Can hypertension (HTN) cause gout?

Relationship Between Hypertension and Gout

Hypertension itself does not directly cause gout, but it is a significant risk factor for gout development, and certain antihypertensive medications, particularly diuretics, can increase serum uric acid levels and precipitate gout. 1

Pathophysiological Connection

Hypertension and gout share a complex relationship with several connecting mechanisms:

• Epidemiological association: Studies show hypertension is strongly associated with gout, with hypertensive individuals having a fourfold higher incidence of gout compared to normotensive controls (RR = 3.93) 1

• Bidirectional relationship: The association between hypertension and gout appears to be bidirectional, with each condition increasing the risk of developing the other 2

• Shared risk factors: Both conditions share common risk factors including obesity, metabolic syndrome, and chronic kidney disease

Medication-Induced Hyperuricemia

The most significant connection between hypertension and gout is through antihypertensive medications:

1. Diuretics: These are the most problematic antihypertensive drugs regarding gout risk

   • Increase serum uric acid levels (OR = 1.72) 1
   • Associated with 2.36 times higher risk of incident gout 3
   • Mechanism: Volume depletion and reduced uric acid secretion 4

2. Beta-blockers: Associated with 1.48 times increased risk of gout 3

3. ACE inhibitors: Associated with 1.24 times increased risk of gout 3

4. Non-losartan ARBs: Associated with 1.29 times increased risk of gout 3

Protective Antihypertensive Medications

Some antihypertensive medications may actually reduce gout risk:

• Losartan: Has uricosuric properties and is associated with 19% reduced risk of gout (RR 0.81) 3

  • Duration effect: Risk reduction increases with longer use (29% reduction after ≥2 years) 3

• Calcium channel blockers: Associated with 13% reduced risk of gout (RR 0.87) 3

  • Duration effect: Risk reduction increases with longer use (25% reduction after ≥2 years) 3

Management Recommendations for Patients with Both Conditions

For patients with both hypertension and gout:

1. Consider discontinuing diuretics if clinically appropriate 1

   • "Diuretics should be stopped if possible in patients with gout" 1

2. Alternative antihypertensive regimens:

   • Losartan is the preferred antihypertensive for patients with gout due to its uricosuric effect 1
   • Calcium channel blockers are good alternatives as they don't increase uric acid levels 5

3. For hyperlipidemia, consider fenofibrate which has uricosuric effects 1

Clinical Pearls and Pitfalls

• Common pitfall: Continuing thiazide or loop diuretics in patients with recurrent gout attacks

  • Higher doses of diuretics (>50 mg/d hydrochlorothiazide or >25 mg chlorthalidone) significantly increase hyperuricemia risk 1

• Caution: When initiating urate-lowering therapy in hypertensive patients, consider potential drug interactions with antihypertensives

• Monitoring: Patients on diuretics should have their serum uric acid levels monitored regularly

• Weight management: Addressing obesity can help manage both hypertension and gout simultaneously

In summary, while hypertension itself doesn't directly cause gout, it significantly increases the risk through shared pathophysiological mechanisms and through the medications used to treat it. Careful selection of antihypertensive therapy, particularly favoring losartan or calcium channel blockers over diuretics when possible, can help manage both conditions effectively.