Everything You Need To Know About Hyperuricemia: Treatment & Prevention Tips

Despite knowledge of uric acid that was identified at least 2 centuries ago, our understanding of hyperuricemia is not complete or sometimes clear. For years, hyperuricemia was thought to be the same as gout, but uric acid has now been recognized as a marker for a number of health complications such as metabolic and blood circulation abnormalities.

Uric acid, an end product of purine metabolism in humans, is poorly soluble or more difficult to dissolve. About two thirds of uric acid are produced internally, while the remaining third is obtained through dietary purines. In comparison to animals, humans have higher levels of uric acid, mostly due to a deficiency of involved enzymes and a comparatively lower rate of excretion of uric acid.

The kidneys are responsible for about 70% of daily uric acid excretion and the remaining 30% is filtered out by the intestines. In situations where the kidneys fail to keep up with this daily excretion, the intestinal elimination system will increase its load to compensate for the decreased amount of work by the kidneys. Uric acid blood levels are the tipping scale between the breakdown of purines and uric acid excretion rate. While it is believed that this balance can cause hyperuricemia, most clinical cases point to defective elimination as the primary cause for most cases of hyperuricemia.

Fast Facts

Characterized by an elevation of uric acid in the blood
Initially symptomatic, but can lead to other conditions such as gout, renal failure, liver problems, and heart complications
Can be treated through lifestyle changes such as staying hydration, avoiding excessive alcohol consumption, following a low purine diet and maintaining a healthy weight

What Causes Hyperuricemia?

Normal uric acid blood levels varies between genders, 2.4 - 6.0 mg/dL for women and 3.4 - 7.0 mg/dL for men. The upper limit for lies at 7.0 mg/dL where any higher puts you at risk for developing hyperuricemia. The cause of hyperuricemia is divided into three categories: uric acid underexcretion, uric acid overproduction or combined causes.

Underexcretion

Underexcretion makes up most cases of hyperuricemia. Urate (a salt of uric acid) is filtered by the kidneys and undergoes a process that ends in the urate leaving the body through the urine. One misstep in this process can result in renal insufficiency and subsequently a poor rate of uric acid excretion. Underexcretion or poor kidney function can be caused by the following:

Renal insufficiency. Renal failure is one of the most common causes of hyperuricemia. In the case of renal failure, uric acid remains in the blood as the kidneys are unable to properly perform the excretion process or other organic compounds compete for clearance.
Metabolic syndrome. Other health complications such as hypertension, obesity and insulin resistance can contribute to the decreased excretion of urate by the kidneys.
Medications. Diuretics, low-dose salicylates, cyclosporine and nicotinic acid have been linked to causing poor excretion performance by the kidneys.
Genetics. While considered rare, patients with this condition experience progressive renal failure that results in a lower rate of uric acid excretion.
Hypertension. High blood pressure and the associated medications have been known to cause hyperuricemia.
Acidosis. Conditions that increase acidity in the blood such as alcoholic ketoacidosis, diabetic ketoacidosis, lactic acidosis and starvation acidosis can cause poor kidney function and hyperuricemia.
Preeclampsia and eclampsia. These conditions are often associated to elevated uric acid levels which can cause hyperuricemia.
Lead exposure (chronic): Clinical studies have shown that occupational or prolonged exposure to lead can affect kidney function.
Other conditions: Hypothyroidism, hyperparathyroidism, sarcoidosis, and trisomy 21.

