well, it will take a week if I don’t take any tablets, but if I take the three a day tablets, basically it’s gone in about three days, but whilst it’s there, it does curtail a lot of what you can do and I mean one of the most ironic things about it is, when it comes, in order to get the tablets, you can’t just, you’ve got to do the physical effort of getting all the way to the Doctor’s surgery in order for him just to go, “Yes is it gout, yes” and write the - whereas you say, “Well I knew that to start with [laughs], couldn’t you have just written a prescription and given it to me?” but, no they won’t do it, but I have got them to actually now, they give me more than the prescribed amount, they tend to give me 100 which tend to last a couple of years, which is very useful to be honest [laughs] otherwise you keep having to go up there.

People we talked to had different preferences for the tablets they took to treat the pain and inflammation of attacks. Some found that one drug worked better for them than another. Others could not take certain medication because of the side effects or because they had other health issues such as kidney or heart problems (see ‘Side effects of gout medication’ and ‘Living with gout and other conditions’).

Eddie has tried various treatments for his attacks. He prefers to take paracetamol with codeine and ibuprofen because he did not like the side effects of other medication.

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I will take, paracetamol, paracetamol and codeine, colchicine, and they gave me the liquid morphine, that type of thing. But I don’t normally take much only sort of codeine and paracetamol now because the, I found the others can upset me and it upsets me more than it does any good in my mind so I don’t take it any more like that no just the paracetamol, paracetamol codeine mostly and ibuprofen, that’s what I take, yeah.

Is that ibuprofen?

Ibuprofen yeah I take that only when the gout attacks yeah, don’t take it otherwise.

And so you mentioned sort of having some side effects from some of the painkillers, you said they upset you, what kind of …?

The colchicine, when they gave it to me in hospital when I had my heart attack and I didn’t realise what it was, I knew it was a painkiller for gout because they told me, but it upset my tummy, it gave me tremendous diarrhoea and sickness, and I swore blind I would never take it again. And I have heard other people, it affects them like it, there are some who take a low dose and they find it helps but I don’t, no, and it’s like liquid morphine I had a really bad attack and I think doctor had got to the stage where you know he was giving me one of the most powerful ones he could, and I took that. It was such bad pain I think I overtook it, I’ve got to be a bit careful, and it did make me, gave me sickness, and also I was a little bit with the fairies you know, I was walking around not quite knowing where I was, yeah [laughter].

Two of the most common treatments for attacks are non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine. Steroids (tablets or injections) can also be prescribed. Some people chose to take other painkillers, such as paracetamol or co-codamol (paracetamol and codeine), but others found these were ineffective. People we talked to also found ice packs useful for pain relief.

Non-steroidal anti-inflammatories (NSAIDs)

Non-steroidal anti-inflammatory drugs (NSAIDs) are used to relieve pain and inflammation. Examples of these drugs include ibuprofen, naproxen, diclofenac, indometacin (indomethacin) and etoricoxib (Arcoxia).

Ibuprofen can be bought over the counter in a pharmacy, but a doctor can prescribe other drugs and stronger doses.

Aspirin is not recommended for treating gout, but people who are taking low daily doses (75mg) to prevent heart attacks should continue taking it as usual.

NSAIDs can cause problems such as stomach upsets, indigestion or damage to the lining of the stomach. Drugs that help to protect the stomach can be prescribed to prevent these problems (e.g. omeprazole and lansoprazole). Arthrotec tablets contain an NSAID diclofenac and misoprostol, which prevents the side effects of diclofenac.

Vic tried colchicine and various NSAIDs but they gave him digestive problems. He was then prescribed Arthrotec.

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Age at interview: 75

Sex: Male

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It went on for some time, taking colchicine when it was really bad, but unfortunately the side effects of colchicine are even worse, in that vomiting and diarrhoea is the point at which you stop taking the medication.

I’d started to take NSAIDs after that, because once the major problem’s gone it’s still painful for some time afterwards, but they gave me digestive problems. Eventually, we settled on a drug called Arthrotec, which is an NSAID, but it’s also got a gastric element to it, so you can take it and it doesn’t give you the side effects.

