Gout: cardiovascular benefits seen when treating serum urate levels to target

By Rebecca Jenkins

Treating serum urate levels to target in people with gout is associated with a reduced risk of cardiovascular (CV) events, a large cohort study finds.

Gout was known to be associated with 1.5-fold increased risk of CV disease, with growing evidence that gout flares caused this excess risk, UK-led researchers wrote in JAMA Internal Medicine.

To further investigate these associations, they designed a cohort study using data from almost 110,000 adults (mean age, 62.9 years; 22.2% women) with gout who were newly prescribed urate-lowering therapy (ULT).

Patients were split into two arms: those who achieved a serum urate level lower than 0.36 mmol/L (6 mg/dL) within the first 12 months of ULT (27.3%) and those who had not.

Analysing the data, the researchers found patients who had reached target serum urate levels in the first 12 months had a higher five-year survival and a lower risk of CV events than people in the group who had not.

Relative risk reduction was 9% for major adverse CV events, with researchers noting the association was greatest in people at high or very high risk of CV disease.

Gout flares were also less frequent in the treat-to-target arm compared with the other group.

Commenting on the study, Professor Lyn March, Professor of Rheumatology and Musculoskeletal Epidemiology at The University of Sydney, said the proposed mechanisms were not fully understood but were likely related to the lowering of systemic inflammation and the reduction of gout flares.

The target used in the study aligned with Australian clinical guidance, Professor March added, noting there was strong evidence that treating to target reduced tissue urate build-up, prevented gouty attacks, reduced tophi, protected the kidneys and reduced renal failure.

‘However, studies in Australia and overseas show that the treat to target is not well adhered to and adherence to the long-term use of ULT is suboptimal, with one study suggesting that less than 50% reach the target,’ she told Medicine Today.

Highlighting the potential CV benefits of reducing gout flares could help patients to adhere to long-term ULT, she added.

When starting ULT it was important to educate patients about the risk of flares as the levels dropped and the need to monitor serum urate monthly with the dose titrated up if the target was not reached.

‘For example, you might start with 100 mg allopurinol daily (less if significant renal disease) and build up by 100 mg each month until reaching the target urate (<0.36 mmol/L),’ Professor March said.

She noted that there was also the need for prophylaxis (with regular low-dose colchicine once or twice daily, NSAIDs or low-dose prednisolone) until the target urate was reached and the ULT was at a stable dose.

This might take three to six months of regular prophylaxis to prevent the gout flares that often caused patients to give up on their ULT, she added.

JAMA Intern Med 2026; doi: 10.1001/jamainternmed. 2025.7453.