Which patients with asymptomatic hyperuricemia require treatment? Is it a risk factor for cardiovascular events or renal failure?
George Nuki: I think it has almost certainly been proven now that it is a risk factor but we do not have good enough evidence, because we have no evidence from randomized controlled trials showing that when treating people with asymptomatic hyperuricemia the benefits will outweigh the risks. I think, in general, that should not be done, but of course patients after their first attack of gout are very frequently asymptomatic for a long period of time, even though they have crystal deposition. We are treating many of these patients with urate-lowering drugs – most of those patients, one would hope. The evidence with regard to renal disease has definitely increased in recent years and hyperuricemia is a risk factor for ongoing renal insufficiency; I think that has been established. But I think around the world it is only in Japan where consensus guidelines actually recommend treatment of asymptomatic hyperuricemia with urate-lowering drugs.