ORIGINAL ARTICLE

Effects of Combined Enalapril and Folic Acid Therapy on

the Serum Uric Acid Levels in Hypertensive Patients:
A Multicenter, Randomized, Double-blind,
Parallel-controlled Clinical Trial
Haibo Li 1, Xianhui Qin 1, Di Xie 2, Genfu Tang 1, Yan Zhang 3, Jianping Li 3,
Fanfan Hou 2, Xiaobin Wang 4, Yong Huo 3 and Xiping Xu 1

Abstract
Objective The efficacy of combined treatment consisting of enalapril and folic acid (FA) was compared to
that of enalapril alone in reducing the serum uric acid (UA) levels in adult hypertensive patients in China.
Methods Patients with mild to moderate hypertension (n=480) were randomly assigned to one of three
treatment groups: (1) 10 mg enalapril (control group), (2) 10 mg enalapril plus 0.4 mg FA (low-FA group) or
(3) 10 mg enalapril plus 0.8 mg FA (high-FA group) daily for eight weeks. The primary outcome was the
UA ratio (week 8 UA: baseline UA).
Results The final analysis included 450 patients (43.1% men, 27-75 years of age). An adjusted multivariable regression analysis revealed no significant differences in the UA ratio between the three groups after
eight weeks of treatment. In the subgroup analysis stratified according to the baseline UA level, the high-FA
group demonstrated a significantly greater UA-lowering response among the patients with an elevated baseline UA concentration (UA !
310 mol/L) [median UA ratio (25th percentile, 75th percentile): 0.94 (0.83,
1.01)], compared with that observed in the control group [0.97 (0.90, 1.00), p=0.025]. Similar results were
found in the participants with baseline hyperuricemia (HUA; UA: men >420 mol/L, women >350 mol/L).
Conclusion In this sample of adult hypertensive patients, the administration of a daily dose of 10 mg of
enalapril combined with 0.8 mg of FA had a greater beneficial effect on the serum UA levels than did that of
10 mg of enalapril alone in patients with either an elevated UA concentration or HUA.
Key words: folic acid, uric acid, hypertension, randomized, controlled trial
(Intern Med 54: 17-24, 2015)
(DOI: 10.2169/internalmedicine.54.2931)

UA level within the normal range (>310-330 mol/L), can

significantly increase the risk of stroke, stroke-related mortality (2) and coronary heart disease events (3). Hypertension may provide a link between elevated UA and stroke. A
growing body of evidence indicates that HUA and hypertension often co-exist and appear to feed into each other. HUA
is associated with an increased risk of incident hypertension
that is independent of traditional risk factors (4, 5). On the
other hand, the use of diuretics or aspirin in hypertensive
patients may increase the serum UA levels (6). In light of

Introduction
The global prevalence and incidence of hyperuricemia
(HUA) have both risen steadily over the past 40 years (1) in
parallel with the rising prevalence of other chronic diseases,
including hypertension and cardiovascular disease. Uric acid
(UA) is the final product of purine metabolism in humans. It
is well established that elevated serum UA (or HUA) is the
cause of gout. In addition, HUA, or an even mildly elevated

Institute of Biomedicine, Anhui Medical University, China, Guangdong Institute of Nephrology, Southern Medical University, China, Department of Cardiology, Peking University First Hospital, China and Center on the Early Life Origins of Disease, Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, USA
Received for publication March 24, 2014; Accepted for publication May 25, 2014
Correspondence to Dr. Xiping Xu, xipingxu18@gmail.com

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nation with two different doses of FA on the serum UA levels after an eight-week treatment period. In addition, we explored whether the treatment effect varied according to the
baseline UA level.

