Objective <p>Uric acid&#xa0;(UA) to high-density lipoprotein&#xa0;(HDL) ratio (UHR) has recently been proposed as a novel biomarker of inflammation. This study aimed to investigate the association between the UHR and carotid atherosclerosis (CAS) in patients with type 2 diabetes mellitus (T2DM).</p> Methods <p>In this single-center, retrospective cross-sectional study, 379 patients with T2DM were enrolled and categorized into two groups: 259 T2DM patients with CAS (T2DM-CAS) and 120 T2DM patients without CAS (T2DM-WCAS). Carotid intima‒media thickness (CIMT) and carotid atheromatous plaques (CAPs) were assessed via Doppler ultrasound. UHR values were compared between the groups, and receiver operating characteristic (ROC) curve analysis was employed to evaluate their diagnostic performance.</p> Results <p>The UHR was significantly greater in the T2DM-CAS group than in the T2DM-WCAS group (<i>P</i> &lt; 0.001). Multivariate logistic regression analysis identified the UHR as an independent risk factor for T2DM-CAS (<i>P</i> &lt; 0.001). The area under the ROC curve (AUC) for UHR to detect CAS was 0.750, with an optimal cut-off value of 0.35.</p> Conclusion <p>The UHR is an independent risk factor for CAS in patients with T2DM and may serve as a valuable biomarker for predicting CAS in this population.</p>