In short
A gout attack treated in the first few hours settles far faster than one treated on the third day. What matters most is starting quickly, resting the joint, and not making the two changes that reliably make things worse: starting urate-lowering medicine mid-attack, or stopping it.
Reviewed by Dr. Ashish Baweja, DM Clinical Immunology & Rheumatology, AIIMS Rishikesh · last updated October 2026
Gout usually announces itself in the small hours. The joint at the base of the big toe is the classic site, and the pain is out of proportion to anything visible at first — people describe being unable to bear the weight of a bedsheet. Within a few hours the joint is red, hot, shiny and swollen.
The most useful thing to know is that speed matters more than which medicine is chosen. An attack treated within twelve to twenty-four hours typically settles in a few days. The same attack left for seventy-two hours can take two weeks.
The first few hours
Rest the joint and raise it. Walking on an inflamed toe keeps it inflamed. Take the weight off it and prop the foot up.
Apply cold, not heat. An ice pack wrapped in a cloth, twenty minutes at a time, several times a day. Heat feels soothing on a stiff joint and is the wrong instinct for a hot one. Never put ice directly on skin.
Start the medicine you have already been given for this. Many people with recurrent gout are given a supply to keep at home precisely so that treatment can start at the first twinge rather than after a clinic visit. If you have that supply, this is what it is for.
Drink water. Not as a cure — it does not flush crystals out — but because dehydration is a common trigger and makes everything else harder.
The medicines, in plain terms
Three classes are used to settle an attack. Which one suits you depends on your kidneys, your heart, your stomach and what else you take, which is why this is a prescribing decision rather than a shopping list.
NSAIDs — such as naproxen or indomethacin — work well and quickly in people who can take them. They are avoided or used cautiously with kidney impairment, heart failure, uncontrolled blood pressure, a history of stomach ulcers, or alongside blood thinners.
Colchicine works best when started early. Modern practice uses a low dose; the old approach of taking it repeatedly until diarrhoea set in caused a great deal of avoidable harm and is no longer recommended. The dose has to be reduced in kidney disease, and it interacts with several common drugs, including clarithromycin and some statins. Colchicine explained in full covers that.
Steroids — tablets for a short course, or an injection into the joint — are the usual choice when NSAIDs and colchicine are both unsuitable. An injection into a single large joint works quickly and avoids a systemic dose.
Paracetamol alone is rarely enough for a true gout attack, though it can be added.
The two mistakes that prolong an attack
Starting allopurinol or febuxostat during an attack. Beginning a urate-lowering medicine while a joint is inflamed can intensify and extend the attack, because a falling urate level disturbs the crystal deposits already in the joint. Urate-lowering treatment is started once things have settled, under cover of a preventive medicine.
Stopping allopurinol or febuxostat because an attack has happened. This is the commoner and more damaging error. If you are already established on urate-lowering treatment and an attack occurs, keep taking it. Attacks are expected in the first months of treatment and are not a sign that the medicine has failed — they are a sign the deposits are being dissolved. Stopping and restarting repeatedly is how people end up with years of attacks and no progress. When urate-lowering medicine is started and why it continues explains the reasoning.
What does not help
- Massaging or manipulating the joint. It is not a stiff joint; pressure makes it worse.
- Hot fomentation. Widely recommended for joint pain generally, and wrong for an acute attack.
- Starting a strict diet mid-attack. A sudden fast or crash diet can raise urate and has been known to trigger attacks. Diet is a long-term lever, and a gout diet built around an Indian kitchen is worth setting up when you are well, not at two in the morning.
- Checking the uric acid level during the attack. It is frequently normal or low in the middle of an attack, which misleads people into thinking it is not gout. If a level is needed, it is measured a couple of weeks after things settle.
When it is not gout
This matters, because the treatment for the main alternative is completely different and urgent.