Most people were cautious about the way they took NSAIDs because they were aware of the possible side effects. Peter always takes them after food to avoid stomach problems. Other people made sure that they only took a short course of tablets.

NSAIDs slightly increase the risk of heart attacks and strokes. This means that these drugs should be used with caution in people who might be at higher risk, for example because of high blood pressure, high cholesterol, diabetes or smoking. NSAIDs are not advised for people with heart or kidney failure.

Colchicine

Colchicine helps reduce the inflammation caused by uric acid crystals in and around joints. In the UK it cannot be bought over the counter but only with a prescription.

Common side effects of colchicine are nausea and/or vomiting and diarrhoea. Most people who took high doses had these side effects. Lower doses are effective and less likely to cause side effects (for more see ‘Side effects of gout medication’).

For Alastair, the thought of an attack without medication is ‘horrendous’. Colchicine has usually improved his symptoms within six hours.

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I mean I can’t imagine what it must be like to have to endure it without medication, because the medication, it works so quickly, you know. I mean it’s probably – it’s hours. I mean it works with me, I would say within a matter of five or six hours max. So, you know, now when – well, if I were to have another attack, I would just hightail it to the doctors and get the medication. The thought of enduring it without medication is horrendous, you know. I mean it’s on a par, I would suggest, with a fracture. And, you know, I’ve broken my leg and I know what that feels like, you can’t sleep. Well, it certainly prevented me from sleeping, which is like my litmus test. You know, if it’s stopping you sleeping then it’s serious, you know.

Steroids

Steroids are usually only prescribed if NSAIDs and colchicine are not effective in treating an attack, or if these drugs are unsuitable for a particular person. Steroids can be prescribed as an injection into the joint or muscle, or as a course of tablets (usually prednisolone).

Paula was prescribed steroids. She did not know what to expect but was impressed with how quickly they reduced the inflammation and pain.

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Age at interview: 46

Sex: Female

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Well, I’d never had steroids before in my life, so I wasn’t quite sure what to expect. I mean they said that it was to manage the pain. I’d have taken anything they gave me because the pain was so bad. But I was quite impressed, because they did work very quickly for me. They took the inflammation down in my feet, in my foot, you know, within about two days the pain had gone.

How quickly did you notice that they were having an effect?

I think about 12 hours after I’d started them I was in – that the pain started to subside.

Ice packs

An ice pack on the affected joint can reduce swelling, heat and pain. Ice packs can be used in addition to any of the medications for gout. It is best to protect the skin from direct contact with the ice (e.g. by wrapping an ice pack in a towel). Many people we spoke to found ice packs helpful in relieving symptoms during an attack.

Ian learnt to recognise the first signs of an attack. He used ice to cool his joint and found that moving around was helpful.

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I think you soon get to realise after your first couple of attacks, you know exactly when you get - start getting the dull feeling, you know you're going to get an attack, well I can only speak from my experience, but yes, you know that, you start getting a dullness and a lack of mobility around a particular joint, and then the dullness starts and then it gets more acute, so you definitely start to recognise that, you know about it. I was never recommended to put ice around it but that’s what I did myself because it felt quite hot and whatever and quite red so I'm a great believer in putting ice on many an injury, so I tried it on gout and it - it did make a - make an impact on it, it did reduce down the - the pain and it made - gave me greater mobility quicker, so I would recommend people trying that as well, so that's what I did learn through experience. They were the two things really I did - probably the third thing was you know you'd rest and put your leg up, particularly if it was obviously in your foot and things like that, but I - as you get used to getting the attacks you just sort of get on and get up with it, you don’t stay at home feeling sorry for yourself, you get on, carry on with your normal day, because I think it does wear off. If you stay immobile and - and just - with your foot in the air or whatever, or lying on the settee - I think you'll have it for longer than if you get up and move around.

(For more see ‘Decisions and feelings about treatments’).

*Mechanisms of inflammation in gout. Dalbeth N, Haskard DO. Rheumatology (Oxford). 2005 Sep;44(9):1090-6.

Last reviewed December 2016
Last updated Decemeber 2016