the bi-directional relationship between hypertension and

HUA, there is a need to develop therapies to simultaneously
control hypertension and HUA, which may be more effective in preventing HUA and gout in hypertensive patients.
Conventional HUA therapies aim at either reducing UA
production using xanthine oxidase (XO) inhibitors, such as
allopurinol, or increasing renal UA excretion with drugs,
such as benzene bromide malone and probenecid. While
these agents can effectively lower the serum UA levels, they
do have a number of side effects, including allergic reactions, liver damage, kidney damage, bone marrow suppression and gastrointestinal symptoms (7). As a result, there is
a clear need to explore safe and effective therapeutic options.
Among the commonly used antihypertensive agents,
angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers may improve the renal function
and protect against the development of HUA (8). However,
ACE inhibitors alone are inadequate for controlling HUA,
although the addition of folic acid may be beneficial, in particular among Chinese hypertensive patients who are known
to have a high prevalence of elevated homocysteine
(Hcy) (9, 10).
An elevated Hcy level is an established risk factor for hypertension (11) and cardiovascular disease (12, 13). In addition, elevated Hcy and the methylenetetrahydrofolate reductase (MTHFR) 677T allele have been linked to
HUA (14-16). One possible mechanism for this phenomenon
is the decreased renal clearance of UA associated with an
elevated Hcy level. In addition, the generation of adenosine
originating from S-adenosyl-homocysteine, a precursor of
Hcy, may constitute a link between the metabolic pathways
of Hcy and UA (15). On the other hand, in patients with the
MTHFR 677TT genotype, renovascular atherosclerosis and/
or the complications of systemic vascular disease may reduce the renal clearance of UA, resulting in elevation of the
serum UA level (16). Therefore, lowering the Hcy level is
likely to have a beneficial effect on the serum UA level,
particularly in subjects with the MTHFR 677TT genotype.
Previous studies have demonstrated that folic acid (FA)
treatment can effectively lower the Hcy level (17), and a
meta-analysis showed that the optimal daily dose of FA is
0.8 mg (18). Moreover, elevated Hcy is widespread in the
Chinese population, with levels as high as 70% in hypertensive Chinese patients, due to a combination of inadequate
dietary intake, the lack of grain FA fortification and a
relatively high frequency of the MTHFR gene mutation
(C677T) (19, 20). A cross-sectional study in Taiwan reported an inverse association between FA intake and the
blood UA level (21).
We hypothesize that combination therapy with an ACE inhibitor and FA is a promising treatment for lowering the UA
level and reducing the risk of HUA in hypertensive Chinese
patients. In this multicenter, randomized, double-blind,
parallel-controlled clinical trial, we investigated the effects
of an ACE inhibitor (enalapril) alone vs. that used in combi-

Materials and Methods

Participants and ethics
This was a multicenter, randomized, double-blind controlled trial of hypertensive Chinese adults (clinicaltrials.gov;
identifier: NCT00520247 (10, 22). In total, 480 patients
with mild or moderate hypertension were recruited from six
hospitals in different regions of China (Haerbin, Shanghai,
Shenyang, Beijing, Xian and Nanjing) from September to
December 2005. All six hospitals were certified as clinical
pharmacology centers by the State Food and Drug Administration of China. The inclusion criteria were as follows: 1)
an age between 18 and 75 years; 2) a seated systolic blood
pressure (SBP) between 140 mmHg and 180 mmHg and/or
seated diastolic blood pressure (DBP) between 90 mmHg
and 110 mmHg; 3) consent to use a reliable method of contraception during the study among women of reproductive
age; and 4) agreement to not take any other drugs that may
affect blood pressure or any vitamin B supplements during
the week before the start of the study. Participants were excluded if they were pregnant or planned to become pregnant
during the study period, had serious diseases (cardiovascular
disease, tumors, hepatic disease and so on) or expected to
take other drugs that may affect blood pressure or any vitamin B supplements during the study period. This study was
approved by the Ethics Committee of Peking University
First Hospital, Beijing, China. The purpose and procedures
of the study were carefully explained to all participants, and
written informed consent was obtained from each subject.
Intervention and data collection
Eligible participants were randomly and double-blindly
assigned to one of the three treatment groups: (1) enalapril
tablet only (10 mg, control group); (2) enalapril-FA tablet
(10 mg enalapril combined with 0.4 mg of FA, low FA
group); or (3) enalapril-FA tablet (10 mg enalapril combined
with 0.8 mg of FA, high FA group), once daily for eight
weeks. Demographic and clinical information was obtained
at baseline. Blood pressure was measured at baseline and
every two weeks for a total period of eight weeks. The serum UA concentration was measured at baseline and after
eight weeks of treatment.
Randomization and blinding
In order to achieve a balance among the three treatment
groups, permuted-fixed block randomization with a block
length of six was used. The allocation of participants was
programmed at an independent statistical coordinating center, encrypted and then sent to each study center. Tablet containers were labeled with the name of the trial and the allo18

