Gout treatment involves two distinct categories of medication: drugs that stop a painful flare while it’s happening, and drugs you take daily to lower uric acid levels and prevent future attacks. Most people with recurring gout end up on both at different points. The right combination depends on how frequent your flares are, your kidney function, and other health conditions.
Medications for Acute Gout Flares
When a gout attack strikes, the goal is to reduce inflammation and pain as fast as possible. Three types of medication are used for this, and they all work best when taken early, ideally within the first 12 to 24 hours of symptoms.
NSAIDs
Nonsteroidal anti-inflammatory drugs like naproxen and indomethacin are often the first choice for a gout flare. They’re taken at higher doses for the first few days, then tapered as the pain subsides. Over-the-counter options like ibuprofen can also help, though prescription-strength NSAIDs tend to work faster on a full-blown attack. These aren’t ideal if you have kidney problems, stomach ulcers, or are on blood thinners.
Colchicine
Colchicine is one of the oldest gout treatments and works by dialing down the inflammatory response to uric acid crystals in your joint. The standard approach is 1.2 mg at the first sign of a flare, followed by 0.6 mg one hour later, for a total of 1.8 mg on day one. After that, you typically continue with 0.6 mg twice daily until 48 hours after the flare resolves. Timing matters here: colchicine is far more effective when taken within the first few hours. If you wait a day or two into a flare, it’s less likely to help much.
Corticosteroids
Steroid pills or injections directly into the affected joint are the go-to option when someone can’t tolerate NSAIDs or colchicine. Oral steroids are typically prescribed as a short course that tapers down over several days. A steroid shot into the joint can provide rapid relief, especially when only one joint is involved. Steroids are effective but come with their own considerations, particularly for people with diabetes, since they can raise blood sugar.
Daily Medications to Lower Uric Acid
Treating flares alone doesn’t address the underlying problem. Gout happens because uric acid builds up in the blood, forms sharp crystals, and deposits them in joints. Urate-lowering therapy aims to bring your blood uric acid level to 6 mg/dL or below, the threshold at which existing crystals begin to dissolve and new ones stop forming.
Allopurinol
Allopurinol is the most widely prescribed long-term gout medication. It works by blocking the enzyme that produces uric acid in the first place. The standard starting dose is 100 mg per day, increased by 100 mg each week until your uric acid level hits the target. For people with kidney impairment, the starting dose drops to 50 mg daily, with slower increases of 50 mg every two to four weeks to reduce the risk of serious side effects.
One important consideration: a small percentage of people carry a gene variant called HLA-B*5801 that puts them at risk for a severe, potentially life-threatening skin reaction to allopurinol. The American College of Rheumatology recommends genetic testing before starting allopurinol for people of Southeast Asian descent (including those with Han Chinese, Korean, or Thai heritage) and for African American patients, since these groups carry the variant at higher rates.
Febuxostat
Febuxostat works through the same mechanism as allopurinol, blocking uric acid production, and is typically reserved for people who can’t tolerate allopurinol or don’t respond to it. There’s an important safety signal to be aware of: a large clinical trial found that while febuxostat and allopurinol had similar rates of major cardiovascular events overall, febuxostat was linked to higher rates of death from heart-related causes (4.3% vs. 3.2%) and all-cause mortality (7.8% vs. 6.4%). Because of this, febuxostat is generally not the first choice, especially for people with existing heart disease.
Probenecid
Unlike allopurinol and febuxostat, which reduce uric acid production, probenecid works on the other end of the equation. It helps your kidneys excrete more uric acid into your urine. It’s less commonly used today and isn’t appropriate for people with kidney stones or significant kidney disease, since pushing more uric acid through the kidneys can make those conditions worse. You also need to drink plenty of water while taking it.
Why Flares Get Worse When You Start Treatment
One of the most frustrating things about starting urate-lowering therapy is that it can actually trigger gout flares in the first few months. When uric acid levels drop, existing crystal deposits start to shift and dissolve, which can provoke inflammation. This doesn’t mean the medication isn’t working. It’s actually a sign that your body is clearing out the crystals.
To prevent these flares, doctors typically prescribe a low dose of colchicine (0.5 to 0.6 mg once or twice daily) or a low-dose NSAID like naproxen alongside the urate-lowering drug. This protective bridge therapy usually lasts at least three months, continuing for at least one month after uric acid levels have reached target. Skipping this step is one of the main reasons people abandon their urate-lowering therapy early, thinking it’s making things worse.
Treatment for Severe, Uncontrolled Gout
A small number of people have gout that doesn’t respond to standard urate-lowering drugs, or they can’t take those drugs because of side effects or other health conditions. For these patients, pegloticase is a specialized option. It’s an enzyme delivered by IV infusion every two weeks, each session lasting at least two hours. The enzyme directly breaks down uric acid in the bloodstream, which standard medications can’t do.
Pegloticase is specifically reserved for what’s called refractory gout: cases where uric acid levels haven’t normalized despite maximum doses of other medications, or where those medications are contraindicated. It’s not a first- or second-line treatment, and the infusion setting means it’s a significant time commitment compared to a daily pill.
How Long Treatment Lasts
Medications for acute flares are short-term, taken only during an attack and for a day or two after symptoms resolve. Urate-lowering therapy, on the other hand, is typically a lifelong commitment. Gout is a chronic condition driven by how your body handles uric acid, and stopping the medication usually means uric acid levels climb back up and flares return. Most people notice a significant reduction in flare frequency within the first year of consistent treatment, and many become flare-free after two to three years as crystal deposits fully dissolve.
The most common reason treatment fails isn’t that the medication doesn’t work. It’s that people stop taking it, either because of the paradoxical early flares, because they feel fine between attacks, or because they weren’t told the medication needs to be taken indefinitely. Sticking with daily therapy even when you feel well is the single most important factor in keeping gout under control long-term.