How should I approach the management of a patient with gout who is experiencing recurrent attacks despite treatment?

For patients with recurrent gout attacks despite ongoing treatment, consider reviewing and optimizing urate-lowering therapy (ULT) using a treat-to-target strategy to achieve a serum urate level below 360 micromol/L (6 mg/dL), or below 300 micromol/L (5 mg/dL) if they have tophi or ongoing flares despite lower levels ¹.

Start or adjust ULT at least 2-4 weeks after a gout flare has settled, and consider initiating during a flare if flares are frequent ¹.

Use a low dose of ULT initially and guide dose increases with monthly serum urate levels until the target is reached ¹.

Discuss with the patient the benefits and risks of continuing or initiating long-term ULT, and consider adding or optimizing prophylactic treatment to prevent flares during titration, such as colchicine, NSAIDs, or corticosteroids, especially if flares are frequent or severe ¹.

Ensure management of comorbidities and lifestyle factors, including weight management, alcohol intake, and medication review, to reduce flare frequency ¹.

If flares persist despite optimal ULT, consider referral to a rheumatology service for further assessment and management ¹.