OBJECTIVE: The patient experience of a gout flare is multi-dimensional. To establish the most appropriate methods of flare measurement, there is a need to understand the complete experience of a flare. This qualitative study aimed to examine what factors contribute to the severity of a flare from the patient perspective. METHODS: Face-to-face interviews were conducted with people with gout. Participants were asked to share their experience with their worst gout flare and contrast it to their experience of a less severe or mild flare. Interviews were audio-recorded and transcribed verbatim. Data was analysed using a reflexive thematic approach. RESULTS: Twenty-two participants with gout (17 males, mean age 66.5 years) were interviewed at an academic centre in Auckland, New Zealand. Four key themes were identified as contributing to the severity of a flare: flare characteristics (pain intensity, joint swelling, redness and warmth, duration, and location), impact on function (including walking, activities of daily living, wearing footwear, and sleep), impact on family and social life (dependency on others, social connection, and work) and psychological impact (depression, anxiety, irritability, and sense of control). CONCLUSION: A wide range of interconnecting factors contribute to the severity of a gout flare from the patient perspective. Capturing these domains in long-term gout studies would provide more meaningful and accurate representation of cumulative flare burden.