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Appendices

Appendix 1. Search strategies

Database: Ovid MEDLINE(R) 1946 to Present with Daily Update
Search Date: 22 February 2016
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
1 hyperuricemia/ (2165)

2 (hyperuricemi$ or hyperuricaemi$ or uric acid).tw. (21963)

3 1 or 2 (22241)

4 (allopurinol or alinol or allohexal or allohexan or alloprin or allo puren or allo purinol or allopur or allopurin or alopurin or allorin or allpargin or allural or aluline or allurit or apulonga or apurin or apurol or burmadon or apulonga or apurin or atisuril or bleminol or caplenal or capurate or cellidrin or dabrosan or dabroson or embarin or epidropal or epuric or suspendol or foligan or hamarin or jenapurinol or lopurin or lysuron or mephanol or milurit or milurite or mylurit or nektrohan or novopurol or progout or pureduct or purinol or quimica or remid or rimapurinol or roucol or sigapurol or tipuric or uribenz or uriconorm or uridocid or uripurinol or urosin or urtias or xanthomax or xanturat or xanturic or zygout or zyloprim or zyloric or febuxostat or adenuric or uloric).mp. (9207)

5 Xanthine Oxidase/ai (1522)

6 uricosuric agents/ (1123)

7 (benzbromarone or benzbromaron or benzbronaronum or benbromazone or desuric or exurate or normurat or urinorm or uricovac or besuric or benzbromaronratiopharm or acifugan or narcaricin).mp. (447)

8 (apazone or azadimethadione or azapropazone or azapropazon or azopropazone or dolo prolixan or tolyprin or rheumox or prolixan).mp. (257)

9 (halofenate or livipas or mk‐185 or mk185 or benzeneacetic acid).mp. (176)

10 (probenecid or probalan or procid or pro‐cid or probecid or probemicid or probenecide or prolongine or benuryl or benecid or benemid or benemide or benemin or uricosid or urocid).mp. (4660)

11 (sulfinpyrazone or sulphinpyrazone or sulfoxyphenylpyrazolidin or anturane or anturan or anturidin or enturen or falizal or g28315 or g‐28315 or rabenid or sulfinpyrazon).mp. (1252)

12 (zoxazolamine or zoxazolamin or zoxine or deflexol or fexilon or flexilon or flexin or zoxamin).mp. (482)

13 (benziodarone or algocor or ampliacor or amplivix or beniodarone or benziodaron or bendiodaronum or benzoidazone or cardivix or cinodio or corofam or dila vasal or dilafurane or l‐2329 or plexocardio or retrangor or vasadil or vasilar or vasospas or weiscor).mp. (119)

14 (uric acid adj2 lower$).tw. (446)

15 or/4‐14 (17468)

16 exp hypertension/ (224327)

17 hypertens$.tw. (322344)

18 blood pressure.mp. (366781)

19 or/16‐18 (615282)

20 randomized controlled trial.pt. (406624)

21 controlled clinical trial.pt. (90068)

22 randomized.tw. (325394)

23 placebo.tw. (159293)

24 drug therapy/ (28723)

25 randomly.tw. (215623)

26 trial.tw. (371430)

27 groups.tw. (1383999)

28 or/20‐27 (2073001)

29 animals/ not (humans/ and animals/) (4156964)

30 28 not 29 (1706642)

31 3 and 15 and 19 and 30 (134)

32 remove duplicates from 31 (134)

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Database: Cochrane Central Register of Controlled Trials on Wiley <2016, Issue 2> via Cochrane Register of Studies Online
Search 22 February 2016
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
#1 (hyperuricaemi* or hyperuricemi*) 467

#2 "uric acid" 2192

#3 #1 OR #2 2367

#4 (allopurinol or alinol or allohexal or allohexan or alloprin or allo puren or allo purinol or allopur or allopurin or alopurin or allorin or allpargin or allural or aluline or allurit or apulonga or apurin or apurol or burmadon or apulonga or apurin or atisuril or bleminol or caplenal or capurate or cellidrin or dabrosan or dabroson or embarin or epidropal or epuric or suspendol or foligan or hamarin or jenapurinol or lopurin or lysuron or mephanol or milurit or milurite or mylurit or nektrohan or novopurol or progout or pureduct or purinol or quimica or remid or rimapurinol or roucol or sigapurol or tipuric or uribenz or uriconorm or uridocid or uripurinol or urosin or urtias or xanthomax or xanturat or xanturic or zygout or zyloprim or zyloric or febuxostat or adenuric or uloric) 756

