Guide
Why do I still flare? Medication, diet and what each one does
Most people who eat well and still flare haven't done anything wrong. Uric acid is set mostly by how your kidneys clear it, so food moves it only a little, and medication does most of the work. Even at target, crystals already in the joint take months to dissolve, and flares often rise in the first months of treatment before they fall.
By Oliver Silen Sources checked October 5, 2026
The number that predicts fewer flares
The 2020 American College of Rheumatology guideline strongly recommends keeping uric acid below 6 mg/dL for everyone on urate-lowering treatment. The 2016 EULAR recommendations add a lower target, below 5 mg/dL, for severe gout. ACR sets no lower threshold, because no trial has tested one.
A normal reading during a flare doesn't rule gout out. In 339 people seen mid-attack, 14% had uric acid at or below 6 mg/dL. What each band means is on uric acid levels, explained.
Source: ACR 2020 gout guidelineEULAR 2016 gout recommendationsSchlesinger et al. 2009, J Rheumatol
Why flares can rise when treatment starts
As uric acid falls, crystals in the joint loosen, and loose crystals set off flares. The allopurinol label warns of flares "after initiation" for this reason, and the febuxostat label says an increase "is frequently observed". Across three trials of 4,101 patients, flare rates rose by up to 40% when 8 weeks of preventive medicine ended, against 3% to 5% after 6 months of it.
That's why the ACR guideline strongly recommends 3 to 6 months of anti-inflammatory prophylaxis alongside a new urate-lowering drug. More flares in month two usually means the drug is working, not failing. Your doctor decides how long to continue.
Source: Wortmann et al. 2010, Clin TherACR 2020 gout guideline
Crystals take months to clear
Reaching target stops new crystals forming. Old ones dissolve slowly. In 18 men whose uric acid was brought to a median of about 4.9 mg/dL, joint crystals took 3 to 33 months to disappear, and the longer someone had had gout, the longer it took. Among those with gout under 10 years, 9 of 10 joints were clear at one year.
Source: Pascual & Sivera 2007, Ann Rheum Dis
What diet adds on top of medication
Less than most people hope. The ACR guideline says dietary changes "likely yield only small changes" in uric acid. In a 30-person trial of patients already on treatment, six months of diet education left uric acid at 0.27 against 0.30 mmol/L, which the authors called no clinically significant difference. Across 16,760 people in five cohorts, each diet score explained 0.3% or less of the variation in uric acid, against 23.9% for common genetic variants.
Food still matters for flares, even when it barely moves the number. ACR's advice to limit alcohol, purines and high-fructose corn syrup applies to everyone with gout, "regardless of disease activity", and losing weight is recommended for anyone overweight. The gout diet page covers what that looks like day to day.
Source: ACR 2020 gout guidelineHolland & McGill 2015, Intern Med JMajor et al. 2018, BMJ
Alcohol, on and off treatment
In 724 people with gout followed through 1,434 flares, the odds of a flare climbed with each step in drinks over the previous 24 hours, compared with no alcohol:
| Drinks in 24 hours | Flare odds |
|---|---|
| More than 0 to 1 | 1.13x (not significant) |
| More than 1 to 2 | 1.36x |
| More than 2 to 4 | 1.51x |
| More than 4 to 6 | 1.87x |
| More than 6 to 8 | 2.33x |
| More than 8 | 3.13x |
In the same study, people taking allopurinol showed no rise in flare odds with drinking, and the authors concluded the drug "mitigated" alcohol's effect. The study recorded whether people took allopurinol, not whether they had reached 6 mg/dL, so it can't say alcohol is safe at target. Drink-by-drink detail is on alcohol and gout.
Source: Neogi et al. 2014, Am J Med
Other medicines that move uric acid
Diuretics. In 5,789 adults with high blood pressure, starting a diuretic raised uric acid by 0.72 mg/dL more than not starting one. Gout risk was 1.44 times higher on a thiazide and 2.31 times higher on a loop diuretic.
Low-dose aspirin. Taking 325 mg a day or less on two consecutive days was linked to 1.81 times the odds of a flare, an effect that disappeared in people also taking allopurinol. The ACR guideline recommends against stopping low-dose aspirin taken for a heart reason.
