Uric acid is formed when the body breaks down purines, which are found in all cells and in food, and is excreted via the kidneys. In most people with gout the problem is not that they make too much but that the kidneys excrete too little, usually for hereditary reasons, amplified by overweight, alcohol, certain medicines (thiazide and loop diuretics, low-dose aspirin, ciclosporin), reduced kidney function, high blood pressure and insulin resistance. When the uric acid level stays above about 400 µmol/l for a long time, needle-shaped crystals start to precipitate in cool joints, most often the base joint of the big toe (hence "podagra"), the ankle, the midfoot, the knee, the fingers and the elbow. The crystals can lie silent for years, but when something disturbs the balance (a party with beer and shellfish, dehydration, an operation, an injury, starting uric acid-lowering treatment without cover, a new diuretic) they come loose and the immune system responds with an inflammation that is among the most intense there is. Untreated, the attack passes in one to two weeks; with treatment in one to three days. Over the years the attacks become more frequent, affect more joints, and the crystals form lumps under the skin (tophi) on ears, fingers, elbows and heels, and in the kidneys. All of that can be avoided with uric acid-lowering treatment, which lowers the level so the crystals dissolve. Gout is not a disease you earned through good living: it is primarily hereditary, and it is the most treatable joint disease of all.
How a gout attack feels, and what resembles it
| Gout attack | Joint infection (septic arthritis) | Osteoarthritis / hallux valgus | Reactive arthritis / psoriatic arthritis | |
|---|---|---|---|---|
| Onset | Sudden, often at night, maximal in 6–12 hours | Hours to a day, with fever and feeling unwell | Insidious, months to years | Days to weeks |
| The joint | Glowing red, hot, shiny, swollen, extremely tender; one joint, most often the big toe | Red, hot, swollen, very tender; one joint; fever | Stiff, lumpy, moderately tender, rarely red | Swollen, sometimes several joints, "sausage fingers/toes" |
| Course | Over in 1–2 weeks untreated, 1–3 days with treatment, fully recovered between attacks | Worsens until treated; urgent | Chronic | Weeks to months |
| What to do | Your doctor within a day at the first attack; self-treatment for known attacks | Urgent the same day: the joint can be destroyed in days | See hallux valgus, osteoarthritis | Your doctor, rheumatologist |
A first attack should always be assessed by a doctor, since gout and joint infection can look identical and the infection is an emergency; fever, chills or feeling generally ill suggest infection until proven otherwise. The diagnosis of gout is made most reliably by the doctor drawing joint fluid and seeing the crystals under the microscope; in practice it is often made on the typical picture plus uric acid in the blood, which however can be normal during the attack itself (the level drops temporarily), so the test should be repeated after two to four weeks. Ultrasound and a special CT can show crystals. X-ray only shows changes late.
Why uric acid rises
- Heredity: the most important factor; the kidneys' ability to excrete uric acid is largely genetic. Gout in the family doubles the risk.
- Medicines: diuretics (thiazides, furosemide) are the most common triggering medicine; low-dose aspirin, ciclosporin, some TB and cancer drugs. Never switch on your own, but ask for a review.
- Kidney function, blood pressure, insulin resistance, overweight: gout is often part of the metabolic syndrome, and those with gout have an increased risk of cardiovascular disease and should have blood pressure, blood lipids and blood sugar checked.
- Alcohol: beer (purine-rich and increases formation), spirits (reduce excretion); wine in moderation has less effect.
- Diet: purine-rich food (offal, shellfish, sardines, anchovies, a lot of red meat), fructose in soft drinks and juice (increases formation), and to a lesser degree purine-rich vegetables (which however do not increase the risk in studies). Dairy products, coffee, cherries and vitamin C reduce the risk somewhat.
- Dehydration, fasting, rapid weight loss, surgery, injury and infection trigger attacks through temporarily higher levels.
- Sex and age: oestrogen increases excretion, so women rarely get gout before menopause; in men the risk rises from the age of 30.
Treatment of the attack
- Quickly: the earlier treatment starts, the shorter the attack. Anyone who has had gout should have medicines at home and start within hours.
- Anti-inflammatories (naproxen, ibuprofen at full dose) for three to five days are first choice if stomach, kidneys and heart allow; colchicine at low dose (the low-dose regimen is as effective as high and gives less diarrhoea) is the alternative; cortisone as tablets or as an injection into the joint for larger joints, kidney failure or when the others aren't possible. Paracetamol has a poor effect. Opioids shouldn't be needed.
- Rest, raise and cool the joint: cold compresses for 15–20 minutes several times a day relieve and are the only physical treatment with support. No loading, no tight shoe, no weight from the duvet (a cradle or a box holding the duvet up helps at night).
- Don't stop ongoing uric acid-lowering medicines during an attack (it doesn't make it worse), and don't start new ones during the attack without cover.
- Drink water, avoid alcohol and purine-rich food until the attack is over.
