Gout treatments can be divided into broadly two groups: medicines to treat the symptoms of an acute gout attack (or flare) – and those that prevent further attacks, generally known as urate-lowering therapies (ULT).

NSAIDs

Non-steroidal anti-inflammatory drugs (NSAIDs), such as diclofenac, naproxen, or ibuprofen, are commonly used to ease pain, redness, and swelling during a gout flare. They are effective and steroid-free; however, they can have side effects, including indigestion, nausea, diarrhoea, or stomach ulcers. In rare cases, NSAIDs can affect your liver, kidneys, or heart. For these reasons, it is important to speak to your GP before starting an NSAID for gout attacks. Your GP might suggest a proton pump inhibitor (e.g. omeprazole) to protect your stomach. It is also important to take NSAIDs with food. Let your GP know if you experience any side effects.

Avoid aspirin for gout, as it can raise uric acid levels. However, low-dose aspirin (75mg daily) prescribed to prevent heart attacks is generally safe to continue.

Colchicine

Colchicine is another common treatment for acute gout attacks – and is now often used as first- line treatment. It is generally taken for 3 to 5 days but may be extended, if needed, on the advice of your doctor. It is very important not to take colchicine at higher doses than you have been prescribed.

Side effects with colchicine can include nausea or diarrhoea, which may be eased by lowering the dose. Let your GP know if you experience any side effects. Avoid grapefruit and grapefruit juice while using it, as they can increase colchicine levels in your body. Colchicine can interact with some other medications (e.g. certain antibiotics), and so it is important that this is reviewed by your doctor before you are started on colchicine.

Corticosteroids

Corticosteroids can also be prescribed for gout attacks, particularly if NSAIDs or colchicine aren’t suitable or effective. Corticosteroids can be given as an injection into the affected joint, into a muscle, or as a short course of oral treatment (usually prednisolone). Short-term side effects might include trouble sleeping or stomach irritation, but long-term use is avoided due to risks like weight gain, high blood pressure, and osteoporosis (thinning of the bone).

In some people with bad gout flares that have not got better with first-line treatment, your doctor may combine treatments, such as corticosteroids with colchicine.

Other options for managing gout flares

As well as medications, there are other things that you can do to try and alleviate pain and swelling during gout attacks. Applying ice packs to the affected joint(s), as well as resting the affected joint, can help, in addition to taking your prescribed medicine.

In people with gout, preventative medications (known as urate-lowering therapy or ULT) are very important for preventing future attacks of gout, as well as complications such as joint damage and kidney disease. They do this by lowering the level of uric acid (urate) in your blood, which stops new crystals forming and help to dissolve existing crystals.

ULTs work by either:

• reducing the production of uric acid or
• increasing its removal via the kidneys and into your urine.

Unlike acute flare treatments (e.g. NSAIDs and colchicine), preventative ULT medicines must be taken every day to prevent gout attacks. You should continue them even when you experience a gout attack.

All people diagnosed with gout should have ULT medications discussed with them. If you are not on a ULT medicine or would like further information about starting them, then it is important to see your doctor. ULT medicines are particularly important for individuals with recurrent gout attacks, joint damage or complications (such as kidney disease), as these individuals are at greatest risk of long-term problems from their gout.

Once started, your doctor should adjust the dose of your ULT drug until your blood urate levels have fallen below a target level. In most people, this target level is below 360 micromol/litre (6 mg/dl). In some individuals with severe gout (e.g. recurrent attacks or tophi under the skin), a lower target urate level is recommended (below 300 micromol/litre or 5 mg/dl).

Treatment with ULT medicines is usually started 2–4 weeks after a gout flare has settled. However, if attacks are more frequent or troublesome, ULT may be started during a flare.

ULT drugs that reduce the production of uric acid

For long-term control of gout, uric acid levels can be reduced by inhibiting an enzyme called xanthine oxidase, which is involved in the production or uric acid in the body. Xanthine oxidase inhibitor drugs include allopurinol and febuxostat. Both medicines are very effective at preventing the symptoms and complications of gout when taken long-term at the correct dose. NB: Allopurinol should be prescribed instead of febuxostat for patients with gout and significant heart conditions, such as unstable angina, or a history of heart attack or stroke.

Xanthine oxidase drugs are often very well tolerated. The most important side effect to be aware of when starting them is a new skin rash. This can occur several weeks after the medication is started. It is rare but can be serious if not recognised. If you develop a new rash after starting allopurinol or febuxostat, speak to a doctor urgently.

ULT drugs that increase the removal of uric acid

Uricosuric drugs, such as benzbromarone, probenecid and sulfinpyrazone, help to reduce blood uric acid levels by increasing its removal through the kidneys. They are specialist-use medicines in the UK, and so must be prescribed under the supervision of a hospital specialist (usually a rheumatologist). They are typically used in people with gout who haven’t responded well enough, or been able to tolerate, allopurinol or febuxostat. Benzbromarone and probenecid are the most commonly prescribed uricosuric drugs in the UK, while sulfinpyrazone is no longer readily available. Uricosuric drugs are not recommended for people with kidney stones, and staying hydrated is important to prevent stones in people taking uricosuric drugs.

Managing flares when starting or increasing ULT drugs

When ULT drugs are started, or when the dose of ULT drugs is increased, they can sometimes trigger gout flares. This does not mean that the ULT drugs are not working. It takes time for ULT drugs to work and for blood uric acid targets to be reached, and so it is important to remain on them.

To help prevent flares when starting or increasing ULT drugs, your doctor may prescribe colchicine as a preventative tablet until you reach your target uric acid levels. This is often prescribed at a low dose for 3 to 6 months, depending on how severe your gout is. If colchicine isn’t suitable or effective, your GP might recommend a low-dose NSAID (e.g. ibuprofen), but this needs consideration of potential side effects.

While diet can play a role in managing gout, the evidence is clear that it only has a small effect on lowering uric acid levels in the blood. As such, most people with gout will require ULT drugs to reach their target uric acid levels and prevent the symptoms and complications of gout. A healthy lifestyle and diet are, however, very important for preventing many of the conditions that can co-exist with gout, such as diabetes, high blood pressure, and cardiovascular disease. See our information on gout and other health conditions. Weight loss if you are overweight or obese, regular exercise, reducing sugary drinks and alcohol, a healthy balanced diet, and stopping smoking can help to prevent these complications from arising or stop them from getting worse.

Various herbal remedies have been claimed to have a beneficial effect on gout, e.g. nettle leaves, devils claw, and a medicine called quercetin made from plant extracts. However, medical evidence to support their use is extremely limited and the strength and purity of these products may vary.  You should always consult your doctor before taking herbal medicines as they may interact with prescribed medicines that you are already taking. In addition, it may be helpful to speak to a trained therapist in complementary medicine before experimenting with such remedies. There is no evidence that CBD oil is specifically helpful for gout.

Gout is eminently treatable through long-term medications, such as allopurinol and febuxostat. Once you reach your target uric acid levels with these medications, tophi (deposits of urate crystal under the skin) will often gradually reduce over time. In severe cases, surgery to remove the tophi will sometimes be considered, although this needs to be balanced against potential complications and the likelihood of recurrence.