4 Stages of Gout and the Early Signs to Watch Out For

Learn about the four stages of gout, its earliest warning signs and when to consult a doctor.

By Mary Anne Dunkin | Dec. 6, 2022

The most common form of inflammatory arthritis, gout occurs when uric acid forms needlelike crystals that collect in joints and other tissues, causing intense pain, redness and swelling.

Although gout often begins in the joint of the big toe, it can also affect other joints – most commonly the knees, wrists and ankles – and can resemble other inflammatory forms of arthritis such as rheumatoid or psoriatic arthritis. But the stage at which the joints start to become painful and inflamed (a gout attack) is actually the second of four stages of gout, which range from no symptoms at all to the final stage, which can lead to damage to the joints and other tissues if gout is not well controlled. 

For most people, gout can be managed, minimizing or even eliminating attacks and preventing later complications. Recognizing the early stage gout symptoms and getting a proper diagnosis is essential to effective treatment. 

Here’s what you need to know about the four stages, what to watch for and how to prevent further progression of gout and the damage it can cause.  

Stage 1. Asymptomatic Gout

The characteristic collection of uric acid crystals in the joint begins with the accumulation of uric acid in the blood. Uric acid is a natural waste product that is formed when the body breaks down purines. Purine is a compound that occurs in naturally in our tissue and in high levels in some foods, including alcoholic beverages, shellfish, and some meats, including bacon, turkey, venison and organ meats. 

Normally, uric acid dissolves in the blood, is filtered by the kidneys and excreted through urine. However, if the body produces too much uric acid or the kidneys are not efficient at eliminating it, uric acid can reach high levels in the blood, a condition called hyperuricemia. For some people, hyperuricemia never causes symptoms. For others, it is the first stage of gout. 

Stage 2. Acute Gout

When uric acid levels in the blood become too high, it can seep out and form crystals in the spaces around the joints, causing intense pain and swelling. The pain often comes on suddenly and unexpectedly (thus the term, “attack”) and can last from a few days to a few weeks. 

Your first attack will likely be the first time you realize or suspect you have gout. Your doctor can make the diagnosis by drawing some fluid from the affected joints and examining it for uric acid crystals. The presence of crystals is the only way to confirm you have gout rather than another form of arthritis that would require completely different treatment. One of these is calcium pyrophosphate deposition disease (CPPD), a condition commonly known as “pseudogout” because of its resemblance to gout. Similar to gout, pseudogout comes on suddenly and painfully due to crystals that form in the joints. The difference is that the crystals are composed of calcium pyrophosphate dihydrate. It is unknown why these crystals form in the joint. 

Treatment during the acute stage of gout is targeted at relieving the pain and inflammation of the attacks as well as managing uric acid levels to lessen or prevent further attacks. This often involves a diet low in purines along with the use of medications that either decrease the body’s production of uric acid or increase uric acid excretion. 

Stage 3. Intercritical or Interval Gout

After your first gout attack(s) you’ll probably experience a time without symptoms until another attack occurs, which could be months or even years. The stage during which attacks come at intervals — short or long — is known as “intercritical” or “interval” gout.

Even when attacks are not occurring, uric acid can continue to build in the blood and joints at this stage, so your doctor may continue to prescribe uric acid-lowering medications to reduce the chance or severity of future attacks.

If you are overweight, losing weight helps in the management of gout. It is also important during this stage to drink plenty of water and consume a diet low in purines. 

Stage 4. Chronic Tophaceous Gout

If uric acid levels are not well controlled during the interval stage, gout may progress to its final and most problematic stage — chronic tophaceous gout.

Chronic gout is characterized by accumulations of urate crystals called tophi that can appear as bumps or nodules under the skin. A tophus can form in a joint, in the bursa that cushions and protects the joint, in the bones or cartilage and under the skin.  

Tophi that form in the small joints of the fingers can cause physical changes and restrict movement. Tophi in the cartilage and bone can eventually lead to joint damage and deformity, and tophi under the skin can be unsightly and become infected and sometimes painful. 

Other problems that can occur during this chronic stage include painful joints, aching and kidney stones. 

Due to effective treatments, most people with gout never experience this fourth stage of gout. For those who do, continued use of uric-acid lowering drugs is necessary and can reduce the risk of complications and in some cases eliminate visible tophi completely.