How gout presents
Acute gout flares are intensely painful, most commonly affecting the big toe (podagra), but also the midfoot, ankle, knee and wrist. The joint becomes hot, swollen and exquisitely tender, often waking patients at night. Flares typically reach peak intensity within 12–24 hours. Between flares, patients may be asymptomatic, but recurrent flares can lead to tophaceous deposits (urate crystal nodules), joint damage and renal complications if untreated.
Diagnosis can be confirmed by joint aspiration demonstrating negatively birefringent urate crystals under polarised light microscopy. In clinical practice, the combination of acute monoarthritis with hyperuricemia (serum urate above 6.8 mg/dL) is often sufficient for diagnosis. Imaging may show erosive changes in chronic gout.
- Acute monoarthritis — big toe (podagra), ankle, knee, wrist
- Intense pain, warmth, swelling — often wakes at night
- Recurrent flares — tophaceous deposits if untreated
- Hyperuricemia — serum urate above 6.8 mg/dL
- Joint aspiration — urate crystals under polarised light
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Treatment approach
Acute flares are treated with anti-inflammatory agents (colchicine, NSAIDs or corticosteroids) depending on comorbidities and timing from flare onset. Urate-lowering therapy (allopurinol, febuxostat) is initiated once acute flares have settled, with the goal of achieving a serum urate target below 6 mg/dL (or below 5 mg/dL in tophaceous gout) to prevent crystal deposition and allow existing deposits to dissolve.
Urate-lowering therapy requires gradual dose titration with monitoring of renal function and serum urate levels. Prophylactic colchicine or low-dose NSAIDs are used during the first 3–6 months to prevent flare recurrence during urate lowering. Patient education covers dietary modification (limiting high-purine foods, alcohol and sugary drinks), hydration, weight management and medication adherence.
- Acute treatment — colchicine, NSAIDs or corticosteroids
- Urate-lowering therapy — allopurinol, febuxostat
- Target serum urate below 6 mg/dL (below 5 mg/dL for tophaceous)
- Prophylactic therapy — colchicine during first 3–6 months
- Lifestyle — diet, hydration, weight management