Table 1.

Indications for pharmacologic urate-lowering therapy (ULT)^*

Recommendation	PICO question	Certainty of evidence
For patients with 1 or more subcutaneous tophi, we strongly recommend initiating ULT over no ULT.	1	High
For patients with radiographic damage (any modality) attributable to gout, we strongly recommend initiating ULT over no ULT.	2	Moderate
For patients with frequent gout flares (≥2/year), we strongly recommend initiating ULT over no ULT.	3	High
For patients who have previously experienced >1 flare but have infrequent flares (<2/year), we conditionally recommend initiating ULT over no ULT.	4	Moderate
For patients experiencing their first flare, we conditionally recommend against initiating ULT over no ULT, with the following exceptions.	5	Moderate
For patients experiencing their first flare and CKD stage ≥3, SU >9 mg/dl, or urolithiasis, we conditionally recommend initiating ULT.	5	Very low
For patients with asymptomatic hyperuricemia (SU >6.8 mg/dl with no prior gout flares or subcutaneous tophi), we conditionally recommend against initiating any pharmacologic ULT (allopurinol, febuxostat, probenecid) over initiation of pharmacologic ULT.	57	High†
Strongly recommend Conditionally recommend Strongly recommend against Conditionally recommend against

^*PICO = population, intervention, comparator, outcomes; CKD = chronic kidney disease; SU = serum urate.

^†There is randomized clinical trial data to support the benefit that ULT lowers the proportion of patients who develop incident gout. However, based on the attributable risk, 24 patients would need to be treated for 3 years to prevent a single (incident) gout flare leading to the recommendation against initiating ULT in this patient group.