OBJECTIVES To measure the health care utilization of US veteran patients with gout and to determine additional costs associated with difficult to manage gout (DMG). METHODS Using diagnostic codes (ICD-9 CD = 274.XX), we identified patients with gout in 2004 from the national Veterans Affairs Health Care System (VA) databases. We then collected all administrative data (demographic, inpatient and outpatient care, pharmacy, laboratory, and tests) for these patients over the years 2004-2006. DMG patients were identified by diagnostic codes associated with complications of the skin (tophi), eye, nerve, and kidney. We created data summaries for each patient by year; including diagnoses, treatments, drug therapies, laboratory tests, and surgeries. RESULTS There were 220,451 gout and 10,115 DMG patients identified in 2004. Each year, healthcare costs per patient were significantly higher (Kruskal Wallis tests, P<0.001) for DMG versus other gout patients: inpatient costs = $12,018 (±71334) versus $4,812 (±44587) in 2004, $12,182 (±64877) versus $3,659 (±30603) in 2005, $7,992 (±36851) versus $2,704 (±19774) in 2006; outpatient costs = $4,110 (±9224) versus $2,016 (± 4196) in 2004, $5,851 (± 11057) versus $3,058 (±6095) in 2005, $6,130 (±11169) versus $3265 (±6991) in 2006. In addition DMG patients were significantly (P<0.001) younger (64.4 vs. 66.5 years), but had higher Charlson co-morbidity scores (2.79 vs. 2.22), and were more likely to have concomitant cardiovascular, renal, and liver diseases. A limitation of the study is the lack of specificity of diagnostic codes for complications due to gout, which may impact the sample size. CONCLUSIONS Health care costs are significantly higher for DMG patients. We note that increased inpatient plus outpatient costs for DMG patients were $10,000 to $16,000 per patient-year. These VA patients also have significantly more co-morbid conditions than other gout patients.