How to manage uncontrolled hypertension in a patient with gout and hypercholesterolemia currently taking perindopril and felodipine?

Management of Uncontrolled Hypertension in a Patient with Gout and Hypercholesterolemia

This patient requires immediate intensification of antihypertensive therapy by adding a thiazide-like diuretic to the current regimen of perindopril and felodipine to achieve blood pressure control. 1

Current Status Assessment

The patient presents with:

• Uncontrolled hypertension (BP 152/100 mmHg)
• Current medications: Perindopril 8mg daily, Felodipine 2.5mg daily, Atorvastatin
• History of gout (currently asymptomatic) and hypercholesterolemia
• Elevated GGT (114) and HbA1c (42)
• Alcohol consumption (which can trigger gout)

Treatment Recommendations

Step 1: Optimize Current Regimen

• Increase felodipine dose from 2.5mg to 5mg or 10mg daily 1
  • Current dose is at the minimum range; dihydropyridine CCBs are effective at higher doses
  • Felodipine's usual dose range is 2.5-10mg daily 1

Step 2: Add a Third Antihypertensive Agent

• Add a thiazide-like diuretic (indapamide 1.25-2.5mg or chlorthalidone 12.5-25mg daily) 1
  • The 2024 ESC guidelines recommend a three-drug combination of RAS blocker (perindopril) + CCB (felodipine) + thiazide-like diuretic for uncontrolled hypertension 1
  • Chlorthalidone is preferred due to longer half-life and proven CVD reduction 1
  • Indapamide may be better tolerated in patients with history of gout 1, 2

Step 3: Consider Single-Pill Combination

• Convert to a single-pill combination when possible to improve adherence 1
  • Fixed-dose combinations improve adherence and BP control 3
  • Perindopril-amlodipine combinations have shown significant BP reductions in patients with uncontrolled hypertension 3

Monitoring and Follow-up

1. Schedule follow-up in 1 month to assess response to therapy 1
2. Monitor for adverse effects:
   • Serum uric acid levels (due to history of gout) 2
   • Serum potassium and sodium (especially with diuretic addition) 1
   • Renal function (7-14 days after medication changes) 4
3. Target BP goal: 120-129/70-79 mmHg 1, 4

Additional Recommendations

Lifestyle Modifications

• Reduce alcohol consumption - critical for both BP control and gout management 1
• Adopt DASH diet - emphasize fruits, vegetables, and low-fat dairy products 4
• Sodium restriction to less than 5g/day 4
• Regular physical activity - at least 30 minutes of moderate-intensity exercise most days 4

Addressing Potential Barriers to Control

• Assess medication adherence - poor adherence is a major cause of uncontrolled hypertension 1, 5
  • Provider assessments of adherence often correlate poorly with actual adherence 5
• Consider therapeutic inertia - failure to intensify therapy despite uncontrolled BP 1

Important Considerations

1. Gout management: Thiazide diuretics can exacerbate gout, but indapamide may have less impact on uric acid levels than hydrochlorothiazide 2

2. Alcohol's impact: Alcohol raises BP and triggers gout attacks - emphasize reduction or elimination 1

3. Metabolic parameters: Monitor glucose levels as combination therapy with diuretics may have small but significant effects on glucose metabolism 2

4. Perindopril benefits: Beyond BP lowering, perindopril improves endothelial function and has cardioprotective effects 6

By following this approach, the patient's BP should improve significantly, reducing cardiovascular risk while managing the comorbid conditions of gout and hypercholesterolemia.