A 65-year-old man comes to the office for follow-up on hypertension. He was diagnosed with hypertension 2 years ago and has since followed a low-salt diet and tried to lose weight. At the patient's last clinic visit 8 weeks ago, his blood pressure was 176/95 mm Hg. Medical history is notable for gout; he had 2 episodes of gouty arthritis last year that affected his right big toe and right knee. Allopurinol was prescribed following the first episode but was discontinued after the patient developed oral ulcers. The patient does not use tobacco and drinks alcohol socially.
Blood pressure is 174/101 mm Hg and pulse is 79/min. BMI is 30 kg/m². Examination shows normal S1 and S2. There are no carotid bruits. The lungs are clear bilaterally. Peripheral pulses are full and symmetric.
Laboratory results are as follows:
Liver function tests and urinalysis are unremarkable.
Which of the following is the best initial treatment for this patient?

Question

A 65-year-old man comes to the office for follow-up on hypertension. He was diagnosed with hypertension 2 years ago and has since followed a low-salt diet and tried to lose weight. At the patient's last clinic visit 8 weeks ago, his blood pressure was 176/95 mm Hg. Medical history is notable for gout; he had 2 episodes of gouty arthritis last year that affected his right big toe and right knee. Allopurinol was prescribed following the first episode but was discontinued after the patient developed oral ulcers. The patient does not use tobacco and drinks alcohol socially.
Blood pressure is 174/101 mm Hg and pulse is 79/min. BMI is 30 kg/m². Examination shows normal S1 and S2. There are no carotid bruits. The lungs are clear bilaterally. Peripheral pulses are full and symmetric.
Laboratory results are as follows:

Liver function tests and urinalysis are unremarkable.
Which of the following is the best initial treatment for this patient?

Quizplus · Accepted Answer

11ec193a_9764_8f32_853d_4f22ad3468d0_MD0002_00 Hypertension is common in patients with gout, likely due to activation of the renin-angiotensin system, endothelial dysfunction, and shared risk factors (eg, impaired renal function). This patient's serum uric acid level is currently normal, but an increase could put him at risk for further gout flares. Patients with hypertension >20/10 mm Hg above target will likely need combination antihypertensive therapy with 2 or more medications to reach their goal blood pressure, and medications must be chosen carefully to not increase the patient's risk of gout flare. Most diuretics (eg, hydrochlorothiazide) decrease the fractional excretion of urate and should be avoided in patients with gout (Choices B and C). In contrast, the angiotensin receptor blocker (ARB) losartan has a mild uricosuric effect and is appropriate for first-line treatment of hypertension in patients with gout; other ARBs and ACE inhibitors have less to no uricosuric effect but also are safe to use. When additional lowering of blood pressure is needed, calcium channel blockers (eg, amlodipine) also are safe to use in gout and work well in combination with losartan. (Choices A and E) Beta blockers are not generally recommended for first-line treatment of hypertension unless other indications are present. In addition, some studies have found an increased risk of gout flare with these agents. Educational objective: Diuretics are associated with an increased risk of gout flare and should be avoided in patients with gout. In contrast, losartan has a mild uricosuric effect, which may decrease the frequency of gout exacerbations. __________ References: Antihypertensive drugs and risk of incident gout among patients with hypertension: population based case-control study. (http://www.ncbi.nlm.nih.gov/pubmed/22240117)

A 65-Year-Old Man Comes to the Office for Follow-Up on Hypertension