ACR 2022 Tweet by Robert B Chao, MD

In most mammals, uricase catalyzes the oxidation of uric acid to allantoin, a highly soluble compound easily excreted by the kidneys. But humans lack functional uricase, leaving xanthine oxidase inhibitors (allopurinol/febuxostat) as first-line urate-lowering therapy (ULT). Uricase-based biologics are reserved for uncontrolled/refractory gout patients with gouty flares, active synovitis, and/or non-resolving tophi despite optimized oral ULT.

Lowering serum urate and urate crystals in the body is indispensable for long-term management of gout. The pathophysiology is simple and powerful: no urate crystals, no gout flares. However, this simplicity in goal belies a nuanced consideration in management: how low should serum urate be…