What is the best alternative treatment for uncontrolled hypertension in a patient with gout who cannot take calcium channel blockers due to peripheral edema?

From the Guidelines

For uncontrolled hypertension in a patient with gout who cannot take calcium channel blockers due to feet edema, I recommend starting with a thiazide-like diuretic such as chlorthalidone 12.5-25mg daily or an angiotensin receptor blocker (ARB) like losartan 50-100mg daily, as suggested by the 2020 American College of Rheumatology guideline for the management of gout 1.

Key Considerations

• Losartan is particularly beneficial as it has uricosuric properties that can help lower uric acid levels, making it ideal for patients with gout.
• If blood pressure remains uncontrolled on monotherapy, consider adding a beta-blocker such as metoprolol 25-100mg twice daily.
• For patients with severe hypertension, combining an ARB with chlorthalidone and a beta-blocker may be necessary.

Monitoring and Lifestyle Modifications

• It's essential to monitor serum uric acid levels, as thiazide diuretics can exacerbate gout.
• Ensure the patient is also taking appropriate gout medication such as allopurinol or febuxostat to maintain uric acid levels below 6 mg/dL.
• Regular monitoring of renal function, electrolytes, and uric acid levels is essential, especially when using diuretics.
• Lifestyle modifications including sodium restriction, weight loss if overweight, regular physical activity, and limiting alcohol consumption should be emphasized as complementary approaches to medication therapy.

Additional Guidance

• The 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults provides further guidance on the management of hypertension in patients with gout 1.
• The 2016 updated EULAR evidence-based recommendations for the management of gout also provide guidance on the management of gout, including the use of urate-lowering therapy and lifestyle modifications 1.

From the FDA Drug Label

The antihypertensive effect of losartan was studied in one trial enrolling 177 hypertensive pediatric patients aged 6 to 16 years old. The sitting diastolic blood pressure (SiDBP) on entry into the study was higher than the 95th percentile level for the patient’s age, gender, and height. At the end of three weeks, losartan reduced systolic and diastolic blood pressure, measured at trough, in a dose-dependent manner The LIFE study was a multinational, double-blind study comparing losartan and atenolol in 9193 hypertensive patients with ECG-documented left ventricular hypertrophy. Treatment with losartan resulted in a 13% reduction (p=0. 021) in risk of the primary endpoint compared to the atenolol group

Uncontrolled hypertension in a patient with gout who can’t take calcium channel blockers due to feet edema can be managed with losartan as it has been shown to be effective in reducing blood pressure in various patient populations, including those with hypertension and left ventricular hypertrophy 2.

• Losartan can be used as an alternative to calcium channel blockers.
• The patient's gout condition does not appear to be a contraindication for losartan use.
• However, it is essential to monitor the patient's blood pressure and adjust the losartan dose as needed to achieve adequate control.
• Additionally, consideration should be given to the potential for losartan to affect renal function, particularly in patients with pre-existing renal impairment.
• Lisinopril is another option for managing uncontrolled hypertension, and its use should be considered based on the patient's individual needs and medical history 3.

From the Research

Uncontrolled Hypertension in Patients with Gout

• Uncontrolled hypertension is a common complication in patients with gout and/or hyperuricemia 4
• Hyperuricemia is a risk factor of gout as well as ischemic heart disease in hypertensive patients 4

Antihypertensive Treatment Options

• Calcium channel blockers are not an option due to feet edema
• Diuretics, beta-blockers, and alpha-1 blockers may increase serum uric acid levels and are not recommended 4
• Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are alternative options

ACE Inhibitors vs. ARBs

• ACE inhibitors and ARBs have similar efficacy in reducing blood pressure and cardiovascular outcomes 5, 6
• ARBs have a slightly lower incidence of adverse events, such as dry cough, compared to ACE inhibitors 5, 6
• Losartan, an ARB, has been shown to have a positive effect on serum uric acid levels and may be a good option for patients with gout 7

Treatment Considerations

• ACE inhibitors may be preferred for patients with cardiovascular comorbidities, but ARBs are a suitable alternative when ACE inhibitors are not tolerated 8
• Losartan should be considered as a first-line agent for patients with high blood pressure and elevated serum uric acid, with irbesartan as an alternative when appropriate 7