Overproduction

Overproduction occurs in a minority of patients who have hyperuricemia. Hyperuricemia induced by overproduction may be caused by external factors (high purine diet) or internal factors (increased purine breakdown). Overproduction of uric acid can be caused by the following:

Diet. A diet that majorly consists of high-purine meats, organ foods and legumes can contribute to the overproduction of uric acid.
Lesch-Nyhan syndrome. Processes involved in this syndrome contribute to the overproduction of uric acid. Patients with this syndrome are also more likely to develop gout.
Kelley-Seegmiller syndrome. Processes involved in this syndrome contribute to the overproduction of uric acid. Patients with this syndrome are also more likely to develop gout.
Increased activity of PRPP synthetase.
Increased nucleic acid turnover. Processes involved in this syndrome contribute to the overproduction of uric acid. Patients with this syndrome are also more likely to develop gout and kidney stones.
Tumor lysis syndrome. This syndrome is known to produce the most serious complications of hyperuricemia.
Other conditions: Glycogenoses (III, V, and VII) and exposure to organic pollutants.

Combination Causes

A combination of overproduction and underexcretion can provide to be a problematic cause of hyperuricemia. The combination of both mechanisms can put patients at greater risks of developing complications. Combination causes can be a result of the following:

Alcohol Consumption. Alcohol increases the production of uric acid and also produces competing compounds that lead to the decrease of uric acid excretion by the kidneys.

Fructose Foods and Drinks. Fructose increases uric acid levels by increasing purine metabolism. Additionally, studies have found that fructose also plays a hand in decreasing kidney function and uric acid excretion.

Rapid Weight Loss. The enhanced breakdown of tissue from unhealthy or rapid weight loss may produce more uric acid and decrease excretion due to the sudden and rapid change in urate levels.

Deficiency of aldolase B. This is a common genetic disorder, patients with this deficiency are likely to develop gout.

Glucose-6-phosphatase deficiency. This disorder can also lead to kidney complications or failure.

Who is at Risk?

While specific life factors can contribute to hyperuricemia, studies have found that certain individuals or groups of people are more at risk to develop this condition. These factors include:

Gender

Hyperuricemia and its common successor gout are found to be more common in men than women. About 5% of gout patients are female, but the number tends to increase in women who experience menopause.

Age

Uric acid levels are typically lower in children than in adults. The likelihood to develop hyperuricemia increases with age with men ranging between 20 - 60 and women ranging between 40 and older. Individuals over 60+ are more likely to develop hyperuricemia and gout.

Race

Hyperuricemia caused by underexcretion is prevalent in races of the Pacific. Additionally, African Americans develop hyperuricemia more commonly than white Americans.

Health Conditions

Preexisting health conditions such as obesity, hypertension, diabetes and kidney problems have been linked to the development of hyperuricemia.

Signs and Symptoms of Hyperuricemia

Hyperuricemia typically does not cause any physical symptoms, however if you incur any triggers or introduce factors that can cause other complications, you can expect or look out for the following:

Significantly high uric acid levels
Fever, chills or fatigue (possible in patients with cancer)
Inflammation of a single joint, usually the big toe - known as gout (NOTE: less than 20% of people with hyperuricemia develop gout)
Kidney problems that can include the formation of stones or urination problems.

Since hyperuricemia has a tendency to not develop any symptoms, it is best to consult with your doctor if you are concerned about your risk of developing hyperuricemia.

Complications of Hyperuricemia

Hyperuricemia consists of two stages, asymptomatic and symptomatic.

Asymptomatic hyperuricemia

Most patients during this stage never develop gout or stones. Instead they are monitored and expected to make necessary changes to lower uric acid levels. Depending on the present urate levels, doctors will recommend lifestyle changes or prescribe medication to help lower uric acid levels. Asymptomatic hyperuricemia does not cause any symptoms and can for the most part go unrecognized unless a blood test is performed.

Symptomatic hyperuricemia

Patients who have hyperuricemia have developed physical symptoms or disorders such as gout, uric acid stones or uric acid nephropathy. Symptomatic hyperuricemia can also lead to other health complications that include:

Acute gout
Chronic gout
Uric acid nephrolithiasis
Uric acid nephropathy
Hypertension
Heart disease
Kidney disease
Kidney Stones
Diabetes

When to See a Doctor

You experience inflammation and pain in a single joint (particularly the big toe, ankle or finger joint)
An abnormal or increased heart beat
Bleeding that does not stop after a few minutes
Develop rashes on your skin
Shortness of breath, chest pain or discomfort

Tests and Diagnosis for Hyperuricemia

Testing for hyperuricemia can be performed by your doctor. The following examinations can be conducted to determine your uric acid level and help to determine the next steps for treatment and prevention of other health risks.

