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