Losartan. This blood-pressure drug lowers uric acid slightly. In 13 people with gout it went from 9.0 to 8.3 mg/dL. ACR conditionally recommends switching from hydrochlorothiazide and choosing losartan where feasible, which is a conversation for your doctor, never a swap to make yourself.
Source: McAdams-DeMarco et al. 2012, Arthritis RheumZhang et al. 2014, Ann Rheum DisWürzner et al. 2001, J HypertensACR 2020 gout guideline
Food and drug interactions
Colchicine and grapefruit. The Colcrys label says grapefruit and grapefruit juice "should not be consumed" during treatment, because grapefruit can slow how the body clears colchicine. The label's own 21-person study measured little change, so the warning is precautionary, and it still applies.
Allopurinol and fluids. The allopurinol label advises taking it after meals to limit stomach upset and drinking enough to pass at least 2 liters of urine a day. The febuxostat label says it can be taken with or without food.
Source: Colcrys (colchicine) prescribing information
Quick answers
- Do I still need to watch my diet on allopurinol?
- Diet adds little to urate once you take urate-lowering medication. In a 30-person trial of treated patients, six months of diet education left uric acid at 0.27 against 0.30 mmol/L, no clinically significant difference. The 2020 ACR guideline still recommends limiting alcohol, purines and high-fructose corn syrup for everyone with gout, regardless of treatment, because food can still trigger a flare.
- Why am I getting more flares since I started allopurinol?
- Falling uric acid loosens crystals already in the joint, and the allopurinol and febuxostat labels both warn that flares often rise after starting. In three trials of 4,101 patients, flare rates rose by up to 40% once 8 weeks of preventive medicine ended. The 2020 ACR guideline strongly recommends 3 to 6 months of anti-inflammatory prophylaxis for that reason.
- How long until urate-lowering medication stops my flares?
- Crystals dissolve slowly even at target. In one study of 18 men whose uric acid was brought to a median of about 4.9 mg/dL, crystals took 3 to 33 months to clear, longer for people who had gout longer.
Sources
- 1. Source: FitzGerald JD, et al. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Care Res. 2020;72(6):744–760.
- 2. Source: Richette P, et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis. 2017;76(1):29–42.
- 3. Source: Schlesinger N, Norquist JM, Watson DJ. Serum urate during acute gout. J Rheumatol. 2009;36(6):1287–1289.
- 4. Source: Wortmann RL, et al. Effect of prophylaxis on gout flares after the initiation of urate-lowering therapy: analysis of data from three phase III trials. Clin Ther. 2010;32(14):2386–2397.
- 5. Source: Pascual E, Sivera F. Time required for disappearance of urate crystals from synovial fluid after successful hypouricaemic treatment relates to the duration of gout. Ann Rheum Dis. 2007;66(8):1056–1058.
- 6. Source: Holland R, McGill NW. Comprehensive dietary education in treated gout patients does not further improve serum urate. Intern Med J. 2015;45(2):189–194.
- 7. Source: Major TJ, Topless RK, Dalbeth N, Merriman TR. Evaluation of the diet wide contribution to serum urate levels: meta-analysis of population based cohorts. BMJ. 2018;363:k3951.
- 8. Source: Neogi T, et al. Alcohol quantity and type on risk of recurrent gout attacks: an internet-based case-crossover study. Am J Med. 2014;127(4):311–318.
- 9. Source: McAdams DeMarco MA, et al. Diuretic use, increased serum urate levels, and risk of incident gout in a population-based study of adults with hypertension: the ARIC cohort study. Arthritis Rheum. 2012;64(1):121–129.
- 10. Source: Zhang Y, et al. Low-dose aspirin use and recurrent gout attacks. Ann Rheum Dis. 2014;73(2):385–390.
- 11. Source: Würzner G, et al. Comparative effects of losartan and irbesartan on serum uric acid in hypertensive patients with hyperuricaemia and gout. J Hypertens. 2001;19(10):1855–1860.
- 12. Source: COLCRYS (colchicine, USP) tablets. Full prescribing information and Medication Guide. Takeda Pharmaceuticals America, revised 05/2020.
Last reviewed October 5, 2026.
Related: the gout diet · during a flare · uric acid levels
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