Which patients require a lifelong urate-lowering treatment following the first acute gout attack, and in which patients this is not necessary?
George Nuki: The answer to that is that we should certainly consider using urate-lowering drugs at the time of the first attack. I think if the uric acid level is persistently very high, that is an increased indication for trying to persuade the patient to consider using prolonged urate-lowering drugs even after their first attack. Certainly, if they are having multiple attacks, if they have some coexistent renal disease, if they have evidence of tophi—all of these are very strong indications for using urate-lowering drugs.
At the moment, the recommendation is that you should lower the uric acid level below the target for life. But we really do not have strong evidence to support lifelong treatment. That simply has not been studied. There were some studies way back in the 1970s when there was concern that there might be problems with using allopurinol in terms of muscle deposition and people stopped treatment that had been going on with allopurinol. It was very interesting to see that in some patients it took many months before they started having attacks again. But, on the whole, the recommendation at the moment is that you should go on with lifelong treatment. In a very small minority of patients, changing their lifestyle by gradual loss of weight, not drinking so much beer, not taking so many diets with a lot of meat and shellfish may actually make the difference—would allow one not to be able to do that. But in most patients, lifelong treatment with a urate-lowering drug, which is most often allopurinol, is the recommended treatment.