Managing Hypertensive Patients With Gout Who Take Thiazide

Case 1: A 67-year-old man was referred to our hypertension clinic because of refractory hypertension associated with gout. The onset of hypertension occurred in his 20s. Since his early 30s, he also had recurrent podagra, and at that time was taken off thiazide, but nonetheless continued to experience recurrent gouty episodes every several months. Approximately 1 year prior to his hypertension evaluation, the patient was prescribed allopurinol and last experienced podagra 6 months previously. Recent blood pressures (BPs) had been 152 ⁄78 mm Hg and 175 ⁄88 mm Hg and was 162 ⁄84 mm Hg when seen in the hypertension clinic. Creatinine was 1.1 mg ⁄dL (normal 0.7–1.3 mg ⁄dL) and uric acid was 4.6 mg ⁄dL (normal 3.4–7.2 mg ⁄dL). Medications included atenolol 50 mg twice a day, allopurinol 200 mg twice a day, amlodipine 10 mg once a day, clonidine 0.1 mg twice a day, losartan 50 mg once a day, and terazosin 6 mg at bedtime. The patient was hesitant to retry a diuretic, but was persuaded to take hydrochlorothiazide 12.5 mg daily, subsequently advanced to 25 mg daily. Follow-up BPs were 128 to 132 mm Hg ⁄66 to 72 mm Hg without recurrence of gout 6 months later. Case 2: A 43-year-old man was seen in our hypertension clinic because of uncontrolled BP. Antihypertensive medication was introduced to the patient in his 30s, but thiazide had been avoided due to recurrent episodes of gout. Podagra and gouty flares of the right instep occurred once or twice yearly and were almost always preceded by eating mong beans. BP at the time of evaluation was 146 ⁄90 mm Hg, with a creatinine value of 1.2 mg ⁄dL and uric acid value of 9.4 mg ⁄dL. His medications included lisinopril 40 mg daily, nifedipine extended-release 90 mg daily, and atenolol 50 mg daily. Allopurinol 300 mg daily and hydrochlorothiazide 12.5 mg, advancing to 25 mg daily were prescribed, with a follow-up BP of 130 ⁄82 mm Hg and a uric acid value of 6.4 mg ⁄dL.