There are several drugs which can correct hyperuricemia; these will be considered in detail on Bryan’s gout site.
But when should drug therapy be begun? This is usually accepted as being desirable when all of the following situations apply.
When there is persistent hyperuricemia, greater than 0.42 mmol/L (7 mg per 100 mL)
When the patient has had 2-3 definite attacks of gout (the interval between early attacks may range between a few months to a couple of years), and
When the patient is sufficiently persuaded of the need to take tablets regularly and permanently.
Some patients will decide on the need for drug treatment after a single attack of gout, but many patients who start drug treatment before they are fully persuaded will stop treatment once they have been asymptomatic for a period of months or years.
However, intermittent treatment to correct hyperuricemia is not desirable because, unless the cause is corrected, the hyperuricaemia returns and is followed after a time by further gout.
Nobody likes to make decisions about taking tablets for the rest of their lives unless it is absolutely essential. Accordingly, it is generally better not to begin drug treatment to lower the serum urate until you, the patient, are completely persuaded by the frequency and severity of the gout that you need to continue with drug treatment permanently, together with sufficient observation of serum urate to ensure that it stays within the optimal range.
No harm will usually come from delaying treatment to lower the serum urate until there have been several definite attacks of gout, unless you are needing to take drugs such as NSAIDs frequently to suppress gouty inflammation. In such a situation, severe gout can occur which is often tophaceous and usually difficult to control.
In addition, drug treatment to correct hyperuricaemia should only be begun when the risk of an acute attack of gout is minimal. This means that you should desirably have no acute gout and no residual joint inflammation and should be receiving prophylactic colchicine. Under these conditions, and when any investigation has been completed into contributory factors which might be corrected, drug treatment can begin.
This is probably best undertaken with slowly increasing doses, starting with a low initial dose. This dose can be increased progressively, often with weekly increments, until the optimal dose is reached which can result in appropriate lowering of the serum urate concentration.
As already mentioned, drugs can sometimes be used to control the hyperuricaemia while the cause of the hyperuricaemia is being corrected, if that correction is likely to be prolonged.