A 55-year-old man comes to the office due to severe pain and swelling in his right big toe. He has hypertension, osteoarthritis, glucose intolerance controlled with diet, and recent peptic ulcer disease. The patient is not on medication for hypertension. On physical examination, his first metatarsophalangeal joint has diffuse swelling, and the skin surrounding the joint is erythematous. The joint is exquisitely tender to palpation and has severe restrictions in movement. Aspiration of the joint fluid reveals an inflammatory effusion with multiple negatively birefringent, needle-shaped crystals within polymorphonuclear cells. The patient is treated with colchicine and shows good response to therapy. Two weeks later, he comes for follow-up. Blood pressure is 152/93 mm Hg and pulse is 78/min. BMI is 36 kg/m2. Serum uric acid is 8.2 mg/dL, potassium is 4.1 mEq/L, serum creatinine is 1.2 mg/dL, and liver function tests are within normal limits. Which of the following is the best additional therapy for this patient?
This patient has typical symptoms of acute gout. This condition is usually treated with an oral nonsteroidal anti-inflammatory drug (NSAID; eg, indomethacin), but colchicine is an appropriate alternate treatment for those with contraindications to NSAIDs, such as peptic ulcer disease. A dedicated urate-lowering drug (eg, allopurinol) would also be recommended for patients who experience recurrent attacks or have gouty tophi. Serum uric acid levels can be normal in gout attacks and should not be used to guide acute management.
This patient also has uncontrolled hypertension, which must be managed cautiously in patients with gout. Most diuretics (eg, hydrochlorothiazide, furosemide) decrease the fractional excretion of urate and should be avoided when possible (Choices B and C). By contrast, the angiotensin receptor blocker losartan has a mild uricosuric effect and is effective as first-line treatment for hypertension in patients with gout. ACE inhibitors and angiotensin receptor blockers are also preferred for treating hypertension in patients with chronic kidney disease (regardless of baseline creatinine level) as they improve proteinuria and slow kidney disease progression; renal function should be monitored closely as these medications can cause hyperkalemia and an acute drop in glomerular filtration rate.
(Choice A) Clonidine is effective for treating hypertension in patients with gout. However, it is poorly tolerated (eg, dry mouth, constipation, sedation) and is not recommended as first-line therapy.
(Choice E) Low-dose aspirin has been recommended to prevent cardiovascular events in high-risk patients with diabetes. However, it is not clearly beneficial in low-risk patients or those with nondiabetic glucose intolerance. In addition, aspirin decreases renal urate excretion and is not recommended in patients with gout.
Educational objective:
The angiotensin receptor blocker losartan has a modest uricosuric effect and is a good choice for treating hypertension in patients with gout. Thiazides, loop diuretics, and low-dose aspirin should be avoided in patients with hyperuricemia when possible.