When to Discontinue Gout Medications
The 2020 American College of Rheumatology conditionally recommends continuing urate-lowering therapy indefinitely rather than stopping it, even in patients who achieve clinical remission. 1
The Evidence Against Stopping Treatment
The decision to discontinue gout medications is not straightforward, and current guidelines strongly favor indefinite continuation:
Insufficient evidence exists to safely identify patients who can stop urate-lowering therapy. The American College of Physicians systematic review concluded that despite three prospective observational studies showing some patients remained asymptomatic after stopping treatment, no randomized controlled trials have tested discontinuation strategies, making the evidence insufficient to establish safe stopping criteria. 1
Most patients who stop treatment will experience recurrent flares. In the largest cohort study of 211 patients who discontinued urate-lowering therapy after 5 years of well-controlled serum urate levels, only 13% remained flare-free during 5-year follow-up. 1
If You Must Consider Discontinuation: The "Dirty Dish" Hypothesis
Despite guideline recommendations for indefinite therapy, one high-quality observational study provides the only evidence-based criteria for potential discontinuation:
Consider stopping urate-lowering therapy ONLY if ALL of the following criteria are met:
Minimum 5 years of continuous urate-lowering therapy with consistently maintained serum urate levels <7 mg/dL (416 µmol/L) 1, 2
Complete absence of tophi at baseline, or 5 years after complete resolution of the last tophus 2
No gout flares for at least 1 year while on therapy 1
Annual serum urate levels remain <7 mg/dL after discontinuation 1, 2
Critical Monitoring After Discontinuation
If you attempt discontinuation despite guideline recommendations against it:
Serum urate levels are the strongest predictor of recurrence. Patients whose serum urate remained <7 mg/dL after stopping therapy had significantly lower recurrence rates. 1, 2
Check serum urate levels every 3-6 months after discontinuation to ensure levels remain below saturation threshold. 2
Factors associated with maintaining safe urate levels after stopping therapy include weight loss, use of losartan or fenofibrate, and avoidance of diuretics. 2
Factors predicting failure to maintain safe urate levels include diuretic use and inability to modify lifestyle risk factors. 2
Why Indefinite Treatment is Preferred
The 2020 American College of Rheumatology guideline specifically addressed this question and found:
Patient preference strongly favors continuing treatment. When therapy is well-tolerated and not burdensome, patients expressed preference to continue treatment rather than risk return or worsening of gout symptoms, tophi, or joint damage. 1
The "treat-to-target" strategy requires maintaining serum urate <6 mg/dL indefinitely to prevent crystal formation and achieve disease control. 1
Gout can be effectively cured by maintaining serum urate <6.0 mg/dL long-term, which resolves urate deposition, but this requires ongoing therapy in most patients. 3
Common Pitfalls to Avoid
Do not stop urate-lowering therapy after the first successful year of treatment. This is far too early, and recurrence is nearly guaranteed. 1
Do not discontinue based solely on symptom resolution. Asymptomatic hyperuricemia continues to deposit crystals even without clinical flares. 1, 3
Do not stop monitoring serum urate levels if you attempt discontinuation—this is the single most important predictor of recurrence. 1, 2
Do not attempt discontinuation in patients with history of tophi, chronic kidney disease, or urolithiasis, as these patients have higher disease burden and greater risk of complications. 1, 4
The Bottom Line
For the vast majority of patients with gout, the answer is: you should NOT stop all medications. The 2020 ACR guideline's conditional recommendation for indefinite continuation reflects the reality that stopping therapy leads to recurrence in 87% of patients, even after years of excellent control. 1, 2 If a patient insists on attempting discontinuation despite your counseling, the only evidence-based approach requires 5 years of perfect control, complete absence of tophi, and meticulous ongoing monitoring of serum urate levels to ensure they remain <7 mg/dL. 1, 2