The Toe That Woke You at 2 A.M. Isn't Done With You

Quick answer: Gout is uric acid crystals building up in a joint. Call your doctor the first day, because treatment works best early. Stopping the next attack usually takes more than a diet change, often a daily medication and a blood-test target your doctor sets.

What it feels like

You go to bed fine. Around 2 a.m. your big toe feels like somebody shut it in a car door. The bedsheet touching it's unbearable. By morning it's swollen, hot, red and shiny, and you're hopping to the bathroom like a man in a three-legged race.

That's the classic first attack. The big toe is the favorite target, but ankles, knees, wrists and fingers get hit too. The pain tends to peak within 12 to 24 hours, and an untreated attack can drag on for a week or more.

Men get it more often. Women's risk climbs after menopause, which is one of the changes in What Actually Changes for Women in Their Forties and Fifties.

What's actually going on

Your body makes uric acid when it breaks down purines, which are found in your own cells and in certain foods. Your kidneys clear most of it. When the level in your blood runs high for long enough, needle-shaped crystals can form in a joint. Your immune system treats them as an invasion, and the joint pays for the fight.

Some people simply clear uric acid poorly. It runs in families. It's no verdict on your character, and plenty of lean, careful eaters get gout.

What sets one off

A trigger isn't the cause. Think of it as the match, with the high uric acid level as the gas that was already in the room. The usual matches:

• Alcohol, beer most of all. Spirits count too. A weekend of cookouts can do it.
• Sugary soda and juice sweetened with high-fructose corn syrup.
• A big hit of purines. Organ meats, a heavy red meat dinner, some shellfish.
• Dehydration. A long day in the sun or on a job site with too little water.
• Crash dieting or fasting. Fast weight loss can swing your levels and bring on an attack.
• Injury, surgery or illness. The body under stress stirs things up.
• Certain medications. Water pills (diuretics) and low-dose aspirin can raise uric acid. Don't stop a prescription on your own. Ask your doctor.

The steak-and-beer cookout is the textbook case. You can still go. Just know the third beer is the one that costs you, and nobody at the grill is going to carry you to the car.

The first 24 hours

Call your doctor the same day. Don't wait to see if it passes.

Prescription options for an attack include anti-inflammatory drugs (NSAIDs), colchicine and corticosteroids. Which one fits you depends on your kidneys, your stomach, your blood pressure and whatever else you take. That's why guessing from the medicine cabinet is a poor plan. And skip aspirin on your own, since it can nudge uric acid the wrong way.

What you can do while you wait:

• Rest the joint and keep it raised.
• Put a cold pack on it, wrapped in a towel, for short stretches.
• Drink water. Skip the alcohol.
• Keep the sheet off it if you have to.

Now the annoying part. Your blood uric acid can read normal during an attack. A doctor may still diagnose gout from the story and the exam, or draw a little fluid from the joint to look for crystals under a microscope, which is the surest test. Expect a follow-up blood test a few weeks after the flare settles, when the number means more.

Don't wait on this one: a hot, swollen joint with fever or chills, or a joint you can't move at all, needs urgent care that same day. An infected joint can look just like gout, and infection can't wait. A first-ever attack deserves a professional look for the same reason.

Preventing the next one

Diet helps. It rarely does the whole job. For many men, even a clean diet doesn't pull uric acid down far enough, because the body makes a lot of it on its own. Do the diet part anyway, because it's free and it works with everything else:

1. Cut the beer first. It's the biggest single lever for most men.
2. Drop the regular soda. Water, black coffee or unsweetened tea instead.
3. Shrink the steak. Keep red meat, organ meat and shellfish to smaller, less frequent portions.
4. Drink water all day. Steady, not in a gulp at dinner.
5. Lose weight slowly. Extra weight raises uric acid. A pound or two a week beats a crash.

Then there's the part many men skip. If attacks keep coming, or you've had more than one, your doctor may talk to you about a daily urate-lowering medication such as allopurinol. The goal is a blood uric acid below a target, commonly 6 mg/dL, though your doctor sets yours. Hold that level long enough and the crystals slowly dissolve. The attacks fade out.

Two traps. Starting the drug can trigger flares in the first few months, so doctors often add a low dose of a preventive medicine alongside it. Don't read that as failure. And the pills work when you feel fine, so a man who quits the day the pain stops is signing up for the next 2 a.m. Take them the way you'd keep up on your truck's oil changes. Boring is the point.

Gout travels with other things

Gout tends to show up alongside high blood pressure, kidney trouble, extra weight and blood sugar problems. Some of that's shared causes, some is the medications. Either way, an attack is a decent reason to get the rest checked. Ask about your blood pressure, your kidney function and your blood sugar. If you haven't looked at that last one, start with Your A1C Came Back 5.9. Now What?. And since gout and heart risk keep company, it's worth knowing What a Heart Attack Actually Feels Like before you need to.

Before you walk into the office

Write down the date, what you ate and drank in the 24 hours before, and every medication and supplement you take. Bring it. Your doctor can work with that in five minutes.

Your toe did the talking. Now go listen to the person who can fix it.