Lab Testing and Examinations:

Serum uric acid test
CBC count
Evaluation of electrolytes, BUN and serum creatinine levels
Liver function tests
Serum glucose level
Lipid profile
Calcium and phosphate levels
Thyroid-stimulating hormone levels
Urinary uric acid excretion
Fractional excretion of urate
Spot urine ration of uric acid to creatinine

Imaging Studies

X-ray (conducted on patients who may have joint swelling or gout)
Renal sonogram (performed on patients with symptomatic hyperuricemia to evaluate the kidneys)

Medications for Hyperuricemia

Medications prescribed to patients with hyperuricemia are designed to help reduce and prevent the risk of developing complications. Typically, medications will address high uric acid levels and those prescribed will help counter overproduction of the waste product. Other medications can be prescribed based on any other complications a patient experiences such as gout or kidney related disorders.

Xanthine Oxidase Inhibitors

Function: designed to prevent gout attacks and used to treat hyperuricemia by preventing the activity of the enzyme xanthine oxidase.

Medications: allopurinol, febuxostat

Uricosuric Agents

Function: inhibit the reabsorption of uric acid and promotes the excretion of uric acid while simultaneously lowering urate levels.

Medications: probenecid

Urate Oxidase Enzyme

Function: facilitates the conversion of urate to a more soluble product, such as allantoin.

Medications: pegloticase, rasburicase

Alkalinizing Agents

Function: used to raise the pH in urine.

Medications: potassium citrate

Glucocorticoids

Function: influence a variety of metabolic effects and modify the body’s immune response.

Medications: prednisone, dexamethasone

Carbonic Anhydrase Inhibitors

Function: decrease the solubility of uric acid, combined with an adequate hydration intake increases the benefits of this medication.

Medications: acetazolamide

Antigout Agents

Function: prescribed for patients suffering with gout to treat active attacks and prevent recurrence.

Medications: colchicine

Nonsteroidal Anti-inflammatory Drugs

Function: management of pain and inflammation caused by gout.

Medications: indomethacin

How to Prevent Hyperuricemia

Hyperuricemia is an easily treatable disorder that requires some patient education and understanding on the condition. Patients who have asymptomatic hyperuricemia are urged to make lifestyle changes that can help maintain uric acid levels. Those with symptomatic hyperuricemia are encouraged to perform regular follow-up evaluations to determine current urate levels and to monitor progress. Hyperuricemia is preventable by following making the following lifestyle changes:

Low Purine Diet

Reducing purines in the diet can have a significant impact on uric acid levels and is a huge part of management and prevention. Certain foods contain more purines than others and it’s important to become familiar with them.

Avoid Fructose Sweetened Drinks

Patients with a history of drinking fructose sweetened drinks and having a high sugar consumption have a tendency to have raised uric acid levels. By moderating your sugar intake you can prevent the contribution to a uric acid level imbalance.

Avoid Excessive Alcohol Consumption

Alcohol consumption can lead to the overproduction and underexcretion of uric acid. By avoiding and significantly lessen your chances or developing hyperuricemia.

Maintain a Healthy Weight

Fat tissue tends to hold urate and when the tissue is broken down, it can release the accumulated uric acid causing a rise in blood levels. Additionally, obesity and being overweight can put a strain on your kidneys, affecting their function and contributing to underexcretion.

The Gout & Hyperuricemia Connection

Gout is a painful inflammatory arthritis disease caused by deposits of uric acid crystals in the joints and articular tissues. In most cases, gout is caused by certain lifestyle factors such as obesity, usage of medications and poor diet, all of which can lead to a high level of uric acid in the body. High levels of uric acid lead to the development of the condition known as hyperuricemia, and while only 20% of people with hyperuricemia ever develop gout, in most cases the two are often causation factors of one another.

