When should I consider urate-lowering therapy in patients with gout, and what are the guidelines for initiating treatment?

Urate-lowering therapy (ULT) should be considered in patients with gout who have: multiple or troublesome flares, chronic kidney disease (CKD) stages 3 to 5, diuretic therapy, tophi, or chronic gouty arthritis ¹.

It can also be discussed with patients experiencing their first or subsequent flare, especially if they have risk factors such as CKD, serum urate level over 9 mg/dL, or urolithiasis ¹.

Start ULT at least 2-4 weeks after a gout flare has settled, and ULT can be started during a flare if flares are more frequent ¹.

The treatment should follow a treat-to-target strategy, aiming for a serum urate level below 360 micromol/L (6 mg/dL), with consideration of a lower target below 300 micromol/L (5 mg/dL) for certain patients ¹.

Offer first-line ULT options such as allopurinol or febuxostat, taking into account the person's comorbidities and preferences, with allopurinol recommended first-line for those with major cardiovascular disease ¹.

Consider switching to second-line treatment if the target is not reached or if the first-line treatment is not tolerated ¹.