What Untreated Gout Does: Tophi, Joints and Kidneys
How gout progresses when the urate level is never brought down, which damage is permanent, and how much of it dissolves once it is.
Part of the Complete Gout Guide.
Key fact: Gout is not just a series of attacks. Left untreated, the gaps between flares shorten, urate deposits build into tophi, and joints erode permanently. Most of that damage is preventable, and tophi can dissolve once urate is held below target.
It is not just the attacks
Gout is usually experienced as discrete events with normal periods in between, and that framing is what makes it easy to manage one flare at a time for years. Underneath, urate crystals continue to deposit in and around joints whenever the blood level stays above saturation — whether or not anything hurts.
That is the case for treating the level rather than the episodes. The attacks are the visible part of a process that carries on in the quiet periods.
The gaps get shorter
The natural course, untreated, is fairly predictable:
1
Isolated attacks
One joint, complete recovery in between, sometimes years apart. This is the stage where it feels like bad luck rather than a condition.
2
More frequent attacks
Months rather than years apart, and more joints involved — midfoot, ankle, knee, fingers.
3
Incomplete recovery
The joint no longer returns fully to normal between flares. Background ache and stiffness persist.
4
Chronic gouty arthritis with tophi
Persistent pain, visible deposits, and joint damage on X-ray. Attacks may become less dramatic but the joint is worse.
The speed varies enormously, and nothing about it is inevitable. It is driven by how long the urate level stays above the point at which crystals form.
Tophi
Tophi are lumps of urate crystals deposited in soft tissue. They are usually painless, firm, and slightly yellow or white under the skin, and they appear in characteristic places:
- The outer ear — the rim of the helix, often the first place anyone notices
- Over the elbow, in the bursa at the point of the elbow
- Fingers and toes, particularly around joints already affected
- The Achilles tendon and other tendons
- Over the knee and the forefoot, where shoes then rub
They matter for three reasons. They indicate a substantial urate load rather than an occasional excess. They can ulcerate through the skin and discharge chalky white material, which is then a route for infection. And they drive the treatment target lower — below 300 micromol/litre rather than 360, because a lower level dissolves them faster.
Joint damage
Long-standing gout erodes bone next to affected joints. On X-ray this shows as punched-out erosions with overhanging edges, and clinically as deformity, reduced movement and persistent pain that is no longer episodic.
Once bone is eroded it does not regrow. This is the part of gout that is genuinely irreversible, and it is the strongest single argument for treating to target rather than waiting to see how bad things get. Function follows: people with advanced gout lose grip, struggle with shoes, and become less mobile — which in turn worsens the weight and cardiovascular picture underneath.
Kidneys and stones
- Urate kidney stones. High urinary urate can crystallise in the urinary tract. Stones cause severe loin-to-groin pain, blood in the urine, and sometimes infection or obstruction
- Chronic kidney disease. Kidney impairment and gout drive each other — reduced clearance raises urate, and urate deposition contributes to kidney damage. Chronic kidney disease at stage 3 to 5 is one of NICE's specific reasons to offer urate-lowering treatment
- It narrows the options. Reduced kidney function makes NSAIDs unsuitable for flares and requires dose adjustment of colchicine and allopurinol, so kidney damage makes gout harder to treat as well as more likely
Kidney function should be checked at diagnosis and monitored alongside urate — see what your uric acid level means.
The company gout keeps
Gout is strongly associated with high blood pressure, type 2 diabetes, obesity, chronic kidney disease and cardiovascular disease. The association runs deep enough that a first gout attack is a reasonable moment to check the rest, and treating gout in isolation misses most of what is going on.
This is not a reason for alarm so much as an argument for using the diagnosis. A hot toe at 3am is an unusually motivating entry point into a conversation about blood pressure and weight that might otherwise never happen.
Medicines that make it worse
| Medicine | Why it matters |
|---|---|
| Thiazide and loop diuretics | Reduce urate excretion. Taking a diuretic is one of NICE's listed reasons to offer urate-lowering treatment rather than to keep treating flares |
| Low-dose aspirin | Raises urate. Usually kept because the cardiovascular benefit outweighs it — but it should not be used as a painkiller during a flare |
| Ciclosporin and tacrolimus | Raise urate substantially; relevant after transplant |
| Some tuberculosis treatments | Pyrazinamide and ethambutol raise urate |
Do not stop any of these on your own. Diuretics and aspirin are prescribed for conditions considerably more dangerous than gout. The right move is to tell whoever manages them that you have gout, so the balance can be reconsidered deliberately — sometimes by switching, and often by keeping the medicine and treating the urate instead.
Who should be on urate-lowering treatment
NICE recommends offering urate-lowering therapy to anyone with gout who has:
- Multiple or troublesome flares
- Chronic kidney disease, stages 3 to 5
- Diuretic therapy
- Tophi
- Chronic gouty arthritis
For everyone else, including after a first flare, the guidance is to discuss the option rather than to wait. Treatment is usually started at least two to four weeks after a flare has settled, with colchicine cover while the dose is titrated, because mobilising crystals can provoke flares in the early months. The allopurinol guide covers the practicalities.
What can be undone
| Reversible | Not reversible |
|---|---|
| Tophi — they shrink and can disappear entirely once urate is held below target, over months to years | Bone erosion and established joint deformity |
| Frequency of attacks — they become rare and then stop | Cartilage already destroyed |
| Crystal deposits in and around joints, which dissolve when the blood level falls below saturation | Kidney tissue already scarred |
The reversible column is larger than most people expect, and it is the reason treating a long-standing case is still worth doing. The catch is that dissolution is slow and needs the level held down continuously — stopping treatment once the attacks stop simply restarts the process.
The practical summary: gout is one of the few forms of arthritis that can be genuinely controlled rather than merely managed, and the thing that decides which outcome you get is whether the urate level is brought below target and kept there.
Frequently Asked Questions
What happens if gout is left untreated?
Attacks become more frequent and involve more joints, recovery between them becomes incomplete, urate deposits build into tophi, and bone next to affected joints erodes permanently. Untreated gout is also associated with urate kidney stones and with worsening kidney function.
What are tophi?
Tophi are firm, usually painless lumps of urate crystals deposited in soft tissue, typically on the rim of the ear, over the elbow, around fingers and toes, and along tendons. They indicate a substantial urate load, can ulcerate and discharge chalky material, and lower the treatment target to below 300 micromol/litre.
Can gout damage be reversed?
Partly. Tophi shrink and can disappear once urate is held below target, and crystal deposits dissolve, though this takes months to years of continuous treatment. Bone erosion, established joint deformity and destroyed cartilage do not recover, which is why treating to target early matters.
Does gout affect the kidneys?
Yes, and the relationship runs both ways. High urinary urate can form kidney stones, and urate deposition contributes to chronic kidney disease, while reduced kidney function raises urate. Chronic kidney disease at stage 3 to 5 is one of NICE's specific reasons to offer urate-lowering treatment.
Should I stop my water tablets if I have gout?
Not on your own. Diuretics reduce urate excretion and taking one is a reason NICE gives for offering urate-lowering treatment, but they are prescribed for conditions more dangerous than gout. Tell whoever manages them that you have gout so the balance can be reviewed deliberately.
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.