Can Hyperuricemia Cause Gout?

Hyperuricemia is an indicator for poor management of uric acid levels in the body. Whether it be the overproduction or underexcretion of uric acid - or a combination of the two, there is a significant disconnect in the maintenance of uric acid in the blood. 20% of hyperuricemia patients have been observed to develop gout if their uric acid levels are not managed, implying that there is a direct connection between hyperuricemia and gout.

It is important to note however, that most cases of hyperuricemia do not lead to gout, but instead can lead to other health complications related to kidney, liver and heart function. Additionally, unlike gout, hyperuricemia does not cause any significant physical symptoms. Hyperuricemia becomes symptomatic when you develop other complications such as gout, renal failure or liver disease.

Treating Hyperuricemia

When it comes to asymptomatic hyperuricemia in most cases treatment isn’t necessary. Instead it is encouraged that efforts be made to lower urate levels, this includes making changes to diet or lifestyle. A treatment plan is administered for symptomatic hyperuricemia and when complications such as gout, kidney disease or renal insufficiency develop. Treatment for symptomatic hyperuricemia will vary based on the specific complication and other conditions that need to be addressed.

Dietary modifications are the most critical step in lowering urate levels. Adopting eating habits that correlate with the decrease uric acid production is highly recommended as compared to committing to lifelong therapy for an asymptomatic condition.

Adjusting Your Eating Habits

When it comes to urate lowering dietary restrictions, key things to remember is reducing or avoiding purine-rich foods such as organ or red meats, shellfish and avoiding excessive alcohol consumption, especially beer.

Foods to Avoid

Organ Meats: liver, kidney, heart
Fish and Seafood: anchovies, sardines, salmon, mackerel, clams
Dried legumes: black-eyed peas, lentils, split peas, beans
Meat and Poultry: beef, poultry, lamb, pork
Fruits and Vegetables: broccoli, artichoke, banana, spinach, kiwi
Grains: Pasta made with egg, potato, bread, rice, cooked
Dairy: cottage cheese, plain yogurt
Sugar and Fructose: Juice drinks, soda, candy, chips
Alcohol: Beer, ales, spirits

Foods to Eat

Water
Moderated Protein Amounts: chicken (white meat), eggs, tofu, nut butters
Low-Far or Fat-free dairy: skim or low-fat milk, Greek yogurt
Complex carbohydrates: whole grain bread, whole grain cereal, brown rice, whole grain pasta
Foods high in Vitamin C: oranges, tangerines, red bell peppers, cantaloupe, strawberries and kiwi
Fruits: cherries, blueberries, watermelon, mangos

Putting it all together: To get ideas or learn how to put together a purine-reduced eating plan, visit our recipe section for inspiration or check out our Anti-Gout nutrition plan.

Complementary Supplements

Supplements are a great addition to your therapy and can help provide you with vitamins and minerals that you might not be getting enough of from your diet. In addition, some supplements have been recognized to act as natural urate lowering substances and can be helpful in managing your uric acid levels. Supplements to add to your diet include:

Alpha-lipoic Acid
Turmeric
Milk Thistle
Dandelion
Quercetin
Celery
Vitamin C
Folic Acid

FREQUENTLY ASKED QUESTIONS

What medications cause hyperuricemia?

The following drug agents have been recognized to cause overproduction or underexcretion of uric acid:

Amiloride
Bumetanide
Chorthalidone
Cisplatin
Cyclophosphamide
Cyclosporine
Ethacrynic acid
Ethambutol
Furosemide
Hydrochlorothiazide
Indapamide
Isotretinoin
Ketoconazole
Levodopa
Metolazone
Pentamidine (renal damage)
Phencyclidine
Pyrazinamide
Salicylates
Theophylline
Thiazide diuretics (in addition to the ones listed above)
Vincristine

Does hyperuricemia need to be treated? Can I leave it untreated?

