Acute Gout Attack: Symptoms and Emergency Treatments

The acute gout attack represents one of the most painful rheumatological emergencies, affecting approximately 2% of the French population according to Health Insurance. This sudden joint inflammation requires rapid management to limit the intensity and duration of symptoms.

A 2024 study published in Arthritis & Rheumatism demonstrates that treatment initiated within the first 12 hours reduces attack duration by 60%. This detailed guide will allow you to recognize warning signs, apply proper emergency measures and understand available therapeutic options.

We will successively address the mechanisms of attack, clinical manifestations, emergency treatments, reference medications, and prevention measures to avoid recurrence.

Mechanism and Triggering of Gout Attack

Acute gout attack results from crystallization of uric acid in joints when its blood level (uricemia) exceeds 70 mg/L. These sodium urate crystals trigger intense inflammatory reaction involving neutrophil granulocytes.

According to High Health Authority data, several factors can precipitate an attack:

• Dietary factors: purine-rich meal (organ meats, seafood, beer)
• Dehydration: intense physical exertion, extreme heat
• Physiological stress: infection, surgery
• Medications: diuretics, low-dose aspirin
• Sudden uricemia changes: starting or stopping uric acid-lowering treatment

Gout paradox: initiating uric acid-lowering treatment can trigger attacks during the first months, requiring colchicine prophylaxis.

The big toe (hallux) is the most frequently affected joint (90% of first attacks), but ankle, knee, wrist or elbow can also be affected.

Characteristic Symptoms of Acute Attack

Gout attack presents pathognomonic clinical signs allowing rapid diagnosis:

Intense Joint Pain

• Sudden onset: often nocturnal, waking the patient
• Maximum intensity: reached in 6-12 hours
• Unbearable pain: described as "a burning vice"
• Hyperalgesia: inability to tolerate contact with a sheet

Local Inflammatory Signs

• Redness: bright red joint
• Heat: increased local temperature
• Swelling: significant joint edema
• Functional impotence: inability to use the joint

General Signs

A 2023 NIH study shows that 40% of patients present:

• Moderate fever (38-38.5°C)
• Chills
• General malaise
• Sometimes nausea

For more details on natural progression, see our guide on gout attack duration.

Emergency Measures and First Aid

While awaiting medical consultation, several measures can partially relieve pain:

Ice Application

• Ice: 15 minutes every hour
• Skin protection: cloth between skin and ice
• Avoid heat: worsens inflammation

Rest and Elevation

• Complete rest: avoid any pressure on the joint
• Elevation: raised limb to reduce edema
• Immobilization: splint if necessary

Hydration

• Increase fluid intake: 2-3 liters/day
• Avoid alcohol: worsens dehydration
• Alkaline beverages: bicarbonate-rich waters

Warning: never massage the painful joint, this would worsen inflammation.

Emergency Medications

Attack treatment relies on three main therapeutic classes, whose efficacy is optimal if started early.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

First-line therapy according to VIDAL:

Indomethacin

• Dosage: 150-200 mg/day in 3 doses
• Duration: 3-5 days then tapering
• Efficacy: 80% improvement in 48h

Diclofenac

• Dosage: 150 mg/day in 3 doses
• Better tolerated alternative
• Contraindications: kidney or heart failure

Colchicine

Historical reference treatment:

• Modern dosage: 1 mg then 0.5 mg 1h later, then 0.5 mg 2-3 times/day
• Maximum efficacy: if started within first 12 hours
• Side effects: gastrointestinal disturbances common (30% of cases)
• Dosage adjustment: kidney or liver failure

Corticosteroids

Indicated if contraindications to NSAIDs and colchicine:

• Prednisolone: 30-35 mg/day for 3-5 days
• Progressive tapering: over 10-15 days
• Comparable efficacy to NSAIDs according to studies
• Alternative: intra-articular injection

Monitoring and Hospitalization Criteria

Most attacks are treated outpatient, but certain situations require hospitalization:

Hospitalization Criteria

• Suspected septic arthritis: high fever, chills
• Polyarticular gout: involvement of multiple joints
• Frail patients: severe kidney failure, cardiac disease
• Treatment failure: no improvement after 48-72h

Complementary Exams

• Joint aspiration: search for urate crystals
• Biological assessment: uricemia, creatinine, CRP
• X-ray: exclude other pathologies

For complete support, refer to our guide to medications and natural treatments.

Prevention of Recurrence

Prevention of recurrent attacks is a major challenge, as 60% of patients have another attack within a year.

Lifestyle-Dietary Modifications

Optimal Hydration

• 2 liters of water/day minimum
• Reduce alcohol (beer especially)
• Limit sweet sodas

Dietary Adaptations

• Reduce purine-rich foods
• Increase dairy products
• Moderate consumption of meat and fish

Background Treatment

Allopurinol remains the reference treatment:

• Uric acid target: < 60 mg/L
• Initiation: 2-4 weeks after attack
• Prophylaxis: colchicine 0.5-1 mg/day for 3-6 months
• Monitoring: kidney function, liver enzymes

Important: never start or stop uric acid-lowering treatment during an acute attack.

Complications and Prognosis

Untreated, gout evolves toward disabling complications:

Joint Complications

• Chronic arthropathy: cartilage destruction
• Tophi: subcutaneous urate deposits
• Joint deformities: functional loss

Systemic Complications

• Urinary calculi: uric acid stones (20% of gout patients)
• Chronic kidney failure: uratic nephropathy
• Cardiovascular risk: association with hypertension, diabetes

Early and appropriate management prevents these complications in over 90% of cases.

Frequently Asked Questions

How long does an acute gout attack last?

Without treatment, an attack usually lasts 7 to 14 days with spontaneous resolution. With appropriate treatment started early, improvement occurs in 24-48 hours and complete healing in 3-5 days.

Can you walk during a gout attack?

Rest of the affected joint is strongly recommended during the acute phase. Walking should be avoided if the toe, ankle or knee are affected. Pressure worsens inflammation and prolongs attack duration.

Should you apply heat or cold?

Cold is recommended during the acute inflammatory phase (15 minutes every hour). Heat is contraindicated as it increases vasodilation and worsens edema. Wait for complete resolution before considering heat therapy.

Can gout attack affect multiple joints?

Although involvement is usually monoarticular in first attacks, polyarticular gout is possible, especially in untreated patients for several years. This form often requires hospitalization for differential diagnosis.

When should you seek emergency care?

Seek immediate care if you present high fever (>38.5°C), chills, altered general condition or if pain does not improve after 48-72h of proper treatment. These signs may indicate complications.

Can gout attacks be prevented?

Yes, effective prevention is possible through uricemia control (< 60 mg/L), dietary adaptations, adequate hydration and uric acid-lowering treatment if necessary. Colchicine prophylaxis is recommended when initiating background treatment.