Did you read that study you posted? It doesn’t say what you think it says. When I saw this “U shaped” claim, my thought was immediately “is this a statistical artifact driven by other facors at the low end?”. Because this is super common in U shaped curves. The U shape in BMI is driven by low end being the result of disease, U in alcohol consumption by former drinkers, U in LDL cholesterol levels by disease and so on. This is so common, that when you see a U curve that must be your first thought.
And sure enough, this is exactly the case here. Read the study. The increase in ACM and CVD at the low end of of uric acid levels is driven by malnutrition. Remove malnutrition, and the effect disappears.
The conclusion here is that yet again, if you are healthy and don’t suffer from hidden factors like morbidity (or in this case - malnutrition), lower is better, just as in BMI, LDL-C, alcohol etc.
Therefore, no you do not need to keep your uric acid within range of above 4, whether with drugs or not. My uric acid dropped to 3 after I started on empagliflozin. It is a well known effect. Empagliflozin is a very beneficial drug with multiple pleiotropic advantages. It didn’t suddenly increase my ACM and CVD by dropping my UA from 4 to 3. It did the opposite - enhanced my health and the lower UA is evidence of that.
Here is the text from the study part that you didn’t read:
“The most striking finding in the present study was that the association of a low SUA level with increased risk of all‐cause and CVD mortality is modified by nutritional status. In accordance with our findings, the inverse correlation between low SUA levels and mortality have also been reported in patients with untreated hypertension15 or end‐stage renal disease16 with unclear mechanisms. We found that a low SUA level was only predictive of increased mortality in older people who were malnourished, and this effect was nullified in those with adequate nutrition. Moreover, low SUA‐associated higher mortality was in parallel with the severity of malnourishment and consistent across all subgroups. Several potential mechanisms may explain the effect modification of malnourishment on low SUA‐associated mortality. First, a low SUA level has been proposed as a surrogate of inadequate protein and calorie intake in patients undergoing hemodialysis33because SUA levels correlate with consumption of purine‐rich meat, seafood, and fat.20, 34 A recent report also found that frail malnourished older people who consumed less saturated fat and meat had lower SUA levels as compared with the community‐dwelling healthy elderly.35 It is plausible that protein‐energy wasting resulted in both low SUA levels and higher mortality in our malnourished participants. Second, low SUA levels in malnourished older people may parallel with vitamin C and D deficiency.36, 37 Deficiencies of these antioxidant and anti‐inflammatory vitamins have been linked to increased mortality.38, 39 Finally, low SUA levels may represent reduced total antioxidant capacity. Uric acid acts as a potent antioxidant and contributes to more than 50% of human plasma antioxidant capacity.40 Therefore, SUA might have predominantly acted as an antioxidant in our malnourished participants with SUA levels <4 mg/dL and a relatively low BMI (Table 1). Given the decreased antioxidant capacity and malnourishment in our participants, a low SUA level may serve as a second hit that increases cardiovascular inflammation.41 Taken together, we found that malnourishment acted as an outcome modifier of the relationship between low SUA levels and mortality in the elderly, which help risk stratify older adults with low SUA levels and other distinct patient groups with low SUA‐associated mortality.15, 16”.