In an acute gout attack, should I use ice or heat for pain relief?

Ice for Acute Gout Pain Relief

For an acute gout attack, apply topical ice to the affected joint as an adjunctive measure alongside—not instead of—pharmacologic anti-inflammatory therapy. Ice is recommended by major rheumatology guidelines, but should never be used as monotherapy for gout flares. 1

Evidence-Based Recommendation

• The American College of Rheumatology explicitly recommends topical ice application as an appropriate adjunctive measure to one or more pharmacologic therapies for acute gouty arthritis (Evidence Grade B). 1

• The 2020 ACR guidelines conditionally recommend using topical ice as an adjuvant treatment over no adjuvant treatment for patients experiencing a gout flare, though the supporting data is noted to be limited. 1

• Heat is not recommended and is not mentioned in any major gout management guidelines as a treatment modality for acute gout attacks. 1

Why Ice Works (and Heat Doesn't)

• Ice provides local anti-inflammatory effects by reducing metabolic activity and inflammatory mediator release in the acutely inflamed joint, which is consistent with the pathophysiology of acute gout as a crystal-induced inflammatory arthritis. 2

• Heat would theoretically worsen inflammation by increasing local blood flow and metabolic activity in an already inflamed joint, which is why it has no role in acute gout management. 1

Critical Implementation Points

• Ice must always be combined with first-line pharmacologic therapy—either NSAIDs at full anti-inflammatory doses, low-dose colchicine (1.2 mg followed by 0.6 mg one hour later), or oral corticosteroids (prednisone 30-35 mg daily for 3-5 days). 1, 3, 4

• Rest of the inflamed joint is also recommended as a complementary non-pharmacologic measure during acute attacks. 5

• Ice application should be used throughout the acute flare period until complete resolution of symptoms. 1

Common Pitfalls to Avoid

• Never rely on ice alone for gout pain relief—this would be inadequate treatment and could lead to prolonged suffering and potential joint damage from untreated inflammation. 1

• Do not delay pharmacologic therapy while trying non-pharmacologic measures first; early anti-inflammatory treatment (ideally within 24 hours of symptom onset) is crucial for optimal outcomes. 3, 4

• Do not apply heat to an acutely inflamed gouty joint, as this has no evidence base and could theoretically worsen inflammation. 1

Practical Application

• Apply ice packs to the affected joint for 15-20 minutes at a time, several times daily, while taking prescribed anti-inflammatory medications. 1

• Continue ice application as needed for symptomatic relief throughout the acute flare. 1

• Ensure the patient understands that ice is supplementary to—not a replacement for—their prescribed medications. 1