Gout: Understanding the Causes, Symptoms, and Long-Term Joint Effects

Key Takeaways

Gout is caused by uric acid crystal deposits in joints, triggering severe inflammation
The big toe is most commonly affected, but gout can strike any joint
Untreated gout causes permanent joint damage and kidney problems
Diet plays a role, but genetics is a bigger factor than most people realize
Modern medications can effectively prevent attacks and protect joints
Lifestyle changes help, but most people need medication for long-term control

Gout has a reputation as a “rich man’s disease” linked to overindulgence in food and drink. While diet does play a role, this characterization is misleading and can prevent people from getting the treatment they need.

In reality, gout is a metabolic condition driven largely by genetics. It causes some of the most intense pain in all of medicine and, if left untreated, leads to permanent joint destruction. Understanding gout is the first step toward controlling it.

What Is Gout?

Gout is a form of inflammatory arthritis caused by the deposition of monosodium urate (MSU) crystals in joints and soft tissues.

The Uric Acid Problem

Here’s how gout develops:

Production: Your body produces uric acid when it breaks down purines (substances found in your body and certain foods)
Elimination: Normally, uric acid dissolves in blood, passes through the kidneys, and leaves the body in urine
Accumulation: When uric acid levels get too high (hyperuricemia), it can form needle-shaped crystals
Attack: These crystals deposit in joints, triggering an intense inflammatory response

Think of it like: Supersaturated sugar water. When there’s too much sugar, crystals form. When there’s too much uric acid in your blood, uric acid crystals form in your joints.

Gout Attack Symptoms

A gout attack (also called a flare) is unforgettable. The pain is often described as the worst many people have ever experienced.

Classic Presentation

Location:

Big toe (first attack in ~50% of cases)
Also common: ankle, knee, wrist, finger, elbow
Usually affects one joint at a time initially

Onset:

Often strikes at night or early morning
Can develop within hours
Reaches peak intensity within 12-24 hours

Characteristics:

Extreme pain—even a bedsheet touching the joint is unbearable
Joint is red, hot, and extremely swollen
Skin over the joint may be shiny and tight
Fever and chills sometimes occur

Duration:

Without treatment: 7-14 days
With treatment: Several days
Completely resolves between attacks (in early gout)

Progression Over Time

Early gout:

Attacks are infrequent (months or years apart)
Complete recovery between attacks
Usually one joint affected

Advanced gout:

Attacks become more frequent
Multiple joints affected
Incomplete recovery between attacks
Tophi (uric acid deposits) may develop under skin
Chronic joint pain and damage

What Causes High Uric Acid?

Factors You Can’t Control

Genetics: Most people with gout have inherited genes that affect how their kidneys process uric acid. About 90% of gout cases involve impaired uric acid excretion.

Age and gender:

Men are affected more and earlier (usually after puberty)
Women’s risk increases after menopause (estrogen helps excrete uric acid)
Risk increases with age for both sexes

Medical conditions:

Kidney disease (reduced uric acid excretion)
High blood pressure
Diabetes
Metabolic syndrome
Certain blood disorders

Medications:

Diuretics (water pills)—very common trigger
Low-dose aspirin
Cyclosporine
Some cancer chemotherapy drugs

Factors You Can Influence

Diet:

High-purine foods: organ meats, red meat, shellfish, certain fish
Alcohol, especially beer (contains purines AND impairs excretion)
Sugary drinks (fructose increases uric acid production)

Weight: Obesity increases uric acid production and decreases excretion. Weight loss can significantly lower levels.

Hydration: Dehydration concentrates uric acid and can trigger attacks.

Long-Term Joint Damage

This is why gout treatment matters: untreated gout destroys joints.

Mechanism of Damage

Even between attacks, uric acid crystals remain in the joint and surrounding tissues. These crystals:

Continuously trigger low-grade inflammation
Erode cartilage
Damage underlying bone
Can form large deposits called tophi

Tophi

Tophi are nodular masses of uric acid crystals surrounded by inflammatory tissue. They:

Form in joints, tendons, and soft tissues
Can grow quite large
May ulcerate through skin
Cause permanent joint deformity
Limit joint function

Imaging Findings in Advanced Gout

Joint space narrowing
Bone erosions (characteristic “rat bite” appearance)
Soft tissue swelling
Tophi visible on ultrasound and CT

The Good News

With proper treatment, gout damage is preventable. Even existing tophi can shrink or resolve when uric acid levels are brought down and maintained.