Septic arthritis — infection inside a joint — can look identical: one hot, red, exquisitely painful joint. The features that should send you to a hospital the same day rather than to a pharmacy:
- Fever or chills alongside the joint pain
- A joint that is affected for the first time and you have never had gout before
- A large joint such as the knee, hip or shoulder rather than a toe
- Recent illness, a skin infection or a wound near the joint, a prosthetic joint, or diabetes
- Pain that is severe and getting worse over hours despite treatment
The only way to settle it is to draw fluid from the joint and look at it. A delayed joint infection destroys cartilage quickly, so this is not a wait-and-see situation.
Other conditions that imitate gout include pseudogout, which has a similar presentation but different crystals and often affects the knee or wrist, and a flare of psoriatic arthritis in a toe.
What sets an attack off
Attacks are not random, and knowing your own pattern is worth more than any general list.
The common triggers are a sharp change in urate level rather than a high level by itself: a heavy drinking session, particularly beer or spirits; a large meat or seafood meal; dehydration after a hot day, a long flight or a bout of vomiting; starting or stopping a urate-lowering medicine; a new diuretic for blood pressure; a crash diet or a fast; and any acute illness, surgery or injury.
Minor trauma to the joint counts too — a long walk in tight shoes is a recognised way to start one in the big toe.
Two of those are prescribing issues worth raising with your doctor rather than solving alone: diuretics and low-dose aspirin both raise urate, and in some people a change of blood pressure medicine removes a trigger that diet never would.
What to keep at home
Anyone with recurrent gout should have a plan agreed in advance, because the attack always starts at an inconvenient hour.
That plan usually means a supply of the medicine that suits you, kept where you can find it at three in the morning, with written instructions for the dose and how many days to take it. It also means knowing which of your other medicines to continue — the urate-lowering one — and which features mean this is not an ordinary attack and needs a hospital.
If you have had attacks and have never been given that plan, it is a reasonable thing to ask for. It is the difference between a bad night and a lost fortnight.
After it settles
The attack ending is not the end of the problem. Gout is a deposit disease: urate crystals have formed in and around the joint over years, and an attack is what happens when the body reacts to them. Settling one attack treats the reaction, not the deposits.
Two or more attacks in a year, a tophus, a kidney stone, or joint damage on X-ray are all reasons to treat the underlying urate level properly and permanently. Done correctly — a target level, a dose increased until the target is reached, and preventive cover during the first months — attacks stop altogether and the deposits dissolve over months to years.
That is the part most people never get to, because the attack ends and the subject is dropped until the next one. If you have had more than one attack, it is worth booking a proper assessment rather than waiting for the next three in the morning.
Common questions
How do I stop a gout attack fast?
Start treatment within the first few hours rather than waiting. Rest and elevate the joint, apply cold, and take the medicine your doctor has prescribed for attacks — an NSAID, colchicine or a steroid depending on your kidneys, heart and stomach. Early treatment typically shortens an attack from weeks to days.
How long does a gout attack last?
Untreated, most attacks peak within a day and settle over one to two weeks. Treated early, they commonly settle within three to five days. An attack that is still worsening after a few days of treatment should be reassessed, partly to make sure it is gout.
Should I stop my allopurinol during an attack?
No. If you are already taking allopurinol or febuxostat, continue it through the attack. Attacks in the first months of urate-lowering treatment are expected and do not mean the medicine has failed. Stopping and restarting is the commonest reason people make no progress for years.
Can I start allopurinol during an attack?
Starting it mid-attack can prolong and intensify the attack. Urate-lowering treatment is normally begun once the joint has settled, with a preventive medicine alongside it for the first months.
Is ice or heat better for gout?
Cold. An ice pack wrapped in a cloth for about twenty minutes at a time helps an inflamed joint. Heat is the usual instinct for joint pain and is the wrong one here.
When is a hot swollen joint an emergency?
When there is fever or chills, when a large joint such as the knee is involved, when it is your first such attack, or when you have diabetes, a prosthetic joint or a recent skin infection. Infection inside a joint looks like gout and damages cartilage within days, so it needs assessing the same day.
Sources
- NHS — gout www.nhs.uk
- NIAMS — gout: diagnosis and treatment www.niams.nih.gov
- American College of Rheumatology — gout rheumatology.org
- NHS — septic arthritis www.nhs.uk
This article is general information and does not replace a consultation.