BRIEF REPORT Anakinra for colchicine-intolerant/colchicine-resistant acute gout flare precipitated by decompensated heart failure Saad Shaukat Muhammad Hamza 1 & Muhammad Asim Shabbir 1 & Sukhraj Singh 1 & Mikhail Torosoff 2 & Ruben Peredo-Wende 3 Received: 13 June 2020 /Accepted: 17 July 2020 # Royal Academy of Medicine in Ireland 2020 Background Hyperuricemia and gout are associated with the progression and decompensation of heart failure and atherosclerotic coro- nary artery disease [1, 2]. Although known to cause hyperuri- cemia, the use of diuretics is unavoidable. Among convention- al treatment options for acute gout—NSAIDs (nonsteroidal anti-inflammatory drugs), colchicine, and glucocorticoids— only colchicine is safe in decompensated congestive heart failure. Acute gout flare in this high-risk population presents the challenge of managing gout-related systemic inflamma- tion balanced against avoiding use of medications known to worsen cardiovascular outcomes. Frequent coexistence of chronic kidney disease with heart failure limits the use of colchicine at therapeutic dose [3]. Alternatives are limited and not well-studied. We describe our single-center experi- ence with the use of anakinra (interleukin-1 inhibitor) for acute gout flares precipitated by decompensated heart failure, in patients with contraindications, intolerance, or symptoms refractory to colchicine. Methods Retrospective chart review of adult patients admitted to Albany Medical Center Hospital, between January 2018 and December 2019, for hemodynamically stable acute decom- pensated heart failure who received anakinra for a subsequent gout flare within the same hospitalization. The diagnosis of hemodynamically stable decompensated heart failure required all five criteria to be met: (i) prior history of heart failure, (ii) clinical hypervolemia on initial history/physical examination, (iii) serum brain natriuretic peptide greater than 400 pg/ml at the time of presentation, (iv) use of intravenous diuretics, and (v) no requirement for inotropic support. Patients with active infection or on immunosuppressant medications were exclud- ed. Reasons for colchicine intolerance/contraindication and duration of anakinra treatment (days) were recorded. Daily progress notes and discharge summary were reviewed to de- termine symptom “improvement” and “resolution,” respec- tively, as documented by the physician. Adverse effects or reasons, if any, for premature discontinuation of anakinra were also noted. Results Between January 2018 and December 2019, anakinra (100 mg SQ daily) was administered inpatient for acute gout flare pre- cipitated by decompensated heart failure in 13 hemodynami- cally stable patients. No patients were on other immunosup- pressants or had evidence of active infection. Baseline char- acteristics are described in Table 1. According to the guidelines [4], NSAIDs were universally avoided in decompensated heart failure. Therapeutic dosing of colchicine for acute gout was contraindicated in more than half the patients [8/13; (61.5%)] because of advanced chronic kidney disease (eGFR < 45 ml/min/1.73 m 2 ). Four patients (30.8%) had symptoms refractory to thera- peutic trial of colchicine, and one patient (7.7%) experienced colchicine-related severe diarrhea requiring discontinuation. Despite risk of worsening heart failure, the four patients who failed therapeutic trial of colchicine received oral * Saad Shaukat Muhammad Hamza hamzasaad1991@gmail.com 1 Department of Internal Medicine, Graduate Medical Education Office, Albany Medical College, 43 New Scotland Avenue, Albany, NY, USA 2 Department of Cardiology, Albany Medical College, Albany, NY, USA 3 Department of Rheumatology, Albany Medical College, Albany, NY, USA Irish Journal of Medical Science (1971 -) https://doi.org/10.1007/s11845-020-02322-3