Which is better for patients with hypertension and gout, losartan or amlodipine?

Losartan is Superior to Amlodipine for Hypertension with Gout

For patients with both hypertension and gout, losartan is the clear preferred choice over amlodipine due to its unique uricosuric properties that simultaneously control blood pressure while lowering serum uric acid levels. 1

Primary Recommendation

The American College of Cardiology specifically recommends losartan as the preferred alternative antihypertensive for patients with or at risk of gout, as it uniquely increases urinary uric acid excretion and can lower both blood pressure and serum uric acid levels simultaneously. 1 This dual benefit makes losartan the optimal single agent for this patient population.

Evidence Supporting Losartan's Superiority

Uric Acid Lowering Effects

• Losartan increases urinary uric acid excretion by approximately 25% and reduces serum uric acid by 20-47 μmol/L through its uricosuric properties. 1
• In a randomized controlled trial, losartan 50 mg once daily decreased serum uric acid levels from 538 ± 26 to 491 ± 20 micromol/L (P < 0.01), while irbesartan (another ARB) had no effect on serum uric acid. 2
• When losartan is combined with amlodipine, serum uric acid decreased from 6.5 ± 1.6 to 4.6 ± 1.3 mg/ml (p = 0.0001), demonstrating that amlodipine does not interfere with losartan's uricosuric effect. 3

Guideline-Based Recommendations

• EULAR guidelines recommend stopping diuretics when possible in gout patients and considering losartan for hypertension due to its modest uricosuric effects. 1
• The American College of Rheumatology conditionally recommends switching to alternative antihypertensives (like losartan) in gout patients. 1

Why Not Amlodipine Alone?

While amlodipine is listed as an acceptable alternative to diuretics because it does not increase serum uric acid levels 1, it lacks any uric acid-lowering benefit. Amlodipine is neutral regarding uric acid metabolism, whereas losartan actively reduces uric acid burden. 1, 3

Clinical Algorithm for Implementation

Step 1: Initiate losartan 50 mg once daily 2

• This dose provides significant uric acid reduction while controlling blood pressure
• Standard monitoring for ARB therapy applies, including potassium levels and renal function 1

Step 2: Titrate losartan for blood pressure control

• Can increase to 100 mg once daily if needed for blood pressure
• Note that increasing to twice-daily dosing does not provide additional uric acid lowering 2

Step 3: Add amlodipine if losartan monotherapy insufficient

• The combination of losartan/amlodipine provides excellent blood pressure control while maintaining uric acid reduction 3
• This combination reduced BP from 155/94 to 123/79 mmHg while decreasing uric acid from 6.5 to 4.6 mg/ml 3

Important Caveats

Avoid combining losartan with hydrochlorothiazide in gout patients. While losartan/hydrochlorothiazide combinations are common, the hydrochlorothiazide component increases gout risk (odds ratio 1.72) and negates losartan's uric acid-lowering benefit. 1, 4, 3 In one study, losartan/hydrochlorothiazide showed no significant change in uric acid levels (5.82 to 5.85 mg/ml, p = 0.936), compared to the significant reduction with losartan/amlodipine. 3

Additional Considerations

• Losartan can be combined with urate-lowering therapy (allopurinol or benzbromarone) for additive effects in patients requiring more aggressive uric acid control. 5
• The uricosuric effect of losartan may decrease over time as a new steady state of lower serum uric acid is reached. 2
• While long-term randomized controlled trials evaluating losartan specifically for gout treatment are lacking, the consistent evidence of uric acid reduction across multiple studies supports its use. 1