Managing an Acute Gout Attack
What to do in the first 48 hours, how the choice between an NSAID, colchicine and a steroid is actually made, and the mistake that prolongs a flare.
Part of the Complete Gout Guide.
Key fact: Treat early. An untreated attack usually lasts one to two weeks, and starting anti-inflammatory treatment within the first 48 hours shortens it considerably. If you already take allopurinol, keep taking it — stopping makes things worse.
What to do in the first few hours
Gout attacks reach their worst within about 12 to 24 hours of starting, which means the window for making a difference is short. The single most useful thing you can do is start anti-inflammatory treatment quickly — ideally within the first day, and certainly within two.
1
Start your anti-inflammatory
If you have been prescribed something to keep at home for flares, take it now rather than waiting to see whether this one settles on its own.
2
Rest and raise the joint
Off the foot, elevated. Walking on an inflamed joint prolongs the attack.
3
Ice it
An ice pack or a bag of frozen peas wrapped in a towel, for up to 20 minutes at a time. NICE specifically advises cold therapy alongside medication.
4
Drink plenty of water
Dehydration concentrates urate and does not help.
5
Keep your usual long-term medicine going
Including allopurinol. See below — this is the step most often got wrong.
Which medicine: NSAID, colchicine or steroid
NICE gives three first-line options for a gout flare and does not rank them. The choice is made on your other conditions, your other medicines and your preference — not on which is strongest.
| Option | Suits | Main limits |
|---|---|---|
| An NSAID — such as naproxen or diclofenac | Otherwise healthy people with good kidney function and no stomach or heart problems | Kidney impairment, ulcer or reflux history, heart failure, anticoagulants, some asthma. Usually prescribed with stomach protection |
| Colchicine | People who cannot take NSAIDs; also used at low dose to prevent flares while starting allopurinol | Diarrhoea is dose-limiting; dose reduction in kidney or liver impairment; several drug interactions. The colchicine guide covers dosing |
| A short course of oral corticosteroid | People who can take neither of the above, and multi-joint attacks | Raises blood glucose, which matters in diabetes; not for repeated frequent use |
A steroid injection directly into the joint is another option where a single large joint is involved, and is usually arranged in person rather than remotely.
One at a time. These are alternatives, not a stack. Combining an NSAID with a steroid substantially raises the risk of stomach bleeding, and adding colchicine to a full-dose NSAID adds side effects rather than speed.
Who cannot take which
- Reduced kidney function — NSAIDs are usually avoided, and colchicine needs a lower dose. This is common in people with gout, because the two travel together
- Stomach ulcer, bleeding or bad reflux — NSAIDs are avoided or used with a proton pump inhibitor
- Heart failure, or recent heart attack or stroke — NSAIDs are generally avoided
- Warfarin or a DOAC — NSAIDs raise bleeding risk substantially
- Diabetes — oral steroids will push glucose up for the few days you take them, which is manageable but needs to be expected
- Asthma — a minority of people with asthma react badly to NSAIDs; if you have before, say so
This is exactly why the answer is not "take ibuprofen". Roughly the people most likely to get gout — older, with kidney impairment, on diuretics, with cardiovascular disease — are the people for whom NSAIDs are least suitable.
Do not stop your allopurinol
If you already take allopurinol or another urate-lowering treatment, keep taking it through the attack. Stopping it causes urate levels to swing, which can prolong the current flare and trigger the next. Treat the flare alongside it.
The opposite question — whether to start allopurinol during an attack — has a different answer. NICE advises starting urate-lowering treatment at least two to four weeks after a flare has settled, although it can be started during a flare where attacks are frequent. The allopurinol guide covers starting and titration.
Ice, elevation and the bedclothes problem
Cold therapy has a genuine recommendation behind it rather than being folk advice: NICE advises that applying ice packs in addition to prescribed medicine may help the pain. Twenty minutes at a time, wrapped, with breaks in between.
The other detail worth knowing is that during an attack the joint can be too painful to tolerate even the weight of a duvet. Keeping bedclothes off the foot — a cushion or a box under the covers at the end of the bed — is a small thing that makes the first two nights survivable. Loose footwear or none at all, for the same reason.