#5 xanthine 418

#6 uricosuric 124

#7 (benzbromarone or benzbromaron or benzbronaronum or benbromazone or desuric or exurate or normurat or urinorm or uricovac or besuric or benzbromaronratiopharm or acifugan or narcaricin) 56

#8 (apazone or azadimethadione or azapropazone or azapropazon or azopropazone or dolo prolixan or tolyprin or rheumox or prolixan) 54

#9 (halofenate or livipas or mk‐185 or mk185 or benzeneacetic acid) 33

#10 (probenecid or probalan or procid or pro‐cid or probecid or probemicid or probenecide or prolongine or benuryl or benecid or benemid or benemide or benemin or uricosid or urocid) 423

#11 (sulfinpyrazone or sulphinpyrazone or sulfoxyphenylpyrazolidin or anturane or anturan or anturidin or enturen or falizal or g28315 or g‐28315 or rabenid or sulfinpyrazon) 131

#12 (zoxazolamine or zoxazolamin or zoxine or deflexol or fexilon or flexilon or flexin or zoxamin) 4

#13 (benziodarone or algocor or ampliacor or amplivix or beniodarone or benziodaron or bendiodaronum or benzoidazone or cardivix or cinodio or corofam or dila vasal or dilafurane or l‐2329 or plexocardio or retrangor or vasadil or vasilar or vasospas or weiscor) 8

#14 "uric acid" near2 lower* 73

#15 #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 1747

#16 hypertens* 38052

#17 "blood pressure" or bloodpressure or bp or dbp or sbp 55845

#18 #16 OR #17 73699

#19 #3 AND #15 AND #18 130

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Database: Embase <1980 to 2016 February 22>
Search 22 February 2016
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
1 hyperuricemia/ (10080)

2 (hyperuricemi$ or hyperuricaemi$ or hyperuricacidemia or uric acid).tw. (30593)

3 1 or 2 (34469)

4 (allopurinol or alinol or allohexal or allohexan or alloprin or allo puren or allo purinol or allopur or allopurin or alopurin or allorin or allpargin or allural or aluline or allurit or apulonga or apurin or apurol or burmadon or apulonga or apurin or atisuril or bleminol or caplenal or capurate or cellidrin or dabrosan or dabroson or embarin or epidropal or epuric or suspendol or foligan or hamarin or jenapurinol or lopurin or lysuron or mephanol or milurit or milurite or mylurit or nektrohan or novopurol or progout or pureduct or purinol or quimica or remid or rimapurinol or roucol or sigapurol or tipuric or uribenz or uriconorm or uridocid or uripurinol or urosin or urtias or xanthomax or xanturat or xanturic or zygout or zyloprim or zyloric).mp. (19848)

5 xanthine oxidase inhibitor/ (1132)

6 uricosuric agent/ (999)

7 (benzbromarone or benzbromaron or benzbronaronum or benbromazone or desuric or exurate or normurat or urinorm or uricovac or besuric or benzbromaronratiopharm or acifugan or narcaricin).mp. (1135)

8 (apazone or azadimethadione or azapropazone or azapropazon or azopropazone or dolo prolixan or tolyprin or rheumox or prolixan).mp. (1002)

9 (halofenate or livipas or mk‐185 or mk185 or benzeneacetic acid).mp. (203)

10 (probenecid or probalan or procid or pro‐cid or probecid or probemicid or probenecide or prolongine or benuryl or benecid or benemid or benemide or benemin or uricosid or urocid).mp. (8601)

11 (sulfinpyrazone or sulphinpyrazone or sulfoxyphenylpyrazolidin or anturane or anturan or anturidin or enturen or falizal or g28315 or g‐28315 or rabenid or sulfinpyrazon).mp. (3110)

12 (zoxazolamine or zoxazolamin or zoxine or deflexol or fexilon or flexilon or flexin or zoxamin).mp. (507)

13 (benziodarone or algocor or ampliacor or amplivix or beniodarone or benziodaron or bendiodaronum or benzoidazone or cardivix or cinodio or corofam or dila vasal or dilafurane or l‐2329 or plexocardio or retrangor or vasadil or vasilar or vasospas or weiscor).mp. (218)

14 (uric acid adj2 lower$).tw. (759)

15 or/4‐14 (33133)

16 exp hypertension/ (543494)

17 hypertens$.tw. (474905)

18 blood pressure.mp. (472807)

19 or/16‐18 (961639)

20 randomized controlled trial/ (393135)

21 crossover procedure/ (46126)

22 double‐blind procedure/ (126302)

23 (randomi?ed or randomly).tw. (843067)

24 (crossover$ or cross‐over$).tw. (78021)

