What Your Urate Level Really Means for Gout
Most people think gout is just about painful toes and swollen joints. But the real problem isn’t the pain-it’s the urate in your blood. When urate builds up, it forms sharp crystals in your joints. Those crystals trigger flares. And if you keep letting urate climb, those crystals don’t just go away-they grow. They turn into tophi, lumps under your skin, and can damage bones and kidneys over time.
The solution isn’t just to treat the flare. It’s to lower your blood urate level and keep it low. That’s the core of modern gout care. Major guidelines from the American College of Rheumatology, NICE, and EULAR all agree: if you have gout and need medication, your goal isn’t to feel better next week. It’s to hit a specific number-your urate target.
The Two Targets: 6 mg/dL and 5 mg/dL
There are two clear targets, and which one you need depends on how far your gout has gone.
- Standard target: below 6 mg/dL (360 micromol/L)-This is the minimum for most people. At this level, new crystals stop forming, and existing ones start to slowly dissolve. Studies show keeping urate below this number cuts flare frequency by 74%.
- Stricter target: below 5 mg/dL (300 micromol/L)-If you have tophi, joint damage from gout, or flares even while on medication, you need this lower goal. At 5 mg/dL, crystals dissolve faster. One study showed 89% reduction in tophus size at this level, compared to 72% at 6 mg/dL.
Don’t go lower than 3 mg/dL. There’s no extra benefit, and it might cause problems. The sweet spot is between 3 and 5 mg/dL for severe cases, and between 3 and 6 mg/dL for everyone else.
Allopurinol: The First-Line Choice
Allopurinol is the most common drug for lowering urate. It’s cheap, widely available, and works well-if you take it right.
Here’s how it’s actually used in real life, not just in textbooks:
- Start low: 100 mg per day (50 mg if you have kidney disease).
- Check your urate level after 4 weeks.
- If it’s still above 6 mg/dL, increase by 50-100 mg every 3-4 weeks.
- Keep going until you hit your target.
Most people need more than 300 mg a day. In New Zealand, about half of patients on allopurinol take 400-800 mg daily to reach their goal. That’s normal. It’s not a mistake. It’s the plan.
Some worry about allopurinol causing a serious allergic reaction. It’s rare-0.1% to 0.4% of people. But if you’re Māori, Pacific, or Han Chinese, your risk is higher. Testing for the HLA-B*5801 gene before starting can help avoid this. In places like Hamilton, where many patients come from high-risk groups, clinics are starting to test before prescribing.
Febuxostat: When Allopurinol Isn’t Enough
Febuxostat works differently. It blocks urate production more strongly. That makes it useful when allopurinol doesn’t cut it.
It’s often chosen for:
- People with moderate to severe kidney disease
- Those who can’t tolerate allopurinol
- Patients who need a bigger drop in urate fast
Start at 40 mg/day. If after 4 weeks your urate is still above target, bump it to 80 mg/day. That’s the max. Unlike allopurinol, you don’t need to titrate slowly over months-this is often enough.
It’s more expensive. In the U.S., generic allopurinol costs $4-12/month. Febuxostat runs $30-50. But in New Zealand’s public system, the cost difference is smaller, and it’s covered for patients who need it.
Studies show febuxostat achieves target levels in 15% more patients with kidney disease than allopurinol. For someone with stage 3 or 4 CKD, that’s a big deal.
Why Most People Fail to Reach Their Target
Here’s the hard truth: only about 42% of gout patients in New Zealand hit their urate target within a year. Why?
1. Doctors start too low and don’t titrate. Many GPs prescribe 100 mg allopurinol and say, “Take this and come back in 6 months.” That’s not enough. You need monthly checks until you’re at target.
2. Patients stop because of flares. When you start urate-lowering meds, crystals start dissolving. That can trigger flares. It’s not the drug failing-it’s the process working. Most patients don’t know this. They think the medicine is making it worse. They quit. Then they end up back in the ER.
3. No follow-up. In the U.S., only 54% of patients get their urate checked monthly during titration. In New Zealand, it’s better-but still not good enough. Without testing, you’re flying blind.
4. Cultural and systemic barriers. Māori and Pacific patients are more likely to be prescribed urate-lowering drugs, but less likely to reach target. Access to labs, transport, time off work, and trust in the system all play a role. This isn’t just about medicine-it’s about equity.
What You Can Do Right Now
If you have gout and are on allopurinol or febuxostat:
- Ask for your last urate result. Write it down.
- If you haven’t had a test in 3 months, request one.
- If your level is above 6 mg/dL, ask: “Should I increase my dose?”
- If you’ve had a flare since starting the drug, ask: “Is this part of the process?”
- Ask if you should be tested for HLA-B*5801 if you’re of Māori, Pacific, or Han Chinese descent.
Don’t wait for your next routine appointment. Urate targets aren’t optional. They’re the only way to stop gout from getting worse.
What’s Coming Next
Research is moving fast. A 2024 study called GOUT-PRO found that using genetic testing to guide allopurinol dosing boosted target achievement from 61% to 83% in just six months. That’s huge.
New drugs like verinurad are in trials. They work by helping your kidneys flush out more urate, so you might not need huge doses of allopurinol.
And in 2025, results from the ULTRA-GOUT trial will show whether fixed-dose treatment works as well as titrating to target. That could change how we think about dosing.
But right now, the best tool we have is simple: know your number. Keep it low. And don’t stop until you get there.
