Hyperuricemia! When to treat?

Are we justified to treat asymptomatic hyperuricemia with urate lowering drugs i.e. Allopurinol / Febuxostat?

American College of Rheumatology 2020 guidelines conditionally recommend against using urate lowering therapy for patients with asymptomatic hyperuricemia. Multiple (RCTs) Randomized Controlled Trials, 24 patients would need to be treated with ULT for 3 years to prevent a single (incident) gout flare.

As per ACR guidelines;

"The Voting Panel felt that, on average, for the majority of patients with asymptomatic hyperuricemia (including those with comorbid CKD, CVD, urolithiasis, or hypertension), the benefits of ULT would not outweigh potential treatment costs or risks for the large number of patients unlikely to progress to gout. This is also the case for patients with asymptomatic hyperuricemia with MSU crystal deposition as noted on imaging tests such as ultrasound or dual-energy computed tomography"

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