Patient case (clinical description): A 39-year-old man comes to the emergency department with an acute onset of severe left toe pain.  The toe is red and exhibits swelling. The patient is not febrile, and does not remember any recent trauma. Medical history is not significant except for the similar attacks and the diagnosis of gouty arthritis. His medication history includes Allopurinol to prevent gouty attacks. His father has the same medical condition. However, his older brother who is 41 years old is healthy with no history of gouty arthritis. Physical examination shows a swollen, tender first metatarsophalangeal joint.  Aspiration of the joint showed high leukocyte count, negative Gram stain, and numerous needle-shaped crystals, which is compatible with gouty arthritis.

Patient's own account: I'm a 39-year-old man and got admitted to the ER after an unbearable pain in my left toe. My toe was red and terribly swollen. I was still standing on my feet, not febrile and I don't remember hitting my head or anything. I don't have any special medical history, but I had been diagnosed with gout before. I take Lopurin to prevent my gouty attacks. My dad had the same problem, but my 41-year-old brother is healthy and does not have gouty attacks. The doctor did a physical exam and found that the joints between my toes and the rest of my foot were swollen and tender. The doctor renewed his diagnosis of gouty arthritis.

Clinical trial: Combination Treatment Study in Subjects With Tophaceous Gout With Lesinurad and Febuxostat

Eligibility criteria:
Inclusion Criteria:

          -  Subject is able to understand the study procedures, the risks involved and willing to
             provide written informed consent before the first study related activity.

          -  Subject is willing to adhere to the visit/protocol schedules.

          -  Subject meets the diagnosis of gout as per the American Rheumatism Association

          -  Criteria for the Classification of Acute Arthritis of Primary Gout.

          -  Subject meets one of the following criteria:

          -  Subjects who are not currently taking an approved ULT must have an sUA value of ≥ 8
             mg/dL (476 µmol/L).

          -  Subjects entering the study on a medically appropriate dose of febuxostat or
             allopurinol must have an sUA value of ≥ 6.0 mg/dL (357 µmol/L).

          -  Subject must be able to take gout flare prophylaxis with colchicine or non-steroidal
             anti-inflammatory drug (NSAID) (including Cox-2 selective NSAID) ± PPI.

          -  Subject with at least 1 measurable tophus on the hands/wrists and/or feet/ankles ≥ 5
             mm and ≤ 20 mm in the longest diameter.

          -  Body mass index (BMI) < 45 kg/m2

        Exclusion Criteria:

          -  Subject with known hypersensitivity or allergy to febuxostat.

          -  Subject who is taking any approved urate-lowering medication other than allopurinol or
             febuxostat that is indicated for the treatment of gout within 8 weeks of the Screening
             Visit.

          -  Subject who previously received pegloticase.

          -  Subject who consumes more than 14 drinks of alcohol per week (eg, 1 drink = 5 oz [150
             mL] of wine, 12 oz [360 mL] of beer, or 1.5 oz [45 mL] of hard liquor).

          -  Subject with a history or suspicion of drug abuse within the past 5 years.

          -  Subject with a history of myositis/myopathy or rhabdomyolysis.

          -  Subject that requires or may require systemic immunosuppressive or immunomodulatory
             treatment.

          -  Subject with known or suspected human immunodeficiency virus (HIV) infection.

          -  Subject with a positive test for active hepatitis B or hepatitis C infection.

          -  Subject with a history of malignancy within the previous 5 years with the exception of
             non-melanoma skin cancer that has been treated with no evidence of recurrence, treated
             cervical dysplasia or treated in situ Grade 1 cervical cancer.

          -  Subject within the last 12 months with: unstable angina, New York Heart Association
             thrombosis; or subjects currently receiving anticoagulants.

          -  Subject with uncontrolled hypertension.

          -  Subject with an estimated creatinine clearance < 30 mL/min.

          -  Subjects with a creatine kinase > 2.5 x ULN at any time during the Screening Period.

          -  Subject with active peptic ulcer disease requiring treatment.

          -  Subject with a history of xanthinuria, active liver disease, or hepatic dysfunction.

          -  Subject receiving chronic treatment with more than 325 mg of salicylates per day.

          -  Subject taking valpromide, progabide, or valproic acid.

          -  Subject who has received an investigational therapy within 8 weeks or 5 half-lives
             (whichever is longer) prior to the Screening Visit.

          -  Subject with any other medical or psychological condition, which in the opinion of the
             Investigator and/or Medical Monitor, might create undue risk to the subject or
             interfere with the subject's ability to comply with the protocol requirements, or to
             complete the study.
No condition on gender to be admitted to the trial.
No healthy subjects accepted to join the trial.
Subject must be at least 18 Years old.
Subject must be at most 85 Years

Eligibility (NLI label): Contradiction