Intern Med 54: 17-24, 2015

DOI: 10.2169/internalmedicine.54.2931

480 Essential Hypertension

Patients Randomized

160 assigned to receive

Enalapril 10.0mg daily for
8weeks.
(Control Group)

160 assigned to receive

Enalapril 10.0mg plus Folic
Acid 0.4mg daily for 8weeks.
(Low-FA Group)

160 assigned to receive

Enalapril 10.0mg plus Folic
Acid 0.8mg daily for 8weeks.
(High-FA Group)

7 lost to follow-up

9 lost to follow-up;
2 use of interference drugs

8 lost to follow-up;
4 use of interference drugs

153 included in analysis

149 included in analysis

148 included in analysis

Figure1.Flow chart of sampling frame. FA: folic acid

cated concealment number only. Participants, care partners

and all staff directly involved in the trial were blinded to the
interventions during the study period. No requests were
made to break the blinding protocol.

Outcomes
The primary outcome was the UA ratio, which was defined as the ratio of the UA concentration at week 8 to the
UA concentration at baseline. Since the distribution of the
UA concentration was positively skewed, the UA ratio was
used to better account for the baseline UA concentration and
standardize the outcome measurements across individuals.

Blood sample collection and laboratory methods

After 10-12 hours of fasting, a venous blood sample was
obtained from each participant. The serum and plasma samples were separated within 15 minutes of collection and analyzed within 30 minutes or stored at -80C for a later analysis. Blood samples collected at baseline and at week 8 of
the trial were used to measure the levels of UA, lipids [including total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C) and triglycerides (TG)], glucose, Hcy and
FA. The level of Hcy in the plasma was determined in duplicate using high-performance liquid chromatography. The
intra- and inter-assay coefficients of variation were 3.5%
and 4.2%, respectively. The serum FA level was determined
using a chemiluminescent immunoassay with the Beckman
Coulter ACCESS Immunoassay System (Beckman-Coulter
Canada, Mississauga, Canada). The intra- and inter-assay coefficients of variation were 2.3% and 3.7%, respectively. All
sample collection and testing was performed in an identical
manner, following the same standard protocol.

Statistical analysis
All analyses were performed according to the principle of
intention to treat. Means (SD) or medians (25th percentile,
75th percentile) and proportions were calculated for baseline
characteristics according to the treatment group. The total
UA, Hcy, TG and FA levels were positively skewed and
thus natural log-transformed to normalize their distribution.
A one-way analysis of variance for continuous variables and
the chi-square test for categorical variables were applied to
compare the characteristics of the study subjects among the
three treatment groups. The Kruskal-Wallis rank-sum test
was also used to compare the UA, Hcy, TG and FA levels
among the three treatment groups. Multivariable regression
models were applied to compare the ln-transformed UA ratio among different groups, with or without adjustment of
the major baseline characteristics. We also performed a subgroup analysis, stratified by the baseline UA level. All p values were two-tailed, with a significance level of 0.05. Data
management and all statistical analyses were carried out using the R software program, version 3.0.0 (http://www.Rproject.org/).

