Continuing Hyzaar and Zyloprim with Controlled Gout
Yes, it is appropriate to continue both Hyzaar (losartan/hydrochlorothiazide) and Zyloprim (allopurinol) in this patient with well-controlled gout (uric acid 5.4 mg/dL), though the hydrochlorothiazide component requires careful consideration.
Current Uric Acid Control
- Your uric acid level of 5.4 mg/dL is well below the target of <6 mg/dL (360 μmol/L) recommended for maintaining gout control 1, 2
- This indicates that the allopurinol is effectively managing your hyperuricemia 1
- Allopurinol should be maintained lifelong once the target uric acid is achieved to prevent crystal reaccumulation and future gout flares 1, 2
The Losartan Component: A Beneficial Choice
Losartan is actually the preferred antihypertensive agent for patients with gout because it possesses unique uricosuric properties among all angiotensin receptor blockers 1, 3
- Losartan increases urinary uric acid excretion and lowers serum uric acid levels, unlike other ARBs such as irbesartan 4
- Clinical guidelines specifically recommend losartan for hypertensive patients with gout due to this dual benefit 1
- Studies demonstrate losartan 50 mg daily decreased serum uric acid from 538 to 491 μmol/L in hypertensive patients with gout 4
- Losartan does not increase serum uric acid levels, unlike diuretics, beta-blockers, and alpha-1 blockers 5
The Hydrochlorothiazide Concern
The hydrochlorothiazide component of Hyzaar is the only problematic element, as thiazide diuretics are a common risk factor for gout and hyperuricemia 1
Guideline Recommendations on Diuretics and Gout
- When gout associates with diuretic therapy, guidelines recommend stopping the diuretic if possible 1
- For hypertension in gout patients, consider losartan (without thiazide) or calcium channel blockers 1
- The 2017 ACC/AHA hypertension guidelines note that thiazides should be used with caution in patients with history of acute gout, unless the patient is on uric acid-lowering therapy 1
Critical Decision Point
Since your uric acid is well-controlled at 5.4 mg/dL on allopurinol, the hydrochlorothiazide is acceptable to continue 1
- The ACC/AHA guidelines explicitly state thiazides can be used in gout patients who are on uric acid-lowering therapy 1
- Your allopurinol is effectively counteracting any hyperuricemic effect from the hydrochlorothiazide 6
- Monitor serum uric acid levels regularly to ensure they remain <6 mg/dL 1, 2
Monitoring Requirements
Regular monitoring is essential to ensure continued gout control:
- Check serum uric acid levels periodically (every 6-12 months) to confirm maintenance of target <6 mg/dL 1, 2
- Monitor renal function, as both medications require dose adjustments in renal impairment 1, 6
- Watch for signs of gout flares, though these should be rare with well-controlled uric acid 6
Common Pitfalls to Avoid
- Do not stop allopurinol even with normal uric acid levels, as this will lead to reaccumulation of urate crystals and recurrent gout 1, 2
- Do not discontinue medications during an acute gout flare if one occurs; continue both allopurinol and antihypertensives 2
- Do not assume the hydrochlorothiazide is safe indefinitely without monitoring; if uric acid levels rise above 6 mg/dL, consider switching to losartan monotherapy or adding a calcium channel blocker 1
Alternative Consideration
If blood pressure control permits, switching from Hyzaar to losartan monotherapy (without hydrochlorothiazide) would be the most gout-friendly antihypertensive regimen 1. This eliminates the hyperuricemic effect of thiazide while maintaining losartan's beneficial uricosuric properties 4, 3.