Quick version
Elevated urate (hyperuricemia) means that the amount of uric acid in the blood is above normal, usually because the kidneys excrete too little. High levels rarely cause symptoms directly, but increase the risk of gout and kidney stones and are often linked to obesity, high blood pressure and metabolic health. Without symptoms, no medication is usually required; instead, lifestyle choices such as reduced alcohol intake and lower sugar intake help. In the case of gout, attacks are treated and levels are lowered with medication after an individual assessment.
Elevated urate levels often appear as an unexpected test result. Maybe you took blood tests because of joint pain, fatigue or a general health check, and suddenly it says that uric acid is high. For some, it means nothing right now. For others, it is the first sign of gout, kidney stones or a metabolism that needs to be reviewed.
Elevated urate levels – what does high uric acid mean and what can be done about it?
Elevated urate means that the level of uric acid in the blood is higher than normal. Urate is the form that uric acid most often exists in the body. The substance is formed when the body breaks down purines, which are found naturally in our cells but also in certain foods and drinks. If the body produces more urate than the kidneys can get rid of, the level in the blood rises.
A single elevated value is not the same as disease. Many people with high urate have no problems at all. At the same time, the risk of urate crystals forming in joints and tissues increases when levels are high for a long time, which can lead to gout. High levels can also be associated with kidney stones and are seen more often in people who are overweight, high blood pressure, metabolic syndrome, diabetes and kidney disease.
What is the difference between elevated urate and gout?
This is a common question in healthcare: “If I have high uric acid, does that mean I have gout?” The answer is no. Gout is an inflammatory joint disease in which urate crystals trigger acute inflammation in a joint. Elevated urate, or hyperuricemia, on the other hand, is a laboratory finding. You can therefore have high urate without ever having a gout attack.
Once gout occurs, it often comes on suddenly. Typically, there is intense pain, redness, increased heat and swelling in a joint, often the big toe, foot, ankle or knee. The symptoms often reach their peak quickly, sometimes overnight. In some people, recurrent attacks occur, and in the case of long-term untreated disease, crystals can be stored in soft tissues and form so-called tophi, which can eventually damage joints.
It is also worth knowing that urate levels can be normal during an ongoing gout attack. The diagnosis of gout is therefore not made solely based on a blood test, but on symptoms, examination and sometimes synovial fluid tests or imaging.
Why does uric acid become high?
The most common mechanism is not that the body produces an extremely high amount of uric acid, but that the kidneys do not excrete enough. Therefore, elevated urate levels are often seen together with impaired kidney function or conditions that affect the kidneys' ability to regulate metabolism.
Several factors can contribute simultaneously. Common causes and risk factors are:
- heredity
- overweight and metabolic syndrome
- high blood pressure
- chronic kidney disease
- alcohol, especially beer
- sweetened beverages with fructose
- a diet rich in purines, such as large amounts of offal and certain fish and shellfish
- drugs such as diuretics, niacin and certain immunosuppressive drugs
- high cell turnover, for example in certain blood diseases or cancer treatment
In practice, these are often everyday situations. A person with mildly impaired kidney function, abdominal obesity and blood pressure medication may have rising urate levels without noticing anything. Another person has their first gout attack after a period of heavy alcohol, barbecued food and dehydration. Test results therefore always need to be interpreted in context.
What symptoms can elevated urate cause?
Elevated urate itself usually does not cause any symptoms. It is only when the urate leads to complications that it is usually noticed. The most common is gout, where the joint becomes severely inflamed. Another is uric acid stones in the urinary tract, which can cause kidney stone attacks with severe flank pain, nausea and sometimes blood in the urine.
Long-term high levels can also occur together with other abnormalities in the health profile. Those who have elevated urate are more often overweight, insulin resistance, increased blood pressure or kidney damage. This does not mean that uric acid alone causes all of this, but the finding often serves as a signal that you should take a broader look at your metabolic health.
Seek medical attention quickly if you experience an acutely swollen and very painful joint, especially if you also have a fever or general ill health. In this case, you need to rule out infection in the joint, which can resemble gout but requires prompt treatment. In the event of severe pain from the side of the back or blood in the urine, kidney stones should also be assessed.
What can be done about high urate?
Treatment depends on whether you only have an elevated test result or if you also have gout, kidney stones or other complications. In asymptomatic hyperuricemia, not everyone is routinely treated with urate-lowering drugs just because the value is high. This also applies to chronic kidney disease, where current guidelines do not recommend urate-lowering treatment solely to slow kidney disease in people without symptoms of hyperuricemia.
However, there is much that can be done with lifestyle and by reviewing other risk factors. Often, the most effective thing to do is to work on the whole:
- lose weight if you are overweight
- reduce alcohol, especially beer
- avoid large amounts of sweetened beverages
- drink enough, especially if you get dehydrated easily
- review your diet rather than getting stuck on a few “forbidden” foods
- treat high blood pressure, diabetes and other concomitant conditions
- review your medication with your healthcare provider if you are using medications that can raise urate levels
Many people ask if they have to stop eating everything that contains purines. This is rarely necessary. For most people, it is more relevant to reduce the most obvious burdens, such as high alcohol consumption, large amounts of fructose-sweetened beverages and recurrent overeating, than to try to create an extreme diet. A sustainable dietary change works better than short-term restrictions.
If you have gout, medication may be appropriate. In acute attacks, anti-inflammatory treatment is used, such as NSAIDs, colchicine or cortisone depending on the situation and other diseases. To prevent new attacks and dissolve crystals over time, urate-lowering treatment is used, often allopurinol or febuxostat. Guidelines recommend a treat-to-target strategy where the dose is adjusted to reach a urate target, usually below 360 micromol/L. In more severe gout, a lower target, below 300 micromol/L, may be justified.
It is good to know that gout attacks may paradoxically become more frequent during the first months when urate-lowering treatment is started. Therefore, preventive treatment, such as colchicine, is sometimes recommended during the initiation. This does not mean that the drug “is not working”, but that the crystal deposits are being mobilized.
When should you test urate and what should you check at the same time?
A urate test is particularly relevant if you have recurrent joint attacks, kidney stones, known kidney disease or multiple metabolic risk factors. It may also be justified if you have close relatives with gout or if you are taking medications that can raise uric acid.
However, a urate value is most useful when interpreted together with other tests. Often, you want to simultaneously look at creatinine and eGFR for kidney function, blood sugar or HbA1c, blood fats, liver samples and sometimes urine samples. If you have joint pain or recurrent swelling, there may also be reasons to supplement the investigation with medical advice, since not all joint pain is due to gout.
For those of you who follow your values over time, the trend is often more informative than a single test. A slightly elevated urate in an otherwise healthy person is assessed differently than a rising urate together with impaired kidney function, high blood pressure and previous gout attacks. Therefore, regular follow-up is often more valuable than getting stuck on a single number.
An elevated urate is therefore not just a question of the big toe. In the right context, the test result can be an early marker for how the kidneys, metabolism and lifestyle interact. This knowledge provides the opportunity to act before the problems become acute.