Follow-up of the study subjects

All eligible participants were followed for a total of eight
weeks. Face-to-face interviews were conducted at baseline
and weeks 2, 4, 6 and 8 of the study. The subjects were
asked to maintain their regular dietary habits and not to take
any vitamin B supplements or any other antihypertensive
medications during the entire duration of the study. On day
56, all participants were asked to return to the study center
to complete the same study procedure as applied at baseline.
Lost to follow-up defined subjects who did not complete
the entire study protocol.

Results
Participant flow
The flow of participants through the study is shown in
Fig. 1. A total of 480 eligible patients with mild to moderate
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Table1.Demographic and Clinical Characteristics of Study Subjectsa

Low-FA
High-FA
Control
groupb(149)
groupb(148)
groupb(153)
57.0 3.2
57.3 10.1
56.4 9.6
59(38.6)
65(43.6)
70(47.3)
25.8 3.2
25.7 3.6
25.8 3.6
154.1 11.1
153.4 11.0
154.4 11.3
93.3 8.1
92.4 8.6
93.4 7.7
5.5 1.3
5.6 1.3
5.4 1.2
4.9 0.9
5.1 1.3
5.0 1.1
1.4(1.0, 1.9)
1.4(1.0, 2.0)
1.5(1.0, 2.0)
1.3 0.4
1.3 0.4
1.3 0.4
2.9 0.7
2.9 0.8
3.0 0.9
289.0(228.0,341.4) 295.1(234.0,357.0) 302.4(245.0,352.0)
65.0(57.0, 77.0)
68.0(57.0, 81.0)
68.00(59.6, 78.0)
12.0(9.9, 14.8)
11.7(9.7, 16.2)
12.65(10.1, 16.5)
12.5(9.9, 15.7)
12.2(9.6, 16.4)
12.28(9.5, 15.5)

Age (y)
Men (%)
BMI (kg/m2)
SBP (mmHg)
DBP (mmHg)
FPG (mmol/L)
TC (mmol/L)
TG (mmol/L)
HDL (mmol/L)
LDL (mmol/L)
UA (mol/L)
&Umol/L)
tHcy (mol/L)
FA (nmol/L)
MTHFR gene C677T, N (%)
CC
41(26.8)
34(22.8)
39(26.4)
CT
73(47.7)
78(52.4)
72(48.7)
TT
39(25.5)
37(24.8)
35(23.7)
Participating centers
Haerbin Medical University
20(13.1)
17(11.4)
17(11.5)
Fudan University
20(13.1)
20(13.4)
21(14.2)
Chinese Medical University
25(16.3)
26(17.5)
27(18.2)
Peking University
35(22.9)
37(24.8)
36(24.3)
Xian Jiaotong University
25(16.3)
24(16.1)
24(16.2)
Nanjing Medical University
28(18.3)
25(16.8)
23(15.5)
BMI: body mass index, Cr: creatinine, DBP: diastolic blood pressure, FA: folic acid, FPG:
fasting plasma glucose, HDL: high-density lipoprotein, MTHFR: methylenetetrahydrofolate
reductase, LDL: low-density lipoprotein, SBP: systolic blood pressure, TC: total cholesterol,
TG: triglycerides, tHcy: total homocysteine, UA: uric acid
a
Data are presented as mean SD, median (25th percentile, 75th percentile) or number of
subjects (percentage).
b
The control group received 10.0 mg of enalapril daily for 8 weeks; the low-FA group
received 10.0 mg of enalapril plus 0.4 mg of FA daily for 8 weeks; and the high-FA group
received 10.0 mg of enalapril plus 0.8 mg of FA daily for 8 weeks.

