Which antihypertensive medications are optimal for a patient with gout, avoiding agents that increase serum uric acid?

Optimal Antihypertensive Medications for Patients with Gout

Losartan is the preferred antihypertensive agent for patients with gout, and thiazide or loop diuretics should be discontinued whenever possible. 1, 2

First-Line Recommendation: Losartan

Losartan stands alone among antihypertensive medications as having dual benefit—it controls blood pressure while actively lowering serum uric acid through its unique uricosuric properties. 2, 3

• Losartan increases urinary uric acid excretion by approximately 25% and reduces serum uric acid by 20-47 μmol/L 3
• The optimal dose is 100 mg once daily for maximal cardiovascular and uricosuric benefit, though the uricosuric effect plateaus at approximately 50 mg daily 3
• This is the only angiotensin receptor blocker (ARB) with clinically meaningful uricosuric activity 4, 5
• Monitor potassium levels and renal function regularly, particularly in patients with chronic kidney disease 3

Second-Line Option: Calcium Channel Blockers

When losartan is contraindicated or not tolerated, calcium channel blockers are the preferred alternative as they do not raise serum uric acid levels. 2, 3

• Calcium channel blockers are neutral with respect to uric acid metabolism 4
• They should be considered when losartan causes persistent cough or hyperkalemia 6
• ACE inhibitors are also neutral but may cause cough; standard ARBs (other than losartan) lack the uricosuric benefit 4

Medications to Avoid

Thiazide and loop diuretics must be discontinued whenever clinically feasible, as they significantly increase serum uric acid and precipitate gout attacks. 1, 2

• Thiazide diuretics carry an odds ratio of 1.72 for gout development 6
• Loop diuretics similarly increase gout risk by reducing renal uric acid excretion 6
• The EULAR guidelines explicitly recommend substituting diuretics when gout occurs in a patient receiving these agents 1
• If diuretics cannot be discontinued due to compelling indications (heart failure with volume overload), potassium-sparing diuretics have minimal gout risk (OR 1.06, not statistically significant) and represent the safest diuretic option 6

Beta-blockers and alpha-1 blockers should also be avoided as they raise serum uric acid levels and reduce glomerular filtration rate. 4

Adjunctive Consideration: Fenofibrate for Hyperlipidemia

In patients with concurrent hyperlipidemia and gout, fenofibrate provides dual benefit by treating dyslipidemia while lowering serum uric acid. 1, 2

• Fenofibrate reduces serum uric acid by approximately 20% and increases renal uric acid clearance by about 30% 3
• This makes fenofibrate the preferred lipid-lowering agent in this population 1

Clinical Algorithm

1. Assess current antihypertensive regimen: If patient is on thiazide or loop diuretics, plan to discontinue unless absolutely contraindicated 1, 6

2. Switch to losartan 50-100 mg daily as the primary antihypertensive agent 2, 3

3. If losartan is contraindicated or not tolerated: Use calcium channel blockers as the alternative 3, 6

4. If diuretics cannot be discontinued (e.g., severe heart failure): Switch to potassium-sparing diuretics and optimize urate-lowering therapy with higher allopurinol doses 6

5. For hyperlipidemia: Choose fenofibrate over statins when possible 1, 3

Common Pitfalls to Avoid

• Do not continue hydrochlorothiazide in gout patients when alternatives exist—it is a modifiable risk factor that substantially increases gout risk 3, 6
• Do not abruptly stop diuretics without an alternative antihypertensive plan in patients requiring blood pressure control 6
• Do not assume all ARBs have uricosuric properties—only losartan demonstrates this effect 4, 5
• Monitor electrolytes closely within the first three days after changing diuretic regimens, as this is when the greatest shifts occur 6