Frequent Gout Flares: Next Step After IL-1 Blocker Treatment Did Not Resolve the Acute Flare
This protocol applies to patients with frequent gout flares who have contraindications to colchicine, NSAIDs, and corticosteroids (oral and injectable), and who have no current active infection.
Previous Treatment & Failure Condition
These patients were previously treated with canakinumab or anakinra for the acute gout flare. The goal of that treatment was resolution of the acute flare with relief of joint pain. When that target is not achieved, this protocol provides the defined next step.
Clinical Approach
Management at this stage centres on urate-lowering therapy, titrated to target, combined with specific dietary and lifestyle modifications. The complete regimen — including the agent, titration strategy, and full lifestyle guidance — is available in the structured protocol.
Treatment Goals
- Serum uric acid level <6 mg/dL (360 mmol/L), maintained lifelong
- Serum uric acid level <5 mg/dL (300 mmol/L) for patients with severe gout until total crystal dissolution
References
DOI: 10.1136/annrheumdis-2016-209707
- In patients with frequent flares and contraindications to colchicine, NSAIDs and corticosteroid (oral and injectable), IL-1 blockers should be considered for treating flares.
- Current infection is a contraindication to the use of IL-1 blockers.
- ULT should be adjusted to achieve the uricaemia target following an IL-1 blocker treatment for flare.
- In patients with normal kidney function, allopurinol is recommended for first-line ULT, starting at a low dose (100 mg/day) and increasing by 100 mg increments every 2-4 weeks if required, to reach the uricaemia target.
- Every person with gout should receive advice regarding lifestyle: weight loss if appropriate and avoidance of alcohol (especially beer and spirits) and sugar-sweetened drinks, heavy meals and excessive intake of meat and seafood.
- Low-fat dairy products should be encouraged.
- Regular exercise should be advised.
- For patients on ULT, SUA level should be monitored and maintained to <6 mg/dL (360 mmol/L).
- A lower SUA target (<5 mg/dL; 300 mmol/L) to facilitate faster dissolution of crystals is recommended for patients with severe gout (tophi, chronic arthropathy, frequent attacks) until total crystal dissolution and resolution of gout.
- SUA <6 mg/dL (360 mmol/L) should be maintained lifelong.