Table2.Comparison of UA among Three Treatment Groups in the Total

Sample and in Subgroups Defined by Baseline UAa
UA
Control group
Low-FA group
High-FA group
All subjects
n
153
149
148
Baseline, mol/L
289.0(228.0, 341.4)
295.1(234.0, 357.0)
302.3(245.0, 352.0)
Day 56, mol/L
279.0(228.0, 337.0)
296.0(235.0, 364.9)
289.0(254.0, 346.0)
0.99(0.90, 1.05)
1.00(0.91, 1.08)
1.00(0.92, 1.08)
Ratiob
Subjects with baseline UA 310mol/L
n
61
65
65
Baseline, mol/L
360.0(327.0, 404.0)
367.0(345.9, 426.0)
364.0(337.0, 422.0)
Day 56, mol/L
367.0(311.0, 413.0)*
363.0(342.0, 413.0)*
343.0(301.0, 395.0)*
Ratio
0.97(0.90, 1.00)
0.97(0.89, 1.00)
0.94(0.83, 1.01)#
Subjects with baseline UA < mol/L
n
92
84
83
Baseline, mol/L
237.0(208.8, 262.3)
241.5(205.0, 271.5)
254.0(211.4, 284.0)
Day 56, mol/L
243.0(200.0, 274.3)
242.0(211.0, 285.3)*
266.0(222.5, 289.0)*
Ratio
1.00(0.93, 1.09)
1.00(0.96, 1.14)
1.02(0.97, 1.17)
Subjects with baseline UA Men > PRO/L, Women >35PRO/L
n
24
24
24
Baseline, mol/L
424.2(382.3, 464.3)
442.5(369.3, 477.8)
446.0(417.8, 477.8)
405.5(350.8, 434.2)*
389.0(343.0, 455.8)*
Day 56, mol/L
396.0(361.0, 433.3)*
Ratio
0.95(0.87, 1.00)
0.90(0.85, 0.97)
0.87(0.78, 1.00)
Subjects with baseline UA Men PRO/L, Women 3PRO/L
n
129
125
124
Baseline, mol/L
256.0(219.0, 314.0)
271.0(229.0, 332.0)
284.0(236.8, 321.3)
Day 56, mol/L
267.3(218.0, 308.0)
282.0(232.0, 352.0)
282.7(243.0, 320.3)
Ratio
1.00(0.93, 1.07)
1.00(0.95, 1.10)
1.00(0.94, 1.09)
UA: uric acid, FA: folic acid
a
Data are presented as median (25th percentile, 75th percentile).
b
Ratio is the UA concentration at week 8 to that at baseline.
*
p < 0.05 compared with baseline.
#
p < 0.05 compared with control group.

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Table3.Generalized Linear Regression Analysis of the Association between

Treatment Groups and Change in UA in the Total Sample and in Subgroups
n

UA Ratio a

Crude
SE

Adjusted b
SE
p

All subjects
Control group
153
0.99(0.90, 1.05) Ref
----Ref
----Low-FA group
149
1.00(0.91, 1.08) 0.02
0.02 0.319 0.03
0.02 0.201
High-FA group
148
1.00(0.92, 1.08) -0.00 0.02 0.932 0.00
0.02 0.932
Subjects with baseline UAmol/L
Control group
61
0.97(0.90, 1.00) Ref
----Ref
----Low-FA group
65
0.97(0.89, 1.00) -0.01 0.03 0.793 -0.01 0.03 0.615
High-FA group
65
0.94(0.83, 1.01) * -0.06 0.03  -0.06 0.03 
Subjects with baseli ne UAmol/L
Control group
92
1.00(0.93, 1.09) Ref
----Ref
----Low-FA group
84
1.00(0.96, 1.14) 0.05
0.03 0.125 0.06
0.03 0.056
High-FA group
83
1.02(0.97, 1.17) 0.05
0.03 0.150 0.05
0.03 0.128
Subjects with baseline UA Men > PRO/L, Women > PRO/L
Control group
24
0.95(0.87, 1.00) Ref
----Ref
----Low-FA group
24
0.90(0.85, 0.97) -0.05 0.04 0.249 -0.02 0.05 0.646
High-FA group
24
0.87(0.78, 1.00) * -0.07 0.04 0.063 -0.13 0.05 
Subjects with baseline UA0HQPRl/L , WomeQPRO/L
Control group
129
1.00(0.93, 1.07) Ref
----Ref
----Low-FA group
125
1.00(0.95, 1.10) 0.04
0.02 0.145 0.04
0.02 0.075
High-FA group
124
1.00(0.94, 1.09) 0.01
0.02 0.603 0.01
0.02 0.623
UA: uric acid, FA: folic acid
a
Ratio is the UA concentration at week 8 to that at baseline; ln-transformed ratio was used in
the analyses.
b
Regression Model: Adjusted for baseline sex, age, body mass index, systolic blood pressure,
diastolic blood pressure, ln (triglycerides), high-density lipoprotein cholesterol, total
cholesterol, fasting plasma glucose, methylenetetrahydrofolate reductase gene C677T, ln
(creatinine), ln (homocysteine), ln(UA) and study center.
*
: p < 0.05, trend test.

