Gout is the most common form of inflammatory arthritis and results from persistent hyperuricemia leading to deposition of monosodium urate crystals within joints and soft tissues. Although conventional urate-lowering therapy remains effective for most patients, suboptimal adherence, delayed dose escalation, intolerance, and refractory disease continue to limit long-term disease control. Contemporary management has shifted toward a treat-to-target (T2T) strategy that aims to achieve and maintain serum urate concentrations below the saturation threshold to promote crystal dissolution and prevent recurrent flares, tophus formation, and structural joint damage. Recent advances have expanded therapeutic options through selective urate transporter inhibitors, next-generation xanthine oxidase inhibitors, engineered uricase formulations, immune tolerance platforms, biologic therapies targeting the IL-1 pathway, and novel NLRP3 inflammasome inhibitors. Emerging evidence also supports the potential urate-lowering and cardiometabolic benefits of sodium–glucose cotransporter-2 inhibitors, while advances in proteomics, metabolomics, and transcriptomics have identified promising biomarkers that may improve diagnosis, disease monitoring, and precision medicine approaches. This narrative review summarizes current evidence on treat-to-target strategies, established urate-lowering therapies, emerging pharmacologic agents, biologic therapies, and novel biomarkers, and highlights future directions that may facilitate individualized management of gout.