Moving urate-lowering therapy in gout beyond guideline recommendations

The 'treat -to target serum urate strategy' when using urate-lowering therapy has been recommended by most specialist rheumatology societies for many years. An alternative "treat -to -avoid -symptoms" in gout has been suggested, albeit without a clear definition of what this means and how it might be implemented in clinical trials or clinical practice. This has hampered efforts to design clinical trials that compare the "treat -to -target [urate]" and "treat -to -avoid -symptoms" strategies in the long-term management of gout. In this review we consider the rationale for the treat -to -target urate strategy when using urate-lowering therapy, potential definitions of a "treat -to -avoid -symptoms" strategy, or perhaps what is not "treat -to -avoid -symptoms", and approaches that might address this uncertainty.