Treatment Approaches

Treating Acute Attacks

When a gout attack strikes, the goal is rapid pain relief:

NSAIDs:

Indomethacin, naproxen, or other NSAIDs
Start as early as possible
Higher doses initially, then taper

Colchicine:

Most effective when started within 12 hours of attack onset
Lower doses now preferred (fewer side effects)

Corticosteroids:

Oral prednisone or injection into the joint
Option when NSAIDs and colchicine aren’t appropriate
Very effective for acute relief

Ice and rest:

Supportive measure
Ice for 20-30 minutes several times daily
Keep weight off the affected joint

Long-Term Management (Urate-Lowering Therapy)

The real goal of gout treatment is preventing attacks and damage by lowering uric acid levels.

Who needs urate-lowering therapy:

Frequent attacks (≥2 per year)
Tophi
Joint damage on imaging
Chronic kidney disease with gout
History of kidney stones

Medications:

Allopurinol:

First-line treatment for most people
Reduces uric acid production
Start low, increase gradually
Very effective and affordable

Febuxostat (Uloric):

Alternative when allopurinol isn’t tolerated
More potent
More expensive

Probenecid:

Increases uric acid excretion
Requires good kidney function
Needs adequate fluid intake

Pegloticase:

For severe, treatment-resistant gout
Given by IV infusion
Converts uric acid to a form easily excreted

Target uric acid level: Below 6 mg/dL (below 5 mg/dL if tophi present)

Why Many People Fail Treatment

Gout is very treatable, yet many people continue to suffer. Common reasons:

Starting urate-lowering therapy during an attack: This can prolong or worsen the attack. Treatment should start after the attack resolves.

Not treating long enough: Attacks may temporarily increase when starting urate-lowering therapy (as crystals dissolve). People stop medication thinking it’s not working.

Not reaching target: Many people are undertreated. Uric acid must be brought below 6 mg/dL and kept there.

Poor medication adherence: Gout feels fine between attacks. People stop medications when they feel well, and attacks return.

Lifestyle and Prevention

Dietary Modifications

Diet alone rarely controls gout, but it can help:

Reduce:

Organ meats (liver, kidney, sweetbreads)
Red meat
Shellfish, anchovies, sardines
Beer and liquor
Sugary drinks and foods with high-fructose corn syrup

Moderate:

Other meats and fish
Wine (less problematic than beer)

Enjoy freely:

Low-fat dairy (actually protective)
Vegetables (including high-purine vegetables—they don’t increase risk)
Whole grains
Coffee (may be protective)
Cherries (some evidence for reducing attacks)

Other Lifestyle Measures

Stay hydrated: Aim for 8+ glasses of water daily. Dehydration increases attack risk.

Lose weight gradually: Rapid weight loss can actually trigger attacks. Aim for slow, steady loss.

Limit alcohol: Beer is worst, followed by liquor. Wine in moderation may be acceptable for some.

Review medications: If you take diuretics, ask your doctor if alternatives exist.

Beyond Joints: Other Gout Complications

Kidney Stones

High uric acid increases risk of kidney stones. About 20% of people with gout develop uric acid stones.

Kidney Disease

Chronic hyperuricemia may contribute to kidney damage over time.

Cardiovascular Disease

Gout is associated with increased risk of heart disease and stroke—partly due to shared risk factors, possibly partly due to gout itself.

These risks make treatment even more important.

Frequently Asked Questions

Do I need to avoid all meat?

No. Moderate amounts of chicken, fish, and lean meat are fine for most people with gout. The biggest dietary culprits are organ meats, and excessive red meat and shellfish.

Can gout be cured?

Gout can be controlled but not cured. However, with proper treatment, attacks can be prevented completely, and many people live symptom-free as long as they continue therapy.

Will I need medication forever?

Most people need lifelong urate-lowering therapy. Stopping medication allows uric acid to rise again and attacks to return. Some people who lose significant weight and make major lifestyle changes can reduce or stop medications with careful monitoring.

Is gout hereditary?

Yes, genetics is the biggest risk factor. If your parents or siblings have gout, your risk is significantly higher. However, this doesn’t mean gout is inevitable—treatment and lifestyle modifications can prevent attacks.

Why did I get gout if I eat healthy?

Many people with gout eat reasonably healthy diets. The problem is usually genetic—your kidneys don’t excrete uric acid efficiently. Diet modifications help, but most people need medication regardless of diet.

Can women get gout?

Yes, though it’s less common before menopause. After menopause, women’s risk increases significantly. Gout in women is sometimes underdiagnosed because it’s considered a “male” disease.

Looking for more information on joint conditions? Read about the differences between rheumatoid arthritis and osteoarthritis or explore our conditions hub.

Last medically reviewed: February 2025

Medical Disclaimer: This article is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. If you suspect you have gout, please consult a healthcare provider for proper evaluation and treatment.