Purpose of review Although gout is one of the most common forms of inflammatory arthritis, it has been relatively neglected until recently. Despite progress in many areas of pathophysiology and genetics of gout and the development of new urate lowering therapies, there remain a number of unanswered clinical questions. With the resurgence of interest in gout it is important to recognize key aspects of gout management that remain challenging and require further research. Recent findings The unanswered clinical issues outlined in this review are basic aspects of gout management that clinicians treating people with gout face on a daily basis and include when urate lowering therapy should be commenced, the most appropriate target serum urate, use of prophylaxis when starting urate lowering therapy and the most appropriate urate lowering therapy, particularly for those with chronic kidney disease. Summary Some of the issues outlined in this article are the subject of ongoing clinical research and some, such as use of allopurinol in people with chronic kidney impairment, may be less relevant with the advent of potentially safer urate lowering therapies but until that time further understanding to aid clinical decision-making is required.