High Uric Acid

Meet Dr. Syed Alam, MD, FACR

Double Board-Certified, Fellowship-Trained Rheumatologist · Musculoskeletal Ultrasound Trained · 10+ Years of Experience

Dr. Alam completed his rheumatology fellowship at Temple University Hospital after an internal medicine residency at John H. Stroger, Jr. Hospital. His clinical interests include rheumatoid arthritis, lupus, psoriatic arthritis, gout, Sjögren’s disease, osteoporosis and other rheumatic conditions.

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What uric acid is and why it rises

Uric acid is a waste product created when the body breaks down purines, substances found in our own cells and in some foods. The kidneys clear most of it. When production outpaces clearance, or more commonly when the kidneys do not excrete enough, the level in the blood rises.

In roughly nine out of ten people with high uric acid, the reason is reduced excretion by the kidneys rather than excessive production. This is largely genetic. It is worth knowing, because it corrects the common assumption that a high level reflects poor eating habits.

The word for a high level

A raised uric acid without symptoms is called asymptomatic hyperuricaemia. It is common, affecting a substantial proportion of adults, and the majority never develop gout or any other consequence.

What a high level does and does not mean

It is a risk factor, not a diagnosis

A high uric acid raises the chance of urate crystals forming in joints, but plenty of people carry high levels for decades without an attack. The diagnosis of gout requires symptoms, ideally confirmed by finding crystals in joint fluid, not simply a number on a blood test.

The reverse also applies

Uric acid frequently falls during an acute gout attack, sometimes into the normal range. A normal level measured while a joint is inflamed does not exclude gout, and this is a common source of missed diagnoses. It should be rechecked a few weeks after the attack settles.

What the number means once gout is diagnosed

Here the level becomes genuinely important. Treatment aims to bring uric acid below a target, usually 6 mg/dL, and lower where there are visible deposits called tophi. Below that threshold existing crystals dissolve and no new ones form, and attacks stop for the large majority of people. Uric acid is then measured regularly to confirm the target is being maintained.

Photo for illustration. Images do not depict patients of this practice.

What raises uric acid

Factors you cannot change

• Genetics, which strongly influence how the kidneys handle uric acid
• Male sex, and in women a rise after menopause
• Reduced kidney function
• Increasing age

Factors you can influence

• Beer and spirits, which raise uric acid more than wine
• Drinks sweetened with fructose, including many soft drinks and fruit juices
• Large amounts of red meat, organ meats and shellfish
• Obesity and metabolic syndrome
• Dehydration
• Rapid weight loss and crash dieting, which can trigger attacks

Medications

Diuretics used for blood pressure or heart failure raise uric acid substantially, as does low-dose aspirin. Some transplant medicines have the same effect. None should be stopped without discussion, but where an alternative exists, changing it can make gout considerably easier to control.

Should a high level be treated?

This is the question most people arrive with, and the answer depends on whether you have had symptoms.

If you have had gout attacks

Yes. Urate-lowering therapy, usually allopurinol or febuxostat, is the treatment that actually prevents recurrence. The dose is increased gradually until the blood level reaches target. This is preventive treatment and is continued indefinitely; stopping allows uric acid to rise and attacks to return.

If you have never had symptoms

Routine treatment of a high level alone is generally not recommended. The majority never develop gout, and treating everyone would expose many people to medication they do not need. There are exceptions, including very high levels, kidney stones caused by urate, and certain situations in kidney disease or cancer treatment.

What is worth doing either way

A high uric acid frequently travels with high blood pressure, kidney disease, diabetes and cardiovascular disease. Even where the uric acid itself needs no treatment, it is a useful prompt to check blood pressure, kidney function, glucose and lipids.

Practical steps

• Reduce beer, spirits and fructose-sweetened drinks; these have the largest dietary effect.
• Moderate red meat, organ meats and shellfish rather than eliminating them entirely.
• Stay well hydrated through the day.
• Lose weight gradually if needed; rapid weight loss can trigger attacks.
• Low-fat dairy and cherries are associated with modestly lower risk.
• Review diuretics and low-dose aspirin with your doctor rather than stopping them yourself.

Set expectations realistically. Diet and lifestyle typically lower uric acid by a modest amount, enough to help but rarely enough on its own to reach target in someone with recurrent gout. Treating diet as the whole answer is the most common reason people continue having attacks.

Starting urate-lowering treatment

For anyone with recurrent gout, this is the treatment that ends the problem rather than managing it. It is also the treatment most often stopped early, usually because of two predictable issues that are easily prevented if you know about them in advance.

It can trigger attacks at first

As uric acid falls, existing crystals begin to dissolve, and that process itself provokes inflammation. Attacks in the first three to six months of treatment are common and are a sign the medicine is working, not failing. A low dose of colchicine or an anti-inflammatory is usually prescribed alongside to cover this period. Stopping the urate-lowering drug because you had an attack is the single most common reason treatment fails.

It is titrated to a target, not a fixed dose

Allopurinol is typically started low and increased gradually with blood tests every few weeks until uric acid is below target, usually 6 mg/dL, and lower where tophi are present. Many people are left on a starting dose that never reaches target, which explains why they keep having attacks despite taking a tablet daily. If you are on treatment and still having attacks, ask what your last uric acid level was.

It is long term

This is preventive treatment, like medication for blood pressure. Stopping once attacks have ceased allows uric acid to rise and crystals to reform, and attacks typically return within months. Kidney function is checked before starting and monitored, and reduced function guides the dose rather than ruling treatment out.

What success looks like

Attacks become rare and then stop. Any tophi shrink slowly over months to years. For most people, gout becomes a condition they take one tablet for and otherwise do not think about, which is a realistic goal worth persisting for.

When to see a rheumatologist in Katy

See a rheumatologist if you have had one or more attacks of sudden severe joint pain and swelling, if attacks keep returning, if uric acid will not come down to target on treatment, if you have developed lumps under the skin, or if kidney disease or drug intolerance complicates treatment.

A high uric acid with no symptoms usually does not need rheumatology input, but it is worth discussing with your primary care physician alongside blood pressure, kidney function and cardiovascular risk.

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