What is the best management approach for a 43-year-old patient with mechanical lower back pain, poorly controlled hypertension (HTN) due to medication non-compliance, hyperlipidaemia, and a history of gout, who is currently on Felodipine (Plendil), Losartan, and Lipitor (Atorvastatin), and has previously been treated with allopurinol for gout?

Management of Mechanical Lower Back Pain with Comorbid Poorly Controlled Hypertension, Hyperlipidemia, and Gout History

The immediate priority is addressing medication non-compliance to prevent cardiovascular morbidity and mortality, while simultaneously treating the mechanical lower back pain with NSAIDs and optimizing the antihypertensive regimen to benefit both blood pressure control and gout prevention.

Immediate Medication Compliance and Optimization

Restart and optimize the current antihypertensive regimen immediately, as the patient is already on losartan—the ideal agent for someone with gout history. 1, 2

• The patient's current losartan therapy should be continued and compliance reinforced, as losartan has unique uricosuric properties that lower serum uric acid by 20-47 μmol/L while controlling blood pressure 2
• Consider titrating losartan to 100 mg daily for optimal cardiovascular and urate-lowering benefits 2
• Felodipine (calcium channel blocker) should also be restarted as it does not increase uric acid levels and is appropriate for gout patients 2
• Critically important: Ensure atorvastatin compliance is addressed, but consider switching to fenofibrate if hyperlipidemia control allows, as fenofibrate reduces serum uric acid by approximately 20% while treating hyperlipidemia 1, 2

Key Pitfall to Avoid

• Do not add or switch to thiazide or loop diuretics for blood pressure control, as these significantly increase gout risk 1, 2
• If the patient was previously on hydrochlorothiazide (not clearly documented here), it must be discontinued 2

Mechanical Lower Back Pain Management

For this acute mechanical lower back pain (one week duration, now improving), prescribe NSAIDs as first-line therapy with appropriate gastroprotection. 3, 4

• NSAIDs have moderate evidence for short-term effectiveness in mechanical low back pain and are superior to placebo for pain reduction 3, 4
• Paracetamol (which the patient is currently taking) provides no additional benefit for acute low back pain and should be discontinued 4
• Prescribe a time-limited course (7-14 days) of an NSAID such as naproxen or ibuprofen with proton pump inhibitor gastroprotection 3, 4
• The patient's examination shows no red flags (no neurologic deficits, normal straight leg raise, no cauda equina symptoms), so imaging is not indicated 3

Physical Therapy and Non-Pharmacological Interventions

• Refer for physical therapy with McKenzie method, which has evidence for decreasing recurrence and healthcare expenditures 3
• Educate on prognosis (most mechanical low back pain improves within 4-6 weeks) and encourage early mobilization 3
• Consider osteopathic manipulative treatment or spinal manipulative therapy, which show mixed but potentially beneficial effects 3

Gout Prevention Strategy

Restart allopurinol for long-term urate-lowering therapy to prevent future gout attacks, as the patient has a history of gout with elevated uric acid. 1

• The patient previously stopped allopurinol when gout pain resolved—this is a critical error that must be corrected 1
• Start allopurinol at 100 mg daily and increase by 100 mg every 2-4 weeks to achieve target serum uric acid <360 μmol/L 1
• Provide prophylaxis with colchicine 0.5-1 mg daily during the first months of urate-lowering therapy to prevent acute flares 1
• The combination of losartan (already prescribed) plus allopurinol provides dual urate-lowering benefit 1, 5

Patient Education on Gout Management

• Weight loss and dietary modification (low purine diet, reduced alcohol especially beer) are core management aspects with evidence for reducing serum uric acid 1
• Explain that allopurinol must be continued long-term even when asymptomatic to prevent recurrent attacks and joint damage 1
• Address the metabolic syndrome components (hypertension, hyperlipidemia, likely obesity given gout history) as these are interconnected 1

Cardiovascular Risk Reduction

Address the poorly controlled hypertension and medication non-compliance as the highest priority for mortality reduction.

• The patient had a previous troponin elevation requiring hospitalization—this indicates significant cardiovascular risk 1
• Hyperlipidemia, hypertension, and gout collectively represent metabolic syndrome, which substantially increases cardiovascular mortality 1
• Schedule close follow-up (within 2 weeks) to assess medication compliance, blood pressure control, and response to back pain treatment
• Consider barriers to compliance: cost, side effects, understanding of disease severity, and address these specifically

Monitoring Plan

• Recheck blood pressure in 2 weeks after restarting medications
• Monitor serum uric acid levels 4-6 weeks after restarting allopurinol 1
• Assess lipid panel and liver function if switching to fenofibrate
• Monitor renal function given losartan use and history of elevated troponin 2

What NOT to Do

• Do not continue paracetamol monotherapy for mechanical low back pain—it is ineffective 4
• Do not order lumbar spine imaging at this stage—no red flags are present 3
• Do not prescribe opioids for this mechanical low back pain—NSAIDs are first-line and opioids have established harms 4
• Do not allow the patient to remain off allopurinol—this guarantees recurrent gout attacks 1
• Do not add diuretics for blood pressure control—they will precipitate gout 1, 2