OBJECTIVES: To report on the efficacy and safety of anakinra for treatment of acute gouty arthritis in medically complex, critically ill patients. METHODS: Retrospective chart review of 13 critically ill hospitalized patients treated with anakinra for 20 episodes of acute gouty arthritis between 2009 and 2014 at a single health plan and institution (HealthPartners Medical Group and Regions Hospital) in Saint Paul, Minnesota. Data was obtained on baseline characteristics, medical comorbidities, reason for hospitalization, prior gout treatment, reason for choosing anakinra over standard therapy, anakinra dosing, response to treatment, and adverse outcomes. RESULTS: A total of 10 patients were in the Intensive Care Unit, 1 was in the Burn Unit for extensive 3rd degree burns, 1 was critically ill with a new diagnosis of hemophagocytic lymphohistiocytosis, and 1 was critically ill in isolation with active disseminated multidrug-resistant tuberculosis. Of these patients, 85% had active infections and 92% had renal insufficiency. All patients had a significant response to anakinra treatment: 50% (10/20 episodes) within 24h, an additional 40% (8/20 episodes) by 48h, and the remaining 10% (2/20 episodes) by 72h. Anakinra was well tolerated with only 1 case of leukopenia and 1 possible infectious complication. CONCLUSIONS: Anakinra is a safe and efficacious treatment for acute gouty arthritis in medically complex, critically ill patients when standard treatment modalities cannot be used.