How to manage a patient with hypertension, hyperuricaemia, and chronic leg swelling, who is taking Bendroflumethiazide and has multiple medication allergies?

Management of Hypertension, Hyperuricemia, and Chronic Leg Swelling with Multiple Drug Allergies

Discontinue bendroflumethiazide immediately and switch to amlodipine 5mg daily for hypertension control, while initiating febuxostat 80mg daily for hyperuricemia management. This approach directly addresses the patient's three interconnected problems: bendroflumethiazide is exacerbating both the leg swelling and hyperuricemia, making it contraindicated in this clinical scenario.

Rationale for Discontinuing Bendroflumethiazide

Bendroflumethiazide is directly worsening both the hyperuricemia and leg edema in this patient and must be stopped. The FDA label explicitly states that "hyperuricemia may occur or frank gout may be precipitated in certain patients receiving thiazide therapy" and that "dosage adjustments of antigout medication may be necessary since bendroflumethiazide may raise the level of blood uric acid" 1.

• Thiazide diuretics paradoxically worsen fluid retention in certain patients, particularly when used at higher doses (this patient is on 5mg BD = 10mg daily, which is excessive) 2.
• The optimal dose range for bendroflumethiazide is 1.25-2.5mg daily; doses of 10mg daily cause pronounced adverse biochemical effects including hyperuricemia 2.
• Current guidelines recommend thiazide-like diuretics (chlorthalidone, indapamide) over conventional thiazides like bendroflumethiazide for hypertension management 3.

Hypertension Management Strategy

Amlodipine 5mg daily is the optimal choice for this 74-year-old patient with well-controlled blood pressure (117/75 mmHg), multiple drug allergies, and chronic kidney disease (eGFR 71).

• For patients aged >55 years, calcium channel blockers are recommended as first-line therapy 3.
• The 2024 ESC guidelines recommend targeting systolic BP to 130-139 mmHg in older people aged ≥65 years 3.
• Amlodipine has the additional benefit of reducing hyperuricemia; in renal transplant recipients on cyclosporine, amlodipine significantly decreased serum uric acid from 483 to 431 μmol/L while increasing uric acid clearance 4.
• Given the patient's allergy to ACE inhibitors (candesartan caused severe rash and hair loss), calcium channel blockers become even more essential as they cannot use RAS blockers 3.

Blood Pressure Monitoring Protocol

• Check BP with practice nurse immediately if experiencing dizziness, as this may indicate hypotension from the medication switch 3.
• Recheck BP in 2 weeks alongside uric acid monitoring to ensure adequate control 3.
• Target BP <140/90 mmHg, but given age >65 years, a range of 130-139 mmHg systolic is appropriate 3.

Hyperuricemia and Gout Management

Febuxostat 80mg daily is the appropriate urate-lowering therapy given the patient's allergy to allopurinol and the contraindication to probenecid. The current uric acid level of 0.46 mmol/L exceeds the target of <0.36 mmol/L 3.

• The patient has documented allergies to both allopurinol (rash, hair loss) and probenecid, eliminating these as options 3.
• Febuxostat is effective for achieving target uric acid levels in patients intolerant to allopurinol 3.
• Systematic assessment for comorbidities is recommended in gout patients, including obesity, renal impairment, hypertension, and diabetes—all present in this patient 3.

Dietary Modifications for Hyperuricemia

• Increase water intake to promote uric acid excretion 3.
• Avoid alcohol, particularly beer and spirits (patient reports occasional Baileys/Kahlua monthly and recent wine consumption) 3.
• Reduce red meat and organ meat consumption 3.
• Increase vegetables and fruits 3.

Chronic Leg Swelling Management

The bilateral leg swelling is multifactorial but significantly worsened by bendroflumethiazide; switching to amlodipine requires careful monitoring as calcium channel blockers can also cause peripheral edema.

• Amlodipine-induced edema occurs in some patients, but this is typically dose-dependent and less severe than thiazide-induced fluid retention 3.
• If amlodipine causes unacceptable leg swelling worsening, consider adding a low-dose loop diuretic rather than continuing thiazides, given the hyperuricemia concern 3.
• Non-pharmacological measures are essential: compression stockings and leg elevation 3.

Monitoring for Amlodipine-Related Edema

• Assess leg swelling at 2-week follow-up visit 3.
• If edema worsens significantly on amlodipine, consider alternative strategies such as adding a small dose of loop diuretic (which has less hyperuricemic effect than thiazides) or switching to a different antihypertensive class 3.

Special Considerations for Multiple Drug Allergies

This patient's extensive allergy profile (candesartan, allopurinol, Fosamax, morphine, probenecid) significantly limits treatment options and requires careful drug selection.

• ACE inhibitors and ARBs are contraindicated due to the severe reaction to candesartan (rash, hair loss) 3.
• Beta-blockers are not preferred initial therapy but could be considered if amlodipine fails, though they may worsen peripheral circulation 3.
• Alpha-blockers like doxazosin should be avoided as they increase heart failure risk 3.

Renal Function Considerations

With an eGFR of 71 mL/min/1.73m² (improved from 60), individualized BP targets and careful medication selection are warranted.

• In patients with CKD, systolic BP should be lowered to 130-139 mmHg 3.
• Amlodipine is renally safe and does not require dose adjustment at this level of renal function 4.
• Monitor renal function and electrolytes in 2 weeks given the medication changes 3.

Additional Metabolic Concerns

The patient has Type 2 diabetes (on Galvumet), which influences both BP targets and medication selection.

• In people with diabetes, target SBP to 130 mmHg and <130 mmHg if tolerated, but not <120 mmHg 3.
• In older people with diabetes (aged ≥65 years), target SBP range of 130-139 mmHg 3.
• Thiazides can worsen glucose control; bendroflumethiazide may elevate blood glucose levels 1.

Follow-Up Plan

• Blood test in 2 weeks: uric acid, renal function, electrolytes 3.
• BP check in 2 weeks with practice nurse 3.
• Assess leg swelling response to bendroflumethiazide discontinuation 3.
• Follow-up appointment scheduled for 10/11/2025 3.
• Specialist referral pending within 8 weeks for persistent leucocytosis (WCC 13.6, down from 15.2) 3.