Gout: an animated, cited guide

This page needs JavaScript for its animations. The outline and key answers are below, and every claim in the full version carries a numbered citation.

Not medical advice. Gout Companion is an educational synthesis of published literature. It does not replace a clinician.

What is in it

What gout is Who gets it, the numbers, and the four stages from high urate to tophi.
Where urate comes from Purines, xanthine oxidase, and how the kidney and gut handle urate.
Crystals vs serum urate Why crystals form above about 6.8 mg/dL and dissolve below the target.
A flare, hour by hour From a shed crystal to the NLRP3 inflammasome, interleukin-1β and neutrophils, then resolution.
Colchicine inside the cell From the pill to the neutrophil to the microtubule.
Treating a flare Colchicine, NSAIDs, glucocorticoids, IL-1 blockers and ice.
Colchicine dosing and safety Published doses, kidney function and drug interactions.
How urate-lowering drugs work Allopurinol, febuxostat, uricosurics and pegloticase.
Treat to target Titrating to below 6 mg/dL, and why flares rise in the first months.
Safety of urate-lowering drugs HLA-B*58:01, the CARES and FAST trials, interactions.
Diagnosis and the ACR/EULAR score Crystals under polarised light, imaging, and the 2015 classification calculator.
The differential Calcium pyrophosphate crystal arthritis, septic arthritis, cellulitis and others.
Gout, kidneys and heart Chronic kidney disease, stones, blood pressure and cardiovascular risk.
Living with gout Diet, alcohol, weight, other medicines and a flare plan.
Nursing care Assessment, giving the medicines, teaching and documentation.
Toward a cure Dissolving crystals for good, and the research pipeline.
History and people From podagra to polarised light and allopurinol.
Flashcards, quiz and glossary Revision for students.
Sources Every reference behind the app.

Part 2 · Treating a flare

Treating a flare

Colchicine, an NSAID or a steroid all treat a gout flare about equally well, so the choice turns on the person's other conditions. Slide the start time to see why guidelines say start early, then switch on conditions and watch which options get flagged.

Treatment starts at 12 h

Days

Schematic. No trial has randomised people to different start times, so these curves only illustrate the published reasoning: a flare peaks within a day and settles within two weeks even untreated, and guidelines advise treating early (within 12 h in EULAR 2016, within 24 h in ACR 2012, colchicine only within 36 h). The single real data point is labelled with its source. ^{20,203,290,331,406}

What the trials measured

Trial

Grow bars

Choosing by the person's other conditions

ACR 2020 strongly recommends colchicine, an NSAID or a glucocorticoid (oral, intra-articular or intramuscular) as first line, chosen by patient factors; no first-line agent is ranked above another. NICE 2022 says the same. ^135,293

Switch on a condition to see which options the published guidance flags. This mirrors guideline lists; it is not a prescribing tool.

Flags follow ACR 2012's comorbidity examples, EULAR 2016, the COLCRYS label and the canakinumab label. In 575 people with gout, more than 90% had at least one contraindication to NSAIDs, and colchicine was prescribed despite a strong contraindication in 30–39.6%. ^{117,175,198,203,331}

Keep urate-lowering therapy going

ACR 2012: do not interrupt established urate-lowering therapy during a flare (Evidence C). Starting it is a separate question: ACR 2020 conditionally allows starting during a flare when it is indicated, while NICE prefers 2–4 weeks after the flare settles unless flares are frequent. ^135,203,293

When one drug is not enough

ACR 2012 judged combination therapy appropriate for severe or polyarticular flares (Evidence C), and defined an inadequate response as under 20% pain improvement within 24 hours or under 50% at 24 hours or later. The Hong Kong 2023 consensus does not recommend combining an NSAID with a systemic glucocorticoid because of additive toxicity. ^203,440

NSAID vs steroid, pooled

Across 6 trials (817 people), pain at under 7 days did not differ, but corticosteroids caused less indigestion (RR 0.50), nausea (RR 0.25) and vomiting (RR 0.11). A Cochrane review of 5 trials (712 people) found total adverse events higher with NSAIDs (RR 1.6). ^24,418

Established

IL-1 is the flare's key signal

In an open pilot, all 10 people unable to take standard therapy responded to anakinra 100 mg daily for 3 days. In anaGO (88 people), anakinra was non-inferior to usual care; in a phase II trial (165 people) it was not superior to triamcinolone 40 mg on the primary end point (−41.2 vs −39.4). ^178,344,371

Debated

Was the canakinumab comparator fair?

ACR 2020 makes IL-1 inhibition a conditional recommendation (moderate certainty) and notes that the comparator, triamcinolone 40 mg, was weak and that cost favours other agents. Canakinumab carries EU (2013) and US (2023) approval for selected people with gout. ^109,121,135

Ice, and what does not help

ACR 2020 conditionally recommends topical ice as an add-on, and NICE advises ice packs alongside medicine. ACR 2012 voted cherry juice, willow bark, ginger and other oral complementary agents inappropriate for treating a flare. ^135,203,293

Exam hookFirst line = colchicine, NSAID or glucocorticoid, chosen by comorbidity, none ranked higher. Low-dose colchicine (1.8 mg over 1 h) = high dose for benefit, far less diarrhoea. Do not stop urate-lowering therapy during a flare. ^135,203,406

In plain wordsSeveral medicines work about equally well. The best one for you depends on your kidneys, heart, stomach and other medicines. Take it at the first sign of a flare, and keep taking any urate-lowering medicine you already use.