Management of Acute Gout with Uncontrolled Hypertension and Renal Impairment

Immediate Management of the Acute Gout Flare

The American College of Physicians recommends prescribing prednisolone 30-35 mg daily for 3-5 days to treat the acute flare, as corticosteroids have equivalent efficacy to NSAIDs but superior safety in chronic kidney disease 1, 2
The European League Against Rheumatism suggests avoiding NSAIDs entirely in patients with renal impairment, uncontrolled hypertension, and likely underlying heart failure risk given the triple antihypertensive regimen 1, 3

The American Heart Association recommends adding a fourth antihypertensive agent immediately, considering adding hydralazine 25 mg three times daily or amlodipine 5-10 mg daily, to manage severely uncontrolled hypertension 4
The European Society of Cardiology suggests evaluating for secondary causes of hypertension, particularly renal artery stenosis in the setting of hypertensive nephropathy 4

The American College of Rheumatology recommends starting allopurinol at 50-100 mg daily, then increasing by 50-100 mg every 2-4 weeks until serum uric acid is <6 mg/dL, to prevent future flares and reduce tophus burden 6, 3
The European League Against Rheumatism suggests targeting serum uric acid <6 mg/dL lifelong to prevent future flares and reduce tophus burden 6, 3

The American College of Rheumatology recommends prescribing colchicine 0.5 mg daily, reduced from 0.5-1 mg daily given the renal impairment, for at least 6 months when starting urate-lowering therapy to prevent mobilization flares 6, 2

The American Heart Association suggests weight loss if obese, as obesity worsens hyperuricemia and hypertension, and eliminating alcohol, especially beer and spirits, which increase uric acid production 4
The European Society of Cardiology recommends avoiding sugar-sweetened drinks and foods high in fructose, which raise serum urate levels, and reducing intake of red meat and seafood, which are high in purines 4

The American College of Physicians suggests not stopping urate-lowering therapy during acute flares, as this perpetuates the cycle of recurrent attacks, and not prescribing NSAIDs in patients with renal impairment, uncontrolled hypertension, and cardiovascular risk 1, 2