What is the most appropriate antihypertensive medication for a patient with a history of hypertension and gout, considering options like Hydrochlorothiazide (HCTZ), Lisinopril, or Amlodipine?

From the Guidelines

Lisinopril or Amlodipine are the most appropriate antihypertensive medications for a patient with a history of hypertension and gout, as they do not have a significant impact on uric acid levels, unlike Hydrochlorothiazide (HCTZ) which can increase uric acid levels and worsen gout.

Reasons for Choice

• HCTZ is not recommended due to its potential to increase uric acid levels and worsen gout, as stated in the 2020 American College of Rheumatology guideline for the management of gout 1.
• Losartan is a good alternative, as it has a uricosuric effect and can help lower uric acid levels, but it is not one of the options provided in the question.
• Lisinopril and Amlodipine are safe options, as they do not have a significant impact on uric acid levels and can be used to manage hypertension in patients with gout.

Key Points

• The 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults recommends using ACE inhibitors, such as Lisinopril, or calcium channel blockers, such as Amlodipine, as first-line treatments for hypertension 1.
• The 2020 American College of Rheumatology guideline for the management of gout recommends switching from HCTZ to an alternate antihypertensive agent, such as Lisinopril or Amlodipine, when feasible 1.
• The 2016 updated EULAR evidence-based recommendations for the management of gout also recommend considering alternative antihypertensive agents, such as Losartan or calcium channel blockers, in patients with gout 1.

From the FDA Drug Label

In controlled clinical studies of patients with mild to moderate hypertension, patients were treated with lisinopril 20 mg to 80 mg daily, hydrochlorothiazide 12. 5 mg to 50 mg daily or atenolol 50 mg to 200 mg daily; and in other studies of patients with moderate to severe hypertension, patients were treated with lisinopril 20 mg to 80 mg daily or metoprolol 100 mg to 200 mg daily. Lisinopril demonstrated superior reductions of systolic and diastolic compared to hydrochlorothiazide in a population that was 75% Caucasian

The most appropriate antihypertensive medication for a patient with a history of hypertension and gout is Lisinopril or Amlodipine, as there is no direct information in the provided drug labels that supports the use of Hydrochlorothiazide (HCTZ) in patients with gout.

• Lisinopril has been shown to be effective in reducing blood pressure in patients with mild to moderate hypertension.
• Amlodipine is not mentioned in the provided drug labels, but it is often considered a suitable alternative for patients with hypertension and gout.
• Hydrochlorothiazide (HCTZ) may exacerbate gout, although this is not explicitly stated in the provided drug labels 2.

From the Research

Antihypertensive Medication Options for Patients with Hypertension and Gout

• The choice of antihypertensive medication for a patient with a history of hypertension and gout should consider the potential effects of the medication on gout risk.
• Amlodipine has been shown to reduce the risk of gout by 37% compared to chlorthalidone and by 26% compared to lisinopril 3.
• Lisinopril has been found to nonsignificantly lower gout risk compared to chlorthalidone 3.
• Hydrochlorothiazide (HCTZ) is a thiazide diuretic that can provoke hyperglycaemia and diabetes, and its use may be associated with an increased risk of gout due to its diuretic effects 4, 5.

Considerations for Each Medication

• Amlodipine:
  • Has a low renal clearance and long half-life, allowing for sustained anti-hypertensive effect 6.
  • Has been shown to reduce blood pressure variability and lower blood pressure in patients with hypertension 6.
  • May be a wise choice for older adults due to its ability to control blood pressure and protect against stroke and myocardial infarction 6.
• Lisinopril:
  • Is an angiotensin-converting enzyme (ACE) inhibitor that has been shown to reduce all-cause mortality in hypertensive patients 4.
  • May be a suitable alternative to amlodipine, but its effect on gout risk is less clear 3.
• Hydrochlorothiazide (HCTZ):
  • Is a thiazide diuretic that is often used as a first-line treatment for hypertension 4.
  • May be associated with an increased risk of gout due to its diuretic effects, which can lead to hyperuricaemia 5.

Overall Recommendation

• Based on the available evidence, amlodipine may be a suitable choice for patients with hypertension and gout, due to its ability to reduce gout risk and control blood pressure 3.
• However, the decision should be made on a case-by-case basis, taking into account the individual patient's medical history, comorbidities, and potential interactions with other medications 6, 3, 4, 5.