We read the article by Inotai et al. with interest [1]. Whether allopurinol should be started before the first gout flare is a practical question, especially in people already at high cardiovascular risk. The authors have appropriately presented their analysis as hypothesis-generating and have acknowledged the uncertainty around causality. Our main concern is therefore not the presence of this caveat, but whether its implications were tested quantitatively in the model. The projected cardiovascular and renal benefits should be interpreted cautiously.
