What adjustments should be made to the medication regimen of a 60-year-old male with uncontrolled hypertension, dyslipidemia, and gouty arthritis, who is currently taking allopurinol (100mg once daily), telmisartan (40mg once daily), and has lab results indicating impaired renal function and hyperuricemia?

Medication Adjustments for Uncontrolled Hypertension, Dyslipidemia, and Gouty Arthritis

Increase telmisartan to 80mg daily, initiate atorvastatin 40mg at bedtime, and titrate allopurinol to 200mg daily if BUA remains >6 mg/dL at follow-up, while continuing flare prophylaxis for at least 6 months from allopurinol initiation. 1, 2, 3

Hypertension Management

Telmisartan dose escalation is appropriate and necessary given BP 140/100 mmHg. 1

• Increase telmisartan from 40mg to 80mg once daily as planned 1
• The patient's BP remains uncontrolled despite current therapy, and resistant hypertension guidelines emphasize optimizing existing antihypertensive agents before adding additional medications 1
• Telmisartan (an ARB) is specifically recommended in gout patients as it has mild uricosuric properties, making it preferable to other antihypertensives 1
• Critical caveat: NSAIDs like celecoxib can interfere with blood pressure control and should be avoided in resistant hypertension 1
• Monitor BP closely after dose adjustment; if still uncontrolled at 80mg, consider adding a thiazide-type diuretic (preferably chlorthalidone 12.5-25mg daily) rather than hydrochlorothiazide for superior 24-hour BP control 1

Dyslipidemia Management

Initiate atorvastatin 40mg at bedtime as planned. 1

• TC 217.39, LDL 133.15, TG 203.23, and HDL 43.87 indicate mixed dyslipidemia requiring statin therapy 1
• Atorvastatin 40mg is an appropriate starting dose for this cardiovascular risk profile 1
• Important monitoring: Patients on both statins and colchicine have increased risk of muscular toxicity and rhabdomyolysis 1
• Since the patient is no longer in acute flare and colchicine was only for acute treatment, this interaction risk is minimized with prophylactic low-dose colchicine 1
• Repeat lipid profile in 4-6 weeks to assess response and adjust dose if needed 1

Gout and Urate-Lowering Therapy Management

Continue allopurinol with dose titration based on BUA at follow-up, and ensure adequate flare prophylaxis. 1, 2, 3

Allopurinol Dosing Strategy

• Current dose: 100mg daily is appropriate as initial therapy 1, 2, 3
• If BUA <6 mg/dL at follow-up: Continue allopurinol 100mg daily 1, 2
• If BUA >6 mg/dL at follow-up: Increase to 200mg daily 1, 2, 3
• With creatinine 1.27 (suggesting mild renal impairment), the patient can safely receive allopurinol up to 300-400mg daily with appropriate monitoring 2, 3
• The FDA label recommends starting at 100mg daily and increasing by 100mg increments weekly until serum uric acid <6 mg/dL is achieved 3
• EULAR guidelines recommend dose escalation every 2-4 weeks rather than weekly for better tolerability 1, 2

Critical Flare Prophylaxis Requirement

The patient MUST receive flare prophylaxis for at least 6 months from allopurinol initiation. 1, 4, 5, 2

• The plan does not mention ongoing prophylaxis, which is a critical omission 1, 5
• Recommended prophylaxis options (in order of preference for this patient):
  • First-line: Colchicine 0.5-0.6mg daily (dose-adjusted for renal function: 0.3mg daily or 0.5mg every other day given creatinine 1.27) 1, 5, 2
  • Second-line: Low-dose prednisone <10mg daily if colchicine contraindicated 5, 2
  • Avoid: NSAIDs given uncontrolled hypertension and potential renal impairment 1
• Continue prophylaxis for minimum 6 months after starting allopurinol, or until BUA has been at target (<6 mg/dL) for at least 3 months without flares 1, 5, 2
• Common pitfall: Failing to provide adequate prophylaxis is the most common reason for treatment failure and patient non-adherence to urate-lowering therapy 1, 5

Renal Function Considerations

• Creatinine 1.27 mg/dL with BUN 22.41 suggests mild renal impairment (likely CKD stage 2-3) 2
• Allopurinol is preferred over febuxostat in this patient because he has no history of cardiovascular disease, and allopurinol has more extensive safety data 4, 2
• Febuxostat would be indicated if: 4
  • Allopurinol hypersensitivity develops
  • Target BUA cannot be achieved with maximum tolerated allopurinol dose
  • Patient develops cardiovascular disease (though febuxostat carries FDA black box warning for CV risk) 4
• Monitor renal function (creatinine, BUN) every 2-3 months during dose titration 2

Monitoring Plan

• At follow-up visit: 1, 2
  • Check BUA, creatinine, and compliance with medications
  • If BUA <6 mg/dL: Continue allopurinol 100mg daily
  • If BUA >6 mg/dL: Increase allopurinol to 200mg daily
  • Ensure flare prophylaxis is in place
• Subsequent monitoring: 1, 2
  • Recheck BUA every 2-5 weeks during dose titration
  • Once target BUA <6 mg/dL achieved, monitor every 6 months
  • Continue prophylaxis for at least 6 months total from allopurinol initiation 1, 5, 2

Additional Considerations

Avoid celecoxib for breakthrough pain given hypertension and potential renal impairment. 1

• NSAIDs interfere with blood pressure control and should be avoided in resistant hypertension 1
• NSAIDs increase cardiovascular and renal risks, particularly in patients with existing renal impairment 1
• For breakthrough musculoskeletal pain, consider acetaminophen as a safer alternative 1

Lifestyle modifications are essential but often overlooked: 1

• Reduce alcohol intake (particularly beer and spirits)
• Avoid high-purine foods (organ meats, certain seafood)
• Maintain adequate hydration (at least 2 liters daily) 3
• Weight reduction if overweight
• These measures complement but do not replace pharmacologic urate-lowering therapy 1