What hypertension (Htn) medications help lower uric acid levels and reduce gout flares?

Hypertension Medications That Help Lower Gout Flares

Losartan is the preferred antihypertensive medication for patients with gout or hyperuricemia due to its unique uricosuric properties that lower serum uric acid levels and reduce gout flare risk. 1

Antihypertensive Medications and Their Effect on Uric Acid Levels

Medications That Increase Uric Acid Levels

• Thiazide and thiazide-type diuretics (chlorthalidone, hydrochlorothiazide, indapamide, metolazone) increase serum uric acid levels and should be avoided in patients with gout when possible 1
• Beta-blockers can increase serum uric acid levels by reducing glomerular filtration rate 2
• Alpha-1 blockers may also contribute to elevated uric acid levels 2

Medications That Do Not Affect or May Lower Uric Acid Levels

• Losartan has a unique uricosuric effect among angiotensin II receptor blockers (ARBs), lowering serum uric acid by increasing renal uric acid clearance 1, 3, 4
• Calcium channel blockers (CCBs) do not increase serum uric acid levels 2
• ACE inhibitors generally do not increase serum uric acid levels 2
• Other ARBs (except losartan) do not have significant uricosuric effects 3, 5

Evidence Supporting Losartan for Hypertension in Gout Patients

• Losartan significantly decreases serum uric acid levels from 538 to 491 μmol/L (p<0.01) in hypertensive patients with hyperuricemia and gout 3
• The European League Against Rheumatism (EULAR) recommends losartan for hypertension management in gout patients due to its uricosuric action 1
• Losartan is the only ARB that consistently demonstrates significant reduction in serum uric acid levels 5
• Losartan 50 mg once daily is sufficient to achieve uricosuric effects; increasing to twice daily dosing does not provide additional uric acid-lowering benefits 3

Practical Recommendations for Managing Hypertension in Gout Patients

First-line Approach

• For patients with hypertension and gout/hyperuricemia, losartan should be considered as the preferred antihypertensive agent 1, 4
• Standard losartan dosing for hypertension (50-100 mg daily) is appropriate and provides uricosuric benefits 1, 3

Alternative Approaches

• If losartan is insufficient for blood pressure control, consider adding a calcium channel blocker rather than a diuretic 2
• If a patient is currently on a diuretic and develops gout, consider discontinuing the diuretic if clinically appropriate and switching to losartan 1, 6

Special Considerations

• For patients with hyperlipidemia and gout, fenofibrate has shown uricosuric effects and can lower serum uric acid by approximately 20% 1
• Avoid combination therapy with ACE inhibitors and ARBs as this is potentially harmful and not recommended for hypertension treatment 1
• In patients with severe gout requiring urate-lowering therapy, losartan can be used as an adjunctive therapy to allopurinol or febuxostat 1

Monitoring Recommendations

• Monitor serum uric acid levels before and after initiating losartan therapy to assess effectiveness 3
• Monitor renal function, as the uricosuric effect of losartan may be reduced in patients with chronic kidney disease, particularly when GFR is <30 mL/min 1, 7
• Be aware that the uricosuric effect of losartan may decrease over time as a new steady state of lower serum uric acid is reached 3

Remember that while losartan helps reduce serum uric acid levels, patients with established gout may still require specific urate-lowering therapy (allopurinol, febuxostat, or probenecid) to achieve target serum urate levels and prevent gout flares 1.