Gout is an inflammatory crystal arthritis characterised by hyperuricaemia and deposition of monosodium urate crystals (MSU) into joints and soft tissues. It manifests clinically as acute, intermittent, debilitating joint and soft tissue flares. If hyperuricaemia in people with gout is left untreated over time, flares can increase in frequency with more joints recruited and affected and tophi (nodular masses of MSU crystals) can deposit in joints and soft tissues resulting in irreparable erosive damage and disability. Urate lowering therapy (ULT) results in suppression of serum uric acid (SUA) and dissolution of deposited MSU crystals and tophi. Long-term ULT prevents acute, painful gouty episodes and formation of tophi with associated disability and can result in cure of gout if used early and effectively in the condition. ULT are usually offered to people who have had 2 or more acute gout flares; people with tophi; people with gout and chronic kidney disease and people with evidence of gouty erosive changes or tophaceous deposition on imaging. In current UK practice, allopurinol is used as first line ULT and febuxostat as second line when allopurinol is not tolerated or contraindicated. Rasburicase is not specifically licenced for the management of gout, however, it has the potential to reduce serum uric acid levels. Amlodipine, fenofibrate, losartan and Vitamin C have been reported to reduce serum urate levels, but it is unclear if they have a role in gout. This review evaluates which ULT is effective as first-line and second line treatment.