From the Guidelines
The best treatment approach for gout in patients with hypertension is to use colchicine or prednisolone for acute flares, allopurinol as the first-line option for long-term urate-lowering therapy, and losartan or calcium channel blockers for hypertension management, while avoiding diuretics and emphasizing lifestyle modifications. When managing gout in patients with hypertension, it is essential to consider the potential interactions between medications used to treat both conditions. For acute gout flares, colchicine (0.6 mg twice daily for 1-3 days) or prednisolone (30-40 mg daily for 3-5 days) are preferred over NSAIDs, which can worsen hypertension and kidney function, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1. For long-term urate-lowering therapy, allopurinol (starting at 100 mg daily and gradually increasing to achieve serum urate <6 mg/dL) is the first-line option, with febuxostat (40-80 mg daily) as an alternative for those who cannot tolerate allopurinol, according to the same EULAR recommendations 1. Regarding hypertension management, losartan and calcium channel blockers are preferred as they have mild uricosuric effects that can help lower urate levels, as suggested by the 2006 EULAR evidence-based recommendations for gout management 1. Some key points to consider in the management of gout in patients with hypertension include:
- Avoiding diuretics, especially thiazides and loop diuretics, which can increase uric acid levels and trigger gout attacks
- Using beta-blockers and ACE inhibitors other than losartan as neutral options
- Emphasizing lifestyle modifications, such as weight loss if overweight, limiting alcohol (especially beer), avoiding high-purine foods, reducing sodium intake, and maintaining adequate hydration
- Regularly monitoring blood pressure, serum urate levels, and kidney function to ensure optimal management of both conditions. Overall, a comprehensive approach that considers the complex interactions between gout and hypertension is necessary to provide effective management and improve patient outcomes, as supported by the most recent and highest quality study available 1.
From the FDA Drug Label
The dosage of allopurinol tablets to accomplish full control of gout and to lower serum uric acid to normal or near-normal levels varies with the severity of the disease. The minimal effective dosage is 100 to 200 mg daily and the maximal recommended dosage is 800 mg daily
The best treatment approach for gout in patients with hypertension is to use allopurinol with a dosage of 100 to 200 mg daily as the minimal effective dose, and to adjust as necessary to achieve a serum uric acid level of 6 mg/dL or less, without exceeding the maximal recommended dosage of 800 mg daily 2.
- Key considerations include:
- Monitoring serum uric acid levels
- Adjusting dosage based on disease severity and patient response
- Maintaining adequate fluid intake and urinary output
- Being cautious in patients with renal impairment, as allopurinol accumulation can occur 2. Note that colchicine may also be used for treatment of gout flares, but the provided drug labels do not directly address the use of colchicine in patients with hypertension 3 3.
From the Research
Treatment Approach for Gout in Patients with Hypertension
The treatment of gout in patients with hypertension requires careful consideration of the potential interactions between gout medications and hypertension.
- The use of nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided in patients with cardiovascular disease or heart failure, as they may increase the risk of adverse cardiovascular events 4.
- Colchicine is considered safe and potentially reduces the risk of myocardial infarction in patients with cardiovascular disease or heart failure who present with an acute gout flare 4.
- For long-term urate-lowering therapy (ULT), allopurinol and probenecid should be considered first-line treatments in patients with cardiovascular disease or heart failure, given their safety and potential for reducing cardiovascular outcomes 4.
- Febuxostat and pegloticase are not recommended as ULT in patients with cardiovascular disease or heart failure due to an increased risk of cardiovascular death and heart failure hospitalization 4, 5.
- Losartan, an antihypertensive drug, has mild uricosuric properties and may be beneficial in treating hypertensive patients with gout 6.
Considerations for Gout Treatment in Hypertensive Patients
When treating gout in patients with hypertension, it is essential to consider the following:
- The potential effects of gout medications on blood pressure and cardiovascular risk factors 4, 6.
- The use of diuretics, which can increase uric acid levels and worsen gout, and the potential need for alternative antihypertensive medications 6.
- The importance of individualizing treatment according to patient and agent cardiovascular risk factors 4, 7.