When you experience your first gout attack, you’re bound to be full of questions. Most immediately, you’ll want to know how to relieve the excruciating joint pain and swelling that has erupted overnight – probably in your big toe, the site of 50 percent of initial gout attacks. You’ll also want to know what your doctor is likely to do for you in both the short and long term. Here’s a brief overview of what you can expect.

What Caused Your Gout Attack?

Gout attacks occur when excess uric acid crystallizes in the joints. The acid is a byproduct of the breakdown of purines, substances in plants and animals, during the digestive process. Some people’s systems can’t process uric acid efficiently; others produce too much. The buildup results in the pain and inflammation that characterize a gout attack.

How to Handle a Midnight Gout Attack

You may be in so much pain that dashing off to the emergency room is unthinkable. That’s OK – the immediate goal is to relieve pain and to lessen swelling and inflammation. You can begin that process by taking nonsteroidal anti-inflammatory drugs (NSAIDs). 

Commonly used over-the-counter NSAIDs such as ibuprofen (Advil), and naproxen sodium (Aleve) help relieve both pain and inflammation often within 24 hours and are usually the first line of defense. Unfortunately, when taken orally, they can have side effects such as stomach upset or ulcers, headaches, skin rashes, fluid retention, kidney problems or heart disease risk. That means people with gastrointestinal, kidney, or heart problems shouldn’t take them.

Most doctors suggest taking the highest recommended dose for at least the first 24 to 36 hours to handle the pain. Don’t take aspirin – although it is an NSAID, it can change uric acid levels, worsening a gout attack.

An ice pack wrapped in a dish towel and placed on the affected joint for 15 to 20 minutes at a stretch can also relieve pain and inflammation.

See Your Doctor the Next Day

It’s important to see your doctor as soon as possible. He will likely give you a blood test to measure uric acid levels. And he may draw fluid from the affected joint to examine for urate crystals. He will also likely prescribe one or more of the following drugs that can help stop the pain and inflammation: 

Indomethacin (Indocin) is a commonly prescribed NSAID, except for elderly patients.

Colchicine is most effective taken within 12 hours of an attack, and was first used for gout in the 1800s. An alternative for those who can’t tolerate NSAIDs, it works by relieving inflammation and preventing the buildup of uric acid crystals. Sometimes taken in addition to NSAIDs, colchicine may be prescribed for six to 12 months, until your uric acid levels are stabilized by other long-term medication.

Although physicians used to recommend starting with a high dose of colchicine (1.2 mg) following by half of that every hour for six hours, that dose often caused diarrhea or vomiting. According to a 2010 Australian study at the University of Sydney, physicians found that patients given a low dose of colchicine (1.2 mg followed by 0.6 mg an hour later) had 50 percent greater pain reduction than those given the higher dose, and the side effects were cut by at least two-thirds. More doctors are now following a low-dose route.  

Corticosteroids, such as prednisone resemble cortisol, are an anti-inflammatory hormone. They work by suppressing the inflammation of an acute attack usually within 24 hours. For patients who can’t tolerate colchicine or NSAIDs, corticosteroids are injected into the joint. If other medications aren’t working, or if a number of joints are involved, they may be injected into the muscle or taken orally. There are side effects: Corticosteroids may make it more difficult for people with diabetes to control their blood sugar and they can sometimes cause temporary blurry vision.

What’s Next?

Once your acute attack has subsided, usually within days, your doctor will start you on long-term treatment to control uric acid levels. However, you may need to continue to take the drugs you took for the acute attack for six to 12 months until your uric acid levels have stabilized.

Long-term treatments your doctor may prescribe include:

Allopurinol (Lopurin, Zyloprim), the most traditional and widely used medication for lowering uric acid levels, slows the production of uric acid and may dissolve the uric acid crystals in tophi. 

Febuxostat (Uloric) helps prevent uric acid production by blocking an enzyme that breaks down purines into uric acid. 

Probenecid (Benemid, Probalan), when taken orally, lowers uric acid in the body by increasing the amount excreted in urine. It’s most likely to be used by people who have trouble excreting uric acid (as opposed to those who overproduce it). 

Pegloticase (Krystexxa) is used in severe cases of gout when standard medications are unable to lower the uric acid level, a condition known as chronic refactory gout. The drug is administered every two weeks by intravenous (IV) infusion.