How I treat complex and refractory gout flares.

Gout is an increasingly prevalent condition with high global burden of disease due to a myriad of factors, including population ageing, rising affluence, changes in dietary habits and higher rates of obesity and metabolic syndrome. While many cases of gout flares can be managed with standard anti-inflammatory medications (colchicine, non-steroidal anti-inflammatory drugs and/or corticosteroids), increasingly, there are patients who are refractory, intolerant or unsuitable (due to associated cardiometabolic conditions) for such treatments - whom we define as the "difficult-to-treat" cases. In this article, we sought to provide a practical approach to treating such cases of complex and refractory gout flares, through a simple 4A acronym (consider Alternate diagnosis, use of Anakinra and other IL-1 receptor antagonists, ACTH injections and Adjuvant measures).