Hyperuricemia should be addressed by making an effort towards dietary and lifestyle changes. These changes include adopting a diet that is reduced in purines, limits alcohol consumption and sugar intake and also promotes weight loss and daily exercise.

Does homeopathic treatment work for hyperuricemia?

There has been effective homeopathic treatments recognized for hyperuricemia.

Can hyperuricemia cause dizziness?

According to a study, hyperuricemia has been linked to feelings of dizziness.

Can rifampin cause hyperuricemia?

Rifampin has been associated with liver dysfunction and may contribute to elevated uric acid levels.

Does hyperuricemia cause itching?

Urate acid deposits can cause some itching.

Does hyperuricemia cause renal failure?

Symptomatic hyperuricemia can lead to renal failure if left untreated.

How alcohol causes hyperuricemia?

Alcohol increases the production of uric acid and also produces competing compounds that lead to the decrease of uric acid excretion by the kidneys.

How do diuretics because hyperuricemia/how do loop diuretics cause hyperuricemia?

Diuretics cause the body to have low fluid retention, making it difficult for uric acid to be completely deposited from the body.

How does aspirin cause hyperuricemia?

Low-dose aspirin can influence renal function and how the kidneys handle uric acid leading to underexcretion of the waste product and thus hyperuricemia.

How does ethambutol cause hyperuricemia?

Ethambutol can influence renal function and how the kidneys handle uric acid leading to underexcretion of the waste product and thus hyperuricemia.

How does furosemide cause hyperuricemia?

Furosemide can influence renal function and how the kidneys handle uric acid leading to underexcretion of the waste product and thus hyperuricemia.

How does hctz cause hyperuricemia?

HCTZ is a diuretic that enables the reabsorption of urate into the body, leading to poor excretion of uric acid.

How does hyperuricemia cause hypertension?

The mechanics of how hyperuricemia causes hypertension is not yet understood, however based on multiple clinical research, hyperuricemia has been recognized as a causation factor for hypertension.

How does leukemia cause hyperuricemia?

Leukemia can influence renal function and efficiency, contributing to the underexcretion of uric acid.

How does niacin cause hyperuricemia?

Niacin’s agents are known to compete with uric acid for excretion by the kidneys, leading to underexcretion of uric acid.

How does obesity cause hyperuricemia?

Leptin, a gene production of obesity, has been found to interact with uric acid resulting in increasing levels and hyperuricemia.

How does pyrazinamide cause hyperuricemia?

Pyrazinamide inhibits the excretion of urate, leading to poor depositing of the waste product.

How does thiazide cause hyperuricemia?

Thiazide’s agents are known to compete with uric acid for excretion by the kidneys, leading to underexcretion of uric acid.

How does von gierke's cause hyperuricemia?

Von gierek’s disease is a form of glucose-6-phosphatase deficiency that causes poor renal function and also influences the overproduction of waste products (including uric acid and lactic acid) that compete with uric acid for renal excretion. It is a combination causation factor of hyperuricemia.

Perennial hyperuricemia is caused by?

Please ask your doctor.

Hyperuricemia and diabetes is it connected?

Hyperuricemia and diabetes are often associated with one another as the two are a result of poor dietary and lifestyle choices.

What are the effects of xanthine oxidase?

Xanthine oxidase is the enzyme responsible for the formation of uric acid. It is activated when purines enter the body and proceeds to initiate the breakdown of the substance and produce the waste product, uric acid.

Is hyperuricemia a cardiovascular risk factor?

Untreated and prolonged hyperuricemia can cause heart disease and failure.

Is hyperuricemia dangerous?

Untreated and prolonged hyperuricemia can become symptomatic and cause a series of complications, the most morbid including, kidney and liver disease or failure and heart disease or failure.

Is hyperuricemia painful?

