Do I Need to Take Gout Medication Forever?

Gout is a common and painful type of arthritis that affects over 8 million Americans. Gout attacks cause rapid onset of pain, swelling, and warmth in one or more joints at a time. Left untreated, longstanding gout can cause chronic joint pain and permanent joint damage. 

The good news? Gout is one of the most treatable types of arthritis. The not so good news? Treating gout properly involves taking medications for life. Here we’ll explain why that is — and which medications can help.

What causes gout and gout attacks?

The cause of gout is a combination of risk factors and high uric acid blood levels. When uric acid levels are high, uric acid crystals can settle into the joints. These crystals don’t belong there, so the body sends in inflammatory cells that release chemicals to break them down. All that inflammation causes painful, swollen joint(s) of a gout attack. Attacks can also happen when the uric acid level changes very rapidly — up or down. 

Uric acid levels can shoot up quickly because of: 

• Diet: Eating a lot of purine-rich food (like beer and shellfish) all at once can increase levels and cause a flare.

• Stopping gout medications: Gout medications  — allopurinol (Zyloprim) and febuxostat (Uloric) — lower uric acid levels, so stopping them shoots the levels back up. 

Uric acid levels can drop quickly because of: 

• Certain medications: Examples include hydrochlorothiazide (Microzide) or furosemide (Lasix). 

• Major surgery: Examples include gallbladder removal or a hip replacement.

• Dehydration

• Gout medication without medication for attack prevention: When you first start allopurinol or febuxostat, you need to take a second medication for flare prevention. As your uric acid levels go down, crystals form and attract the inflammatory cells that cause gout attacks. So the second medication keeps those inflammatory cells away while levels are down. This prevents attacks.

How do gout medications work?

Medications work by decreasing your uric acid level. At first, you’ll need two medications. Once your uric acid levels are less than 6.0 milligrams per deciliter (mg/dL), you’ll only need one medication.

The first medication — allopurinol or febuxostat — lowers uric acid levels. When you start the medication, your provider will check your uric acid levels every 2 to 4 weeks. That way they can increase the dose if needed. If you don’t increase the dose so that your uric acid level stays less than 6.0 mg/dL, flares will still happen. It can take a few months to find the dose of medication that gets your levels where they need to be (it’s different for everyone). The maximum dose of allopurinol is 800 mg daily. The maximum dose of febuxostat is 80 mg daily.

The second medication — colchicine, NSAIDs, or prednisone — is to prevent gout attacks. When you first start allopurinol or febuxostat, you are at risk of gout flare since your uric acid levels are still too high, and these medications rapidly lower uric acid levels (and this can cause a flare). 

Current guidelines recommend long-term gout medication if you have more than one gout attack per year or already have tophi or joint erosions (more below).

Do I have to take gout medication even when I’m not having a gout attack?

Yes. The name of the game is keeping uric acid levels low. If you never start gout medication, uric acid levels will always stay too high. And if you stop gout medication, uric acid levels will shoot back up.

What is the best gout medication?

The American College of Rheumatology recommends allopurinol as the first-choice medication for the treatment of gout. Allopurinol is effective and less expensive than other options, and it’s safe for people with chronic kidney disease.  

Febuxostat could be an option if you’re allergic to allopurinol or if maximum-dose allopurinol fails to get your uric acid levels under 6.0 mg/dL. Of note, a 2018 trial showed an increased risk of death in people taking febuxostat, resulting in a black-box warning from the FDA. But a second trial in 2020 showed the opposite, with no increased risk of death in people taking febuxostat. A third trial in 2021 also showed no increased risk of death in people taking febuxostat. Despite the black-box warning, febuxostat could still be a good option for some.

Probenecid is another gout medication. But providers rarely recommend it as a first-choice treatment because of safety issues, especially for those with kidney disease. 

What happens if I don’t take gout medication?

Left untreated, gout can turn into chronic gouty arthritis (chronic tophaceous gout). Gout attacks happen more often, and the symptom-free periods in between flares disappear. Then, severe symptoms develop:

• Tophi: These are chalky, white deposits of uric acid. When they are large enough, you can see tophi underneath the skin.

• Joint erosions: Gout can attack the bones and cause permanent damage.

• Deformity and disability: You may have physical changes in the joints and decreased ability to move them.

What can I do to prevent a gout attack?

Here are the most important things you can do to prevent a gout attack:

• Take your gout medications according to your provider’s instructions.

• Confirm that your uric acid level is less than 6.0.

Some additional preventive steps can include the following:

• Review your medication list with your primary care provider. Some medications can increase your risk of a gout flare, so you might need to make changes.

• Limit your intake of purine-rich foods. Diet changes aren’t as important as researchers previously thought — especially if you’re on a proper dose of gout medication — but they can still help. 

• Don’t let anyone stop your gout medications without talking with the provider who first prescribed it. There are very few reasons to stop gout medications, including hospitalization. 

Why trust our experts?

Written by:

Samantha C. Shapiro, MD

Samantha Shapiro, MD, is a board-certified rheumatologist and internist with expertise in autoimmune and inflammatory conditions. She founded the division of rheumatology at Dell Medical School at The University of Texas at Austin.

Edited by:

Mandy Armitage, MD

Mandy Armitage, MD, has combined her interests in clinical medicine with her passion for education and content development for many years. She served as medical director for the health technology companies HealthLoop (now Get Well) and Doximity.

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