Refractory gout remains a major clinical challenge for rheumatologists, especially when patients have multiple comorbidities that contraindicate conventional first-line anti-inflammatory agents, including nonsteroidal anti-inflammatory drugs (NSAIDs) and high-dose corticosteroids. Tumor necrosis factor-α (TNF-α) is a key downstream pro-inflammatory cytokine that drives sustained inflammation in gout, and TNF-α inhibitors have been reported to be effective for refractory gout in small clinical series. We herein report a successful case of refractory gout treated with the widely accessible TNF-α antagonist etanercept in a patient with multiple contraindications to conventional therapy.

A 38-year-old male with a 10-year history of untreated recurrent gout presented with a 5-day exacerbation of polyarticular redness, swelling, and pain after alcohol consumption. His comorbidities included grade 3 hypertension (very high risk), chronic kidney disease, severe iron deficiency anemia, hypoproteinemia, and drug-induced adrenal insufficiency secondary to previous life-threatening gastrointestinal bleeding from a gastric antral ulcer. On admission, physical examination detected multiple subcutaneous tophi across the trunk and limbs, with local tenderness, elevated skin temperature, and limited range of motion of the left knee. Laboratory tests showed marked elevation of inflammatory markers (erythrocyte sedimentation rate 120 mm/h, hypersensitive C-reactive protein 257.06 mg/L, interleukin-6 2556.08 pg/ml), serum uric acid 563 μmol/L, creatinine 155 μmol/L, and hemoglobin 56 g/L. Initial treatment with corticosteroids failed to relieve joint symptoms; NSAIDs were contraindicated due to chronic kidney dysfunction, and high-dose corticosteroids were prohibited by the high risk of recurrent gastrointestinal bleeding. After excluding biologic contraindications (active tuberculosis, viral hepatitis, and malignancy), etanercept 25 mg twice weekly subcutaneous injection was added as rescue therapy.

After one week of etanercept treatment, the patient's joint pain and swelling resolved significantly, and inflammatory markers decreased by >50% from baseline. No adverse events (infection, gastrointestinal bleeding, renal function deterioration) were observed during treatment. The patient was discharged smoothly and remained free of recurrent gout flare at 1-month follow-up.

Etanercept is a safe and effective rescue option for patients with refractory gout who have contraindications to conventional anti-inflammatory therapy, especially those with multiple comorbidities. Given its wide accessibility and lower cost compared to interleukin-1 inhibitors, etanercept is a valuable clinical treatment alternative for refractory gout.