Symptomatic hyperuricemia can lead to the development of gout, kidney stones, kidney complications (such as disease and failure) and liver complications. These complications can all be very painful and drastically affect your quality of life.

What is juvenile hyperuricemia syndrome?

Familial juvenile hyperuricemia is a dominantly inherited condition that is characterized by young-onset hyperuricemia, gout and renal disease.

Can I eat oatmeal is it good food for my case?

Oatmeal is a cereal that is not significantly high in purines and can be consumed by anyone that has high uric acid levels. Unless you suffer from a specific purine metabolism disorder, there is no reason to avoid oatmeal. The key to consuming oatmeal is moderation.

Oliguria hyperuricemia

Oliguria is a condition in which the production of urine is abnormally low. This can lead to underexcretion of uric acid and result in hyperuricemia.

Is quercetin good?

Quercetin has been observed in vitro to act as a natural xanthine oxidase inhibitor and has been thought to help with lowering uric acid levels.

Uncontrolled hyperuricemia can lead to what?

Uncontrolled and neglected hyperuricemia can become symptomatic and cause a series of complications, the most morbid including, kidney and liver disease or failure and heart disease or failure.

What is asymptomatic hyperuricemia?

Asymptomatic hyperuricemia is a stage of hyperuricemia where uric acid levels in the blood are over 7.0 mg/dL, but the patient experiences no symptoms. During this stage, patients are recommended to make dietary and lifestyle changes to reduce uric acid concentration to lower levels.

Is hyperuricemia and metabolic syndrome connected?

Yes.

What is the difference between hyperuricemia and hyperuricosuria?

Hyperuricosuria is the prevalence of excessive amounts of uric acid in the urine, hyperuricemia is the presence of excessive uric acid in the blood.

Is chronic kidney disease connected?

Hyperuricemia can lead to the development of kidney complications such as kidney disease, kidney stones, renal dysfunction and kidney failure.

Can dialysis help?

Dialysis may be a therapy option introduced for severe hyperuricemia and with other health conditions are furthering complications.

Can I get hyperuricemia during pregnancy and what to do about it?

Preeclampsia and eclampsia, are two pregnancy complications that are associated with high levels of uric acid.

Is edema connected?

Edema can be a complication that develops as a result of untreated hyperuricemia.

Hyperuricemia fatigue connected?

Chronic fatigue can be associated with hyperuricemia.

Is hyperuricemia connected to fatty liver?

Fatty liver has been recognized to significantly increase the risk of hyperuricemia.

The effect of beta blockers?

Beta blockers are known to contribute to increased uric acid levels. The mechanism of this medication is not fully understood, but is a common factor among hyperuricemia patients.

Hyperuricemia fructose intolerance are they connected?

Fructose intolerance results in the increased degradation of products that can be converted to uric acid and thus increase levels in the body leading to hyperuricemia.

Hyperuricemia back pain/knee pain/joint pain

Hyperuricemia can lead to the development of gout, a painful arthritis that affects the big toe joint, ankle and knees.

Can you get hyperuricemia from chemotherapy?

Chemotherapy agents can contribute to the overproduction of uric acid, resulting in hyperuricemia.

Hyperuricemia genetic/is hyperuricemia hereditary?

While hyperuricemia itself is not genetic, genetic disorders related to poor renal function and subsequently poor regulation of uric acid levels can contribute to hyperuricemia.

Can bodybuilding lead to hyperuricemia?

Bodybuilders who follow a high protein diet are typically consuming high purine foods that lead to elevated uric acid levels and the possible development of hyperuricemia.

Can young adults also get this problem?

Hyperuricemia is prevalent among men, aged 20 - 60 and is likely to develop following a high purine diet, excessive alcohol consumption and high sugar intake.

Can hyperuricemia lead to rheumatoid arthritis?

Rheumatoid arthritis is rarely found in hyperuricemia patients. About 10% of rheumatoid arthritis patients have high uric acid blood levels.

Does hyperuricemia affect mortality?

Yes, morbid complications include kidney, liver and heart failure.

