Effect of Allopurinol on Blood Pressure (Author Response to Allopurinol on Hypertension: Insufficient Evidence to Recommend)

To the Editor:

We appreciate the comments by Dr Gois and colleagues regarding our meta‐analysis.1 To date, allopurinol remains one of the widely prescribed medications for the management of gout. Although it is generally well tolerated, there is a small (0.1%–0.4%) risk of significant morbidity and mortality.2 Dr Gois and colleagues are correct in pointing out that the studies included in our analysis are heterogeneous and that additional randomized controlled trials are needed before the use of allopurinol can be justified solely to lower blood pressure. However, in recent years, there has been a resurgence of interest in allopurinol in cardiovascular medicine based on its significant pleiotropic effects, including congestive heart failure, angina, atrial fibrillation, and endothelial dysfunction.3 Of note, the use of thiazide diuretics has been reported to increase urate level by as much as 20%.4 Consequently, in patients with refractory hypertension who need a thiazide diuretic, allopurinol may be necessary to control uric acid levels.5 In such select groups of patients, the small but statistically significant blood pressure–lowering effect of allopurinol can be potentially exploited to obtain better blood pressure control. Clearly, based on our analysis, we do not recommend the use of allopurinol as an initial antihypertensive agent. Additional randomized controlled trials are needed to better define safety and efficacy of allopurinol in the management of hypertension. Pending data from such trials, we hope that our meta‐analysis can aid health care providers in making management decisions whenever the use of allopurinol is being considered to facilitate achievement of blood pressure goals.