25 placebo$.tw. (227712)

26 (double$ adj blind$).tw. (159057)

27 assign$.ab. (270705)

28 allocat$.ab. (97187)

29 or/20‐28 (1264990)

30 (exp animal/ or animal.hw. or nonhuman/) not (exp human/ or human cell/ or (human or humans).ti.) (5441707)

31 29 not 30 (1102412)

32 3 and 15 and 19 and 31 (160)

33 remove duplicates from 32 (155)

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Database: LILACS <1982 to 2016>
Search date: 14 March 2016
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
uric acid OR hyperuricemi$ [Words] and hypertens$ OR blood pressure [Words]

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Database: Hypertension Group Specialised Register via Cochrane Register of Studies <1946 to 2016>
Search 22 February 2016
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
#1 (hyperuricemi* or hyperuricaemi* or (uric acid)) (884)

#2 ((allopurinol or alinol or benzbromarone or hamarin or probenecid or probalan or quimica or sulfinpyrazone or uricosuric or xanthine)) (103)

#3 #1 AND #2 (65)

#4 (CCT OR RCT):DE (25622)

#5 (Review OR Meta‐Analyis):MISC2 (1078)

#6 #4 OR #5 (26700)

#7 #3 AND #6 (65)

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Database: ClinicalTrials.gov
Search 22 February 2016
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Search terms: randomized
Study type: Interventional Studies
Conditions: hypertension AND hyperuricemia (4)

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Flow diagram of the study selection
Figuras y tablas -
Figure 1

Flow diagram of the study selection

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figuras y tablas -
Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figuras y tablas -
Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Forest plot of comparison: 1 Uric acid (UA)‐lowering drug vs. placebo, outcome: 1.1 systolic 24‐hour ambulatory blood pressure.
Figuras y tablas -
Figure 4

Forest plot of comparison: 1 Uric acid (UA)‐lowering drug vs. placebo, outcome: 1.1 systolic 24‐hour ambulatory blood pressure.

Forest plot of comparison: 1 Uric acid (UA)‐lowering drug vs. placebo, outcome: 1.2 diastolic 24‐hour ambulatory blood pressure.
Figuras y tablas -
Figure 5

Forest plot of comparison: 1 Uric acid (UA)‐lowering drug vs. placebo, outcome: 1.2 diastolic 24‐hour ambulatory blood pressure.

Forest plot of comparison: 1 Uric acid (UA)‐lowering drug vs. placebo, outcome: 1.3 Clinic systolic blood pressure.
Figuras y tablas -
Figure 6

Forest plot of comparison: 1 Uric acid (UA)‐lowering drug vs. placebo, outcome: 1.3 Clinic systolic blood pressure.

Forest plot of comparison: 1 Uric acid (UA)‐lowering drug vs. placebo, outcome: 1.4 clinic diastolic blood pressure.
Figuras y tablas -
Figure 7

Forest plot of comparison: 1 Uric acid (UA)‐lowering drug vs. placebo, outcome: 1.4 clinic diastolic blood pressure.

Forest plot of comparison: 1 Uric acid (UA)‐lowering drug vs. placebo, outcome: 1.5 serum uric acid.
Figuras y tablas -
Figure 8

Forest plot of comparison: 1 Uric acid (UA)‐lowering drug vs. placebo, outcome: 1.5 serum uric acid.

Forest plot of comparison: 1 Uric acid (UA)‐lowering drug vs placebo, outcome: 1.6 Withdrawals due to adverse effects.
Figuras y tablas -
Figure 9

Forest plot of comparison: 1 Uric acid (UA)‐lowering drug vs placebo, outcome: 1.6 Withdrawals due to adverse effects.

Comparison 1 Uric acid (UA) lowering drug vs placebo, Outcome 1 24h‐Systolic Blood Pressure.
Figuras y tablas -
Analysis 1.1

Comparison 1 Uric acid (UA) lowering drug vs placebo, Outcome 1 24h‐Systolic Blood Pressure.

Comparison 1 Uric acid (UA) lowering drug vs placebo, Outcome 2 24h‐Diastolic Blood Pressure.
Figuras y tablas -
Analysis 1.2

Comparison 1 Uric acid (UA) lowering drug vs placebo, Outcome 2 24h‐Diastolic Blood Pressure.

Comparison 1 Uric acid (UA) lowering drug vs placebo, Outcome 3 Clinic Systolic Blood Pressure.
Figuras y tablas -
Analysis 1.3

Comparison 1 Uric acid (UA) lowering drug vs placebo, Outcome 3 Clinic Systolic Blood Pressure.