How long it should take to settle
12–24hfor an attack to reach its peak
48hthe window in which starting treatment helps most
1–2 wkshow long an untreated attack usually lasts
With treatment started early, most people notice real improvement within a day or two and are substantially better within a week. Skin over the joint often peels as it settles, which is normal and not infection.
If there is no improvement at all after two or three days of appropriate treatment, that is worth a review — both to reconsider the drug and to reconsider the diagnosis.
What not to do
- Do not take aspirin for the pain. Low-dose aspirin raises urate and can worsen an attack. If you take it for your heart, keep taking it — but do not reach for it as a painkiller here
- Do not stop allopurinol — the point above, and worth repeating
- Do not massage or manipulate the joint
- Do not walk it off. Gout is not a stiffness that loosens with movement
- Do not start a crash diet mid-attack. Rapid weight loss and fasting both raise urate and can prolong the flare. Weight management matters, but between attacks — see the gout diet guide
- Do not assume it is gout if this is your first attack, if it is in an unusual joint, or if you feel unwell with it
When it is not just a flare
Get an urgent appointment, or call NHS 111, if joint pain and swelling are getting worse and you also have a high temperature, chills, or feel sick. A hot, swollen joint with fever can be a joint infection, which is a same-day problem and is treated completely differently. Gout or septic arthritis sets out how they differ and why the distinction cannot be made on symptoms alone.
Also worth same-day advice: a first attack in an unusual joint, an attack in a joint with a replacement in it, or an attack while you are on treatment that suppresses the immune system.
Once it has settled
An attack is the moment to ask a question that often goes unasked: should this be happening at all? Recurrent flares are not something to keep managing one at a time. NICE recommends offering urate-lowering treatment to anyone with multiple or troublesome flares, tophi, chronic gouty arthritis, kidney disease at stage 3 or worse, or who takes a diuretic — and discussing it with everyone else after a first attack.
- Get your urate checked at least two weeks after the flare settles — a level taken during an attack can mislead. See what your uric acid level means
- Ask whether any of your medicines are contributing, particularly diuretics
- Keep something at home for the next flare so the 48-hour window is not lost waiting for an appointment
- Look at the modifiable causes between attacks rather than during them
Frequently Asked Questions
How do you stop a gout attack fast?
Start an anti-inflammatory as soon as the attack begins, ideally within the first 48 hours. NICE gives three first-line options: an NSAID, colchicine, or a short course of oral corticosteroid, chosen according to your other conditions. Rest and raise the joint, apply ice for up to 20 minutes at a time, and keep drinking water.
Should I stop taking allopurinol during a gout attack?
No. If you already take allopurinol, continue it through the flare. Stopping causes urate levels to swing, which can prolong the attack and trigger the next one. Treat the flare alongside it. Starting allopurinol for the first time is different and is usually done two to four weeks after a flare settles.
How long does a gout attack last?
An untreated attack usually lasts one to two weeks, reaching its worst within about 12 to 24 hours. With treatment started early, most people improve noticeably within a day or two. Skin over the joint often peels as it settles, which is normal.
Can I take ibuprofen or aspirin for gout?
An NSAID such as naproxen or diclofenac is one of the first-line options, but NSAIDs are unsuitable for many people with gout because of kidney impairment, stomach problems, heart failure or anticoagulants. Aspirin is different: low-dose aspirin raises urate and should not be used as a painkiller for gout.
Does ice help gout?
Yes. NICE advises that applying ice packs to the affected joint in addition to prescribed medicine may help relieve pain. Use an ice pack or frozen peas wrapped in a towel for up to 20 minutes at a time, with breaks in between.
References
- National Institute for Health and Care Excellence. Gout: diagnosis and management (NG219). nice.org.uk
- NHS. Gout. nhs.uk
- NHS. Septic arthritis. nhs.uk
- British Society for Rheumatology. Management of the hot swollen joint in adults. rheumatology.org.uk
- National Institute for Health and Care Excellence. Clinical Knowledge Summary: Gout. cks.nice.org.uk
Medical disclaimer: This article is for informational purposes only and does not constitute medical advice. A hot, swollen joint should never be assumed to be gout without assessment, particularly alongside fever or feeling unwell. Always consult a qualified healthcare professional for diagnosis and treatment. In a medical emergency, call 999.