Preventing the next attack: medicines and diet
Uric acid-lowering treatment (allopurinol first, febuxostat if allopurinol isn't tolerated) is recommended after two or more attacks in a year, with tophi, with uric acid kidney stones, with reduced kidney function, and often already after the first attack if uric acid is high. The target is below 360 µmol/l (below 300 with tophi), checked with a test every four to six weeks during titration and then yearly. The dose is increased slowly and attack prophylaxis (colchicine or a low-dose anti-inflammatory) is given for the first three to six months, since the crystals dissolving otherwise trigger attacks; that is the most common reason people stop a treatment that would have cured them. The treatment is lifelong and harmless for most, and it is the only thing that makes crystals and tophi disappear. Diet and lifestyle lower uric acid by 10–15 per cent, which is rarely enough alone but reduces attacks and is good for the heart: less beer and spirits, fewer soft drinks and juices with fructose, less offal, shellfish and red meat, more dairy, vegetables, coffee and water (two litres a day), slow weight loss (rapid triggers attacks), and regular moderate exercise. Cherries and cherry extract have shown fewer attacks in small studies. Medication review: switch diuretics if possible (losartan lowers uric acid slightly and is a good blood pressure choice with gout). And check blood pressure, blood lipids and blood sugar: gout is a warning flag for cardiovascular disease.
Cupping and massage with gout: clear rules
During a gout attack you should not cup, massage, roll or otherwise work the affected joint or the area around it. The joint is acutely inflamed, the skin is tight and fragile, and mechanical influence increases the inflammation, pain and swelling; suction over an inflamed joint can also cause bruising and skin damage since the tissue is fluid-filled and fragile. The same applies to heat: it increases blood flow and makes the attack worse, while cold relieves. This is also in when to avoid cupping. Cupping has no effect on uric acid or the crystals and is not a treatment for gout. Between attacks, when the joint is completely calm, cool and without swelling, there is no obstacle to cupping the muscles, and it can be valuable for two reasons: those who have had gout in the foot or knee have often walked protectively for weeks and got tight calves, stiff feet and tender thighs and hips, and regular moderate movement and good circulation in the legs are part of the lifestyle that reduces attacks. How to: oil the skin, glide the dynamic cup with light to moderate suction from the ankle up towards the back of the knee on the calf and from the knee up towards the hip on the thigh, ten strokes per path, and the sole with the mini cup from the toes towards the heel with light suction, five strokes, without passing over the base joint of the big toe or other joints that have had attacks, and never over tophi (the lumps under the skin). Stop at the slightest heat, redness or tenderness in a joint afterwards. Five to ten minutes, two to three times a week, followed by calf stretching and foot mobility. More in foot pain and cupping at home.
Read more
When to avoid cupping, toe pain, hallux valgus, foot pain: where does it hurt, swollen knee, rheumatism and joint pain, osteoarthritis and inflammation in the body.
Frequently asked questions
How does a gout attack feel?
It comes suddenly, often at night, and is at its worst within 6–12 hours: one joint, most often the base joint of the big toe, becomes glowing red, hot, shiny, swollen and so tender that the sheet hurts. The ankle, midfoot, knee, fingers and elbow can also be affected. Untreated it passes in one to two weeks, with treatment in one to three days, and the joint is completely normal between attacks. Fever, chills or feeling ill suggest a joint infection, which is an emergency: seek care the same day.
What causes gout?
Uric acid in the blood being too high for too long so that crystals precipitate in the joints, most often because the kidneys excrete too little, which is largely hereditary. Diuretics, reduced kidney function, overweight, high blood pressure, insulin resistance, beer and spirits, fructose in soft drinks and purine-rich food (offal, shellfish, red meat) raise the level. Dehydration, fasting, surgery, injury and starting uric acid-lowering treatment without cover trigger attacks. Women are rarely affected before menopause.
How is gout treated?
The attack: anti-inflammatories at full dose, low-dose colchicine or cortisone, as early as possible, plus rest, elevation and cold. Prevention: uric acid-lowering medicine (allopurinol) lifelong after two attacks in a year, with tophi or kidney stones, with a target below 360 µmol/l and attack prophylaxis for the first months; plus less beer, spirits, soft drinks, offal and shellfish, more water, dairy and vegetables, slow weight loss and a review of diuretics. Properly treated, gout can stop completely.
Which foods should you avoid with gout?
Beer and spirits, soft drinks and juice with fructose, offal (liver, kidney), shellfish, sardines, anchovies and large amounts of red meat. Purine-rich vegetables (spinach, asparagus, mushrooms, legumes) however don't increase the risk. Dairy, coffee, cherries, vitamin C and two litres of water a day reduce it somewhat. Diet lowers uric acid by 10–15 per cent, which is rarely enough alone with repeated attacks; then uric acid-lowering medicine is needed.
Can you cup or massage with gout?
Never on a joint during a gout attack and not in the area around it: the joint is acutely inflamed, and suction, pressure and heat worsen the inflammation and can damage the skin. Cupping doesn't affect uric acid and doesn't treat gout. Between attacks, when the joint is calm and cool, it is fine to cup calves, thighs, hips and the sole with light suction for the muscles tightened by protective walking, without passing over joints that have had attacks or over tophi. Stop at the slightest heat or redness in a joint afterwards.
Written by Curam. Last updated 17 October 2026. This is general self-care information and does not replace medical care. For sudden, severe or unusual symptoms, contact your doctor. Talk to your doctor before cupping if you are pregnant, take blood thinners or have a condition affecting skin, blood vessels or blood.