Comparison 1 Uric acid (UA) lowering drug vs placebo, Outcome 4 Clinic Diastolic Blood Pressure.
Figuras y tablas -
Analysis 1.4

Comparison 1 Uric acid (UA) lowering drug vs placebo, Outcome 4 Clinic Diastolic Blood Pressure.

Comparison 1 Uric acid (UA) lowering drug vs placebo, Outcome 5 Serum uric acid.
Figuras y tablas -
Analysis 1.5

Comparison 1 Uric acid (UA) lowering drug vs placebo, Outcome 5 Serum uric acid.

Comparison 1 Uric acid (UA) lowering drug vs placebo, Outcome 6 Withdrawals due to adverse effects.
Figuras y tablas -
Analysis 1.6

Comparison 1 Uric acid (UA) lowering drug vs placebo, Outcome 6 Withdrawals due to adverse effects.

Summary of findings for the main comparison. Uric acid (UA) lowering drug compared to placebo for hyperuricemia in hypertensive patients

Uric acid (UA)‐lowering drug compared to placebo for hyperuricemia in hypertensive patients

Patient or population: hyperuricemia in hypertensive patients
Setting: several sites in the USA
Intervention: uric acid (UA)‐lowering drug
Comparison: placebo

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with placebo

Risk with Uric acid (UA) lowering drug

24h‐Systolic Blood Pressure

MD 6.19 lower
(12.82 lower to 0.45 higher)

MD ‐6.2 (‐12.8, 0.5)

229
(3 RCTs)

⊕⊕⊝⊝
LOW 1 2

24h‐Diastolic Blood Pressure

MD 3.92 lower
(9.19 lower to 1.36 higher)

MD ‐3.9 (‐9.2, 1.4)

229
(3 RCTs)

⊕⊕⊝⊝
LOW 1 2

Clinic Systolic Blood Pressure

MD 8.43 lower
(15.24 lower to 1.62 lower)

MD ‐8.4 (‐15.2, ‐1.6)

120
(2 RCTs)

⊕⊕⊝⊝
LOW 1 2

Clinic Diastolic Blood Pressure

MD 6.45 lower
(13.6 lower to 0.7 higher)

MD ‐6.5 (‐13.6, 0.7)

120
(2 RCTs)

⊕⊕⊝⊝
LOW 1 2

Serum uric acid

MD 3.09 lower
(3.76 lower to 2.43 lower)

MD ‐3.1 (‐3.8, ‐2.4)

223
(3 RCTs)

⊕⊕⊕⊕
HIGH

Withdrawals due to adverse effects

18 per 1,000

34 per 1,000
(8 to 147)

RR 1.86
(0.43 to 8.10)

241
(3 RCTs)

⊕⊝⊝⊝
VERY LOW 1 3 4

NCT01496469 reported only one withdrawal due to adverse events. However, four adverse events were described in the febuxostat group, which might be drug‐related. Therefore, we decided to include all four cases in the assessment of RR for this study.

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; RR: Risk ratio; OR: Odds ratio; RCT: Randomized controlled trial.

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1 Downgraded for wide CIs

2 Downgraded for high unexplained heterogeneity

3 Downgraded for small number of events and incomplete reporting

4 Unclear randomisation processes in the largest trial (highest weight in meta‐analysis)

Figuras y tablas -
Summary of findings for the main comparison. Uric acid (UA) lowering drug compared to placebo for hyperuricemia in hypertensive patients
Comparison 1. Uric acid (UA) lowering drug vs placebo

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 24h‐Systolic Blood Pressure Show forest plot

3

229

Mean Difference (Random, 95% CI)

‐6.19 [‐12.82, 0.45]

2 24h‐Diastolic Blood Pressure Show forest plot

3

229

Mean Difference (Random, 95% CI)

‐3.92 [‐9.19, 1.36]

3 Clinic Systolic Blood Pressure Show forest plot

2

120

Mean Difference (Random, 95% CI)

‐8.43 [‐15.24, ‐1.62]

4 Clinic Diastolic Blood Pressure Show forest plot

2

120

Mean Difference (Random, 95% CI)

‐6.45 [‐13.60, 0.70]

5 Serum uric acid Show forest plot

3

223

Mean Difference (Random, 95% CI)

‐3.09 [‐3.76, ‐2.43]

6 Withdrawals due to adverse effects Show forest plot

3

241

Risk Ratio (M‐H, Random, 95% CI)

1.86 [0.43, 8.10]

Figuras y tablas -
Comparison 1. Uric acid (UA) lowering drug vs placebo