Figure2.Median UA ratio (UA concentration at week 8 to UA at baseline) by treatment group in

total sample and by baseline UA. #p<0.05, compared with control group. UA: uric acid, HUA: hyperuricemia, FA: folic acid

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and the incidence of adverse events was comparable between the groups.

essential hypertension recruited from the six study centers in

China were randomly assigned to one of the three treatment
groups. This analysis excluded 30 individuals who were lost
to follow-up or ineligible to participate in the trial (seven in
the control group, 11 in the low FA group and 12 in the
high FA group). Accordingly, a total of 450 participants
were included in the final analysis.

Discussion
To our knowledge, this is the first double-blind, randomized, controlled trial to investigate the effects of combination
treatment consisting of ACE inhibitors and two commonly
used physiological doses of FA (0.4 or 0.8 mg/day) on the
serum UA concentrations in hypertensive patients in China.
Although we did not find any differences in UA-lowering
effects between the three treatment groups, we demonstrated
for the first time that combination FA and enalapril therapy
significantly decreases the UA levels in hypertensive patients
with an elevated UA concentration (UA level !310 mol/L)
and HUA (men >420 mol/L, women >350 mol/L) at
baseline. This effect appears to be dose-related, with the
greatest difference observed in the high-FA group (0.8 mg).
These findings may help to address the clinical and epidemiological need to develop a new regimen to simultaneously
treat hypertension and reduce the risk of HUA, given that
hypertension and HUA often co-exist and their prevalence is
increasing worldwide, including in developing countries,
such as China (23, 24).
Our findings are biologically plausible. ACE inhibitors
have traditionally been used to reduce blood pressure in hypertensive patients; however, studies have also indicated that
ACE inhibitors increase the renal excretion of UA by reducing its net reabsorption in the proximal tubules (8, 25). Furthermore, enalapril may counteract the effects of common
diuretics on serum UA in hypertensive patients. However,
not all previous studies support this UA-lowering effect (26, 27).
Despite the lack of consensus regarding the mechanisms
by which FA influences the UA concentration, several hypotheses have been proposed. A reduction in the serum UA
level can be achieved via two methods: decreasing the production of UA by inhibiting purine breakdown or enhancing
UA breakdown and subsequent excretion into the urine. FA
and its derivatives may inhibit XO (28), which converts retinol to retinoic acid and xanthines to UA, which may explain
why changes in the FA concentration affect the UA concentration. In addition, studies have shown that FA is a powerful Hcy-lowering agent. For example, FA supplementation
decreases the plasma Hcy concentration (29), and a lower
Hcy concentration has been reported to be associated with a
lower rate of HUA (30, 31). Therefore, FA supplementation
may also reduce UA production. FA, a water-soluble B vitamin, is an important co-nutrient involved in the breakdown
and metabolism of proteins (32). In this way, it may assist
with removing the UA produced in the body, preventing
gout flare-ups and reducing the pain associated with gout.
The majority of research conducted to date regarding the
association between FA and HUA has primarily been related
to the management of gout. A cross-sectional study (21) in
Taiwan investigated the effects of diet and lifestyle on the