Can hyperuricemia cause liver damage?

Yes.

Is hyperuricemia and neuropathy connected?

Ask your doctor.

What is normal hyperuricemia range?

Is osteoarthritis connected?

Osteoarthritis can be mistaken for gout (an arthritis disease that can develop if hyperuricemia is left unaddressed) since the two diseases share characteristic of inflammation, pain and swelling.

Are people with psoriasis more prone?

Patients with psoriasis have been identified to have a greater prevalence of hyperuricemia. This connection however is not completely understood as further clinical research has not been conducted.

Can I have rash?

Skin rashes can develop if taking medications such as allopurinol to help with hyperuricemia.

Can it cause stroke?

Hyperuricemia can contribute to cardiovascular complications that can sometimes result in a stroke.

What is a good supplement to take?

Please refer to our supplements page

Is this disease associated with uremia?

Hyperuricemia is often associated with uremia due to its potential influence on renal function that can lead to uremia.

I hear a lot of people talk about vitamin b12 what is the deal what do they mean? Does it help against hyperuricemia or causes it?

Vitamin B12 has been linked to the overproduction of uric acid and can lead to hyperuricemia and gout.

References:

Shiraishi H, Une H. The effect of the interaction between obesity and drinking on hyperuricemia in Japanese male office workers. J Epidemiol. 2009. 19(1):12-6 Rho YH, Zhu Y, Choi HK. The epidemiology of uric acid and fructose. Semin Nephrol. 2011 Sep. 31(5):410-9.

Bae J, Chun BY, Park PS, Choi BY, Kim MK, Shin MH, et al. Higher consumption of sugar-sweetened soft drinks increases the risk of hyperuricemia in Korean population: The Korean Multi-Rural Communities Cohort Study. Semin Arthritis Rheum. 2014 Apr. 43(5):654-61.

López-Molina R, Parra-Cabrera S, López-Ridaura R, González-Villalpando ME, Ferrannini E, González-Villalpando C. Sweetened beverages intake, hyperuricemia and metabolic syndrome: the Mexico City Diabetes Study. Salud Publica Mex. 2013 Dec. 55(6):557-63.

Lecoultre V, Egli L, Theytaz F, Despland C, Schneiter P, Tappy L. Fructose-induced hyperuricemia is associated with a decreased renal uric acid excretion in humans. Diabetes Care. 2013 Sep. 36(9):e149-50.

Kim SY, De Vera MA, Choi HK. Gout and mortality. Clin Exp Rheumatol. 2008 Sep-Oct. 26(5 Suppl 51):S115-9.

Liu L, Lou S, Xu K, Meng Z, Zhang Q, Song K. Relationship between lifestyle choices and hyperuricemia in Chinese men and women. Clin Rheumatol. 2012 Nov 7.

Ioannou GN, Boyko EJ. Effects of menopause and hormone replacement therapy on the associations of hyperuricemia with mortality. Atherosclerosis. 2012 Oct 22.

Grassi, Davide et al. “Chronic Hyperuricemia, Uric Acid Deposit and Cardiovascular Risk." Current Pharmaceutical Design 19.13 (2013): 2432-2438. PMC. Web. 28 June 2015.

Ohno I. Relationship between hyperuricemia and chronic kidney disease. Nucleosides Nucleotides Nucleic Acids. 2011 Dec;30(12):1039-44. doi: 10.1080/15257770.2011.611484. PubMed PMID: 22132954.

Dessein PH, Shipton EA, et al. Beneficial effects of weight loss associated with moderate calorie/ carbohydrate restriction, and increased proportional intake of protein and unsaturated fat on serum urate and lipoprotein levels in gout. Ann Rheum Dis 2000;59:539-43.

Morgan JM, Capuzzi DM, Guyton JR "A new extended-release niacin (Niaspan): Efficacy, tolerability, and safety in hypercholesterolemic patients." Am J Cardiol 82 (1998): u29-34