Treatment of acute attacks
One treatment for active gout flares is colchicine. This medicine can be effective if given early in the attack. However, colchicine can cause nausea, vomiting, diarrhea and other side effects. Side effects may be less frequent with low doses. Patients with kidney or liver disease, or who take drugs that interact (interfere) with colchicine, must take lower doses or use other medicines. Colchicine also has an important role in preventing gout attacks (see below).
Nonsteroidal anti‐inflammatory drugs – commonly called NSAIDs – are aspirin‐like medications that can decrease inflammation and pain in joints and other tissues. NSAIDs, such as indomethacin (Indocin) and naproxen (Naprosyn), have become the treatment choice for most acute attacks of gout. There is no proof that any one NSAID is better than others. High doses of short‐acting NSAIDs give the fastest relief of symptoms. These medicines may cause stomach upset, ulcers or diarrhea, but they are well tolerated by most people when used for the short term. Some people cannot take NSAIDs because of health conditions such as ulcer disease or impaired kidney function or the use of blood thinners. The fact sheet on NSAIDs lists the types of patients who cannot take NSAIDs.
In patients with chronic undertreated gout, crystals can be found in uric acid deposits (called tophi) that can damage joints & can appear under the skin. Corticosteroids, such as prednisone, methylprednisolone, and triamcinolone, are useful options for patients who cannot take NSAIDs. Given orally (by mouth) or by injection (shot) into the muscle or affected joint, these medicines can be very effective in treating gout attacks. If only one or two joints are involved, your doctor can inject a corticosteroid directly into your joint.
Health care providers may prescribe a short treatment course of anakinra (Kineret), a biologic drug that is an interleukin 1 beta antagonist. Though this rheumatoid arthritis drug is not approved by the Food and Drug Administration (FDA) for gout treatment, it can quickly relieve gout symptoms for some patients.
Some home remedies may help ease gout pain and reduce flares. Cherry products such as whole cherries or unsweetened cherry juice may reduce gout flares. A glass of skim milk daily may also help to lower uric acid over time. During an attack, rest the affected joint and apply ice packs or cold compresses (cloths soaked in ice water and wrung out) to that spot.
Treatment to remove excess uric acid
Patients who have repeated gout flares, abnormally high levels of blood uric acid, or tophi or kidney stones should strongly consider medicines to lower blood uric acid levels. These medications do not help the painful flares of acute gout, so most patients should start taking them after acute attacks subside. The drug most often used to return blood levels of uric acid to normal is allopurinol (Lopurin, Zyloprim). It blocks production of uric acid. Febuxostat (Uloric), a newer drug, also blocks uric acid.
Probenecid (Benemid) and Lesinurad (Zurampic) help the kidneys remove uric acid. Only patients with good kidney function who do not overproduce uric acid should take these therapies.
Pegloticase (Krystexxa) is given by injection and breaks down uric acid. This drug is for patients who do not respond to other treatments or cannot tolerate them. New drugs to lower uric acid levels and to treat gout inflammation are under development.
Gout flares often can occur when you first start to use medications that lower blood uric acid levels. Patients can help prevent flares when starting these medications by also using low‐dose colchicine or NSAIDs. Often, doctors advise patients to keep taking colchicine in a low, preventive dose together with the uric acid-lowering medicine for at least six months.
If you are taking a uric acid-lowering drug, your doctor should slowly raise the dose and keep checking your blood uric acid levels. Once your uric acid levels drop below 6 mg/dL (normal), crystals tend to dissolve and new deposits of crystals can be prevented. You probably will have to stay on this medicine long term to prevent gout attacks.
What works well for one person may not work as well for another. Therefore, decisions about when to start treatment and what drugs to use should be tailored for each patient. Treatment choices depend on kidney function, other health problems, personal preferences and other factors.
What you eat can increase uric acid levels. Limit the amount of high-fructose drinks, such as non-diet soda. Excess alcohol, especially beer, can trigger gout. Cut back on alcohol drinking. Restrict eating foods that are rich in purines, compounds that break down into uric acid. These compounds are high in meat and certain types of seafood. New research has found purines in vegetables appear to be safe. Low‐fat dairy products may help lower uric acid levels.
In almost all cases, it is possible to successfully treat gout and bring a gradual end to attacks. Treatment also can decrease the number and size of tophi (deposits of uric acid crystals).