Gout Attack: What to Do First
If a gout attack has just started, the most useful thing you can do is treat it in the first few hours rather than waiting to see how bad it gets. Get the joint up and still, put something cold on it, drink water, and take the treatment your doctor has already given you for this situation. What follows is organised by the clock, because with gout the timing matters more than the cleverness of the choice.
Read this first: a hot, red, swollen joint with a fever, shivering or feeling unwell all over can be a joint infection (septic arthritis), not gout. That is an emergency — an infected joint can be destroyed within days, and it looks almost identical to a severe flare. If you have a temperature, feel ill, or are not certain this is gout, seek urgent medical assessment today rather than self-treating.
The first hour: what actually changes the outcome
Acute gout is a chain reaction. Crystals that were sitting quietly in the joint get disturbed, immune cells arrive, and each hour recruits more of them. Treatment works by interrupting that chain, which is far easier at hour two than at hour twenty. Hence the pill-in-pocket approach: people who have had gout before are given medication to keep at home and told to start it at the first twinge, not once the joint is purple.
- Stop using the joint. Sit or lie down and get weight off it. Walking on an inflamed toe grinds the surfaces together and worsens the swelling.
- Elevate it above heart level if you can — pillows under the calf, heel hanging free so nothing presses on the toe.
- Apply cold. Frozen peas or an ice pack wrapped in a tea towel, twenty minutes on, then off until the skin is back to normal temperature. Never ice directly on skin.
- Drink water steadily. Dehydration is a common trigger. Hydration will not end the attack, but it removes one thing working against you.
- Take your prescribed attack treatment now, at the dose your prescriber specified.
If you already have a treatment plan
Most people who have had gout before have been given one of three things to start at the onset of a flare: an anti-inflammatory such as naproxen, colchicine, or a short course of steroid tablets. Which one is right depends on your kidneys, heart, stomach and other medicines — which is why it is a choice your doctor has already made for you rather than one to make from a website. Take it as instructed, and take it early. If the flare has not begun to settle after two or three days on your usual treatment, phone the surgery; that sometimes needs a different drug or a joint injection.
If this is your first attack, or you have nothing to take
Contact a doctor — same day if you can, and urgently if you have a fever. A first episode deserves a proper look, because several conditions imitate gout, including infection and pseudogout, and gout is not diagnosed by appearance alone. It is also the moment to get a blood test and a plan, since an untreated first attack is usually followed by a second.
One thing to know before that appointment: serum urate measured during an attack is often normal or even low, because urate is being pulled from the blood into the joint. A normal result does not rule gout out, and it should be rechecked once things settle — see normal uric acid with gout.
What not to do
- Do not start allopurinol now, and do not stop it if you already take it. A sudden move in urate either way can prolong a flare. If you are already on it, keep taking it exactly as prescribed through the attack — stopping is the mistake that costs people years of progress. Any change is a conversation with your prescriber.
- Do not take aspirin for the pain. Low-dose aspirin raises urate and aspirin is a poor painkiller here. If you take low-dose aspirin for your heart, that is different — keep taking it, and ask your doctor.
- Do not apply heat. Hot baths, heat pads and deep-heat rubs drive more blood into a joint that is already swollen. Cold helps; heat does not.
- Do not massage or manipulate the joint. It hurts and it stirs up more crystals.
- Do not wait it out if you have a fever or feel generally unwell. See the warning above.
- Do not try to fix it with food or drink. No juice, vinegar or supplement ends an attack already in progress.
The next few days
An untreated attack peaks within twelve to twenty-four hours and eases over roughly a week to a fortnight; treated early, it is usually much shorter — our guide to how long a gout attack lasts has the timeline. Meanwhile, practical comfort beats heroics:
- Keep the bedclothes off the joint. A cardboard box with one side cut out, under the sheet, works as well as a proper bed cradle.
- Wear nothing on that foot, or something wide and soft — this is where a roomy toe box earns its keep.
- Do not crash-diet or fast to “flush it out” — rapid weight loss releases urate and can worsen a flare.
- Leave the alcohol alone until it has fully settled.
Once the joint is quiet again
This is the part most people skip, and it decides whether you are doing this again in four months. An attack is the visible symptom of an invisible problem: enough urate in the blood, for long enough, to deposit crystals in the joint. Ice and rest treat the symptom. Only getting urate below target — under 6 mg/dL (about 360 µmol/L), or under 5 mg/dL (about 300 µmol/L) where tophi are present — dissolves the deposits that keep causing attacks.
Book a follow-up, ask for a urate level a few weeks after the flare, and ask whether urate-lowering therapy suits you. It is also worth working out what set this one off; the real trigger list is wider than the beer-and-steak stereotype.
The one habit worth building: ask your doctor for an attack treatment to keep at home, and store it where you will actually find it at 3am. The people with the shortest attacks are not the ones with the best remedies — they are the ones who started treating at hour one instead of hour twelve.
Frequently Asked Questions
Should I go to A&E or the emergency room for a gout attack?
Not usually — a flare in someone with known gout and treatment at home is managed at home. Go urgently if you have a fever, cannot bear any weight on the limb, the joint is a recently replaced one, or this is a first attack you cannot get seen today.
Can I take ibuprofen from the pharmacy if I have nothing prescribed?
Over-the-counter anti-inflammatories suit many people but not everyone — they are a problem with reduced kidney function, stomach ulcers, heart failure and blood thinners, all common among people with gout. Ask the pharmacist, who can check your other medicines in two minutes.
Why does it always seem to start at night?
Attacks cluster in the small hours. The likely reasons are the overnight fall in temperature at the extremities, which makes urate less soluble, mild dehydration, and the night-time dip in the body’s own anti-inflammatory steroid output. The big toe is the classic site for the same temperature reason.
How soon after an attack can I start allopurinol?
Practice is more flexible than the old advice to wait weeks — many specialists now start it during or shortly after a flare, provided anti-inflammatory cover is in place. That decision belongs to your prescriber. What matters is that it happens, rather than being forgotten once the pain goes.
What to read next
- Fast gout pain relief: what actually works
- How long does a gout attack last?
- What triggers a gout attack
- Gout symptoms: what a first attack feels like
