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The label "refractory gout" may be doing more harm than good. Rheumatology expert Dr. Brian Mandell argues that most so-called refractory cases are actually the result of undertreated hyperuricemia, mobilization flares from dissolving urate crystals, or complex comorbidities — not true treatment resistance. He proposes reframing the condition as "difficult gout" and sorting cases into three manageable buckets.
The label "refractory gout" may be doing more harm than good. At the Perspectives in Rheumatic Diseases (PRD) 2026 conference, Dr. Brian Mandell of Cleveland Clinic argued that most cases labeled refractory are actually undertreated hyperuricemia, flares from dissolving urate crystals, or gout complicated by comorbidities — not true treatment resistance. He prefers the term "difficult gout" and believes nearly all cases can be controlled with the right approach and enough time.
Central to his argument is the treat-to-target (T2T) strategy, which aims to keep serum urate below 6 mg/dL. The 2026 GO TEST study found T2T nearly doubled remission rates (39% vs. 24%) compared to symptom-driven care. Mandell also suggested the 6 mg/dL target may still be too high — a 2018 study found nearly 40% of patients at that level still had detectable urate deposits on imaging.
Key Takeaways:
Why it matters: Mislabeling gout as refractory can lead clinicians to abandon effective strategies prematurely. With proper dose optimization, combination therapy, and long-term adherence, most patients — even those with severe disease — can achieve meaningful disease control.