Baseline data
The demographic and clinical characteristics of the study
subjects in each treatment group are shown in Table 1. Of
the 450 subjects (43.1% men, 27-75 years of age), 98.7%
were of Han nationality, with a mean body mass index
(BMI) of 25.7 kg/m2. Participants in each of the three
groups were well-balanced at baseline with regard to relevant demographic and clinical characteristics. Using two
standards [1) UA levels 310 mol/L (2) and 2) UA men >
420 mol/L, women >350 mol/L (hyperuricemia, according
to Internal Medicine, Chinese, 2007)] as the cutoff, the proportion of participants with an elevated UA concentration
was also well-balanced among the three treatment groups
(p=0.729), as was that of the participants with HUA (p=
0.991, Table 2).
Outcomes and estimation
Among the total sample of the participants without HUA,
we did not observe any significant differences in the UA ratio between the treatment groups after the eight-week treatment period compared with that observed at baseline. However, among the subjects with a baseline UA level of !310
mol/L or HUA, the high-FA group showed a significantly
greater UA-lowering response compared with the control
group [as reflected by the median UA ratio (25th percentile,
75th percentile): 0.94 (0.83, 1.01) vs. 0.97 (0.90, 1.00), p=
0.025]. Similar results were observed among the participants
with HUA at baseline [0.87 (0.78, 1.00) vs. 0.95 (0.87,
1.00), p=0.018; Table 3 and Fig. 2]. There were no differences in UA-lowering effects between the control and lowFA groups (Table 3 and Fig. 2). All of the analyses were adjusted for the baseline UA level, study center and other relevant demographic and clinical characteristics. Our data also
suggest the presence of a dose-response relationship between the treatment group and the degree of UA reduction
among the subjects with higher baseline UA levels (p trend
test <0.05) (Table 3). In the total sample and the participants
without an elevated UA concentration (UA <310 mol/L) or
HUA at baseline, there were no significant differences between the groups (Table 3 and Fig. 2).
This analysis excluded 30 individuals who were lost to
follow-up. A sensitivity analysis showed that there were no
significant differences in baseline characteristics between the
excluded and included participants (data not shown).
Adverse events
Finally, there were no severe adverse events during the
study period. All adverse events were mild and reversible,
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weeks of treatment. However, all participants were asked not

to take any nutritional supplements while maintaining their
regular dietary habits during the study period, and the
changes in UA in the control group were quite modest (Table 2). Given that the serum UA levels differed between
men and women, ideally, stratification according to sex
should have been carried out in the statistical analysis. However, we were unable to perform such analyses due to the
small size and instead included sex as a covariate in the
multivariable analysis. Although subdivision according to
the baseline serum UA level was a pre-specified exploratory
analysis in this study, this investigation comprised a nonrandomized analysis of a randomized trial. Therefore, our
results should be viewed as suggestive rather than providing
definitive evidence of the efficacy of FA treatment in lowering the serum UA level.

