Chronic asymptomatic hyperuratemia (HUA), gout paroxysm in patients with chronic hyperuratemia (HU) and normouricemic attacks of gouty arthritis are well known, but poorly understood. A review of the current literature with attempt of its explanation is presented. The natural course of gout is associated with joint structure changes that may be evaluated by different imaging techniques; comparative advantages and shortcomings of each technique are presented. For almost over 50 years the market has not offered new drugs for the control of HU and gout, while management of such patients was a rather neglected field. Over the last five years an unpredictable number of prospective clinical studies have been conducted involving the investigation of the efficacy and safety of new drugs to control HU (febuxostat, pegloticase). The return of pharmaceutical industry into the world of gout has considerably changed the picture. New recommendations have been presented on appropriate colchicine dose regime for acute gouty flares. Emerging therapies, including pegloticase, uricosuric agent RDEA596 and the interleukin -1 inhibitors have shown promises in early and late phase clinical trials. Each of them deserves to be considered for implementation and feasibility in clinical practice as well as outcome measures for clinical trials. Another purpose of this review was to summarize new knowledge on approved drugs to treat hyperuricemia, or the clinical manifestations of gout. Results of several clinical trials provide new data on the efficacy and safety of the approved urate lowering drugs (allopurinol and febuxostat). Lifestyle and dietary recommendations for gout patients should take into consideration overall health benefits and risks, since gout is often associated with metabolic syndrome and an increased future risk of cardiovascular disease and mortality. This review also summarizes the recent data about lifestyle factors that influence serum uric acid levels and the gout risk, and attempts to provide holistic recommendations, considering both their impact on gout as well as on other health implications.