How to manage a patient with recurrent gout, hypertension, and impaired renal function, currently experiencing hypotension?

Management of Recurrent Gout with Hypertension and Hypotension

The patient requires immediate adjustment of antihypertensive medication due to current hypotension, treatment of the acute gout flare with corticosteroids, and optimization of urate-lowering therapy with allopurinol dose adjustment based on renal function. 1

Immediate Management

Addressing Hypotension

• Discontinue losartan temporarily due to current hypotension (BP 96/63) which is likely due to recent medication change from HCTZ to losartan 1, 2
• Once BP normalizes, consider restarting at a lower dose (25mg) with careful monitoring 1
• Losartan is an appropriate choice for hypertension in gout patients as it has uricosuric effects that can help lower uric acid levels 1

Treatment of Acute Gout Flare

• Oral corticosteroids (prednisolone 30-35mg daily for 3-5 days) are the most appropriate first-line treatment given the patient's renal impairment (eGFR 55) 1
• NSAIDs should be avoided due to the patient's renal impairment 1, 3
• Colchicine should be used with caution due to renal impairment; if used, administer low-dose colchicine (0.5mg once or twice daily with dose adjustment for renal function) 1
• Joint aspiration and intra-articular corticosteroid injection is another effective option if the flare is limited to 1-2 joints 1

Long-term Management

Urate-Lowering Therapy Optimization

• Continue allopurinol but adjust dosage based on renal function (current eGFR 55) 1, 4
• Current dose of 300mg may need adjustment; consider dose reduction to 200mg daily with gradual titration based on uric acid levels and renal function 1, 4
• Target serum uric acid level should be <6 mg/dL (360 μmol/L) or <5 mg/dL (300 μmol/L) for severe gout with frequent attacks 1
• Monitor renal function and uric acid levels every 2-4 weeks during dose adjustment 4

Flare Prophylaxis

• Consider prophylaxis with low-dose colchicine (0.5mg daily with renal dose adjustment) during allopurinol dose adjustment to prevent flares 1
• If colchicine is not tolerated, low-dose prednisone (5mg daily) can be considered for prophylaxis 1
• Prophylaxis should continue for at least 3-6 months after achieving target uric acid levels 1, 5

Management of Comorbidities

Hypertension Management

• Once blood pressure normalizes, restart losartan at a lower dose (25mg daily) 1, 2
• Losartan is preferred over thiazide diuretics for hypertension in gout patients 1, 3
• Calcium channel blockers (continue amlodipine 5mg) are also appropriate for hypertension management in gout 1

Diabetes Management

• Continue metformin 500mg BD as current glycemic control is improving (glucose 5.8, down from 6.1) 1
• Encourage weight loss if overweight, as this can improve both gout and diabetes control 1, 5

Lifestyle Modifications

• Reinforce dietary modifications: limit red meat, seafood, and alcohol (especially beer) 1, 2
• Encourage consumption of low-fat dairy products 1, 5
• Maintain adequate hydration to help prevent urate crystal formation 4, 5
• Regular physical activity should be encouraged to help with weight management 1, 3

Follow-up Plan

• Review in 2 weeks to reassess blood pressure and adjust antihypertensive therapy 1
• Monitor renal function and uric acid levels every 2-4 weeks during medication adjustments 1, 4
• Once stable, follow up every 3-6 months to monitor uric acid levels, renal function, and medication adherence 1

Common Pitfalls to Avoid

• Avoid restarting losartan at the previous dose (50mg) due to risk of continued hypotension 1
• Do not use NSAIDs for acute gout treatment in patients with renal impairment 1, 3
• Avoid standard-dose colchicine in patients with renal impairment due to increased risk of toxicity 1
• Do not discontinue allopurinol during acute flares; continue therapy to maintain uric acid control 4, 6
• Avoid undertreatment of uric acid levels; ensure target of <6 mg/dL is achieved 1