self-reported gout status and found that FA, fiber and vitamin C appear to be protective against gout. The authors also
found that very high doses of supplemental FA may be
beneficial in preventing gout and recurrent attacks (33).
Moreover, adding FA and eicosapentaenoic acid to the diet
can assist in relieving symptoms of gouty arthritis (34).
However, other supplementation studies in humans have
failed to find such an effect (35-37). For example, in one
study, oral supplementation of FA in doses up to 1,000 mg
did not significantly lower the serum urate concentration,
urinary urate concentration or total oxypurine excretion in
participants with HUA (36). In addition, in another study,
FA supplementation (0.4 mg/day) for three months resulted
in a significant increase in the UA level (37). These contradictory findings may be due in part to small sample sizes
and differences in population characteristics, for example,
patients treated with or without folate supplementation. Recommendations are commonly found on websites to take
multivitamin supplements containing FA in order to lower
the UA levels (38); however, additional clinical trial evidence is needed to provide more definitive answers.
To date, no studies have investigated the combined effects
of ACE inhibitors and FA on the UA or Hcy levels. However, previous studies have presented interesting related findings. For example, it has been reported that FA may decrease the risk of incident hypertension (39) and enhance
the efficacy of antihypertensive drugs by approximately
5% (40). Furthermore, the Womens Antioxidant and Folic
Acid Cardiovascular Study (WAFACS) reported a 19% reduction in the risk of cardiovascular events and total mortality with the combined use of folic acid and ACE inhibitors (41). Based on the observation in the present study that
the combination of FA and an ACE inhibitor reduces the
UA concentration, we suggest that the underlying mechanism of the effects of combined FA and enalapril therapy is
a simultaneous reduction in blood pressure and plasma glucose, with an increase in the folic acid concentration. As a
result, the administration of FA combined with enalapril
may be superior to that of FA or enalapril alone in improving the renal function and increasing renal UA excretion.
Additional long-term trials are therefore warranted to evaluate this scientific hypothesis and its potential mechanisms.
The differential findings of patients with vs. without elevated UA at baseline or HUA are interesting (Table 2). Additional research in larger samples with longer follow-up is
needed to further examine the relationship between FA and
the serum UA level, as well as the mechanisms underlying
this relationship.
One potential limitation of the current study is the lack of
a true control group that did not receive treatment; all of the
participants had mild to moderate essential hypertension,
which required treatment. As such, we were unable to evaluate the individual effects of FA and enalapril on UA or determine if the combined effect was additive or interactive in
nature. Furthermore, we did not obtain detailed information
regarding dietary intake at baseline or during the eight

Conclusion
In summary, the present results demonstrate that the administration of a daily dose of 0.8 mg FA combined with
enalapril, compared to that of enalapril alone, may be beneficial in lowering the serum UA concentrations in patients
with an baseline elevated UA concentration or HUA. However, further studies with a larger sample size and longer duration are needed to confirm our findings and determine the
most effective dose of FA. The present findings, if confirmed in future studies, may enable medical providers to
offer a safe and effective treatment alternative for controlling
hypertension and lowering the UA levels in patients with
mild to moderate hypertension and elevated UA or HUA.
The authors state that they have no Conflict of Interest (COI).
Acknowledgement
This study was supported in part by a grant from the Major
State Basic Research Development Program of China (973 program, No. 2012CB517703) and the Ministry of Science and
Technology of the Peoples Republic of China (2012zx09101105). We gratefully acknowledge the assistance and cooperation
of the faculty and staff of Anhui Medical University and thank
all of the participants in our study. This study was conducted in
accordance with the current regulations of the Peoples Republic
of China.

References
1. Edwards NL. The role of hyperuricemia in vascular disorders.
Curr Opin Rheumatol 21: 132-137, 2009.
2. Kim SY, Guevara JP, Kim KM, Choi HK, Heitjan DF, Albert DA.
Hyperuricemia and risk of stroke: a systematic review and metaanalysis. Arthritis Rheum 61: 885-892, 2009.
3. Kim SY, Guevara JP, Kim KM, Choi HK, Heitjan DF, Albert DA.
Hyperuricemia and coronary heart disease: a systematic review
and meta-analysis. Arthritis Care Res 62: 170-180, 2010.
4. Feig DI, Kang DH, Johnson RJ. Uric acid and cardiovascular risk.
N Engl J Med 359: 1811-1821, 2008.
5. Grayson PC, Kim SY, LaValley M, Choi HK. Hