Adults
Gout: complex or refractory
Tophi, frequent flares despite urate-lowering therapy, failure to reach target, intolerance, advanced CKD or diagnostic doubt.
What to look for
- Tophaceous gout or radiographic damage
- Two or more flares a year despite adequately dosed urate-lowering therapy (ULT)
- Serum urate not below 6 mg/dL despite titration, or allopurinol hypersensitivity or intolerance
- CKD stage 4–5, transplant, or other comorbidity that makes ULT difficult
- Diagnostic uncertainty (gout vs CPPD vs septic or inflammatory arthritis), especially when aspiration isn't possible
What to do
- Send serum urate, creatinine/eGFR, CBC and liver tests, and include joint aspiration results if available.
- List ULT doses and duration, flare frequency and prophylaxis.
- Pegloticase (with methotrexate) is an option for refractory tophaceous gout.
About this urgency level
Specialist evaluation helps, but these are usually less time-sensitive than new inflammatory arthritis or connective tissue disease.
Timeframes are typical targets. Local pathways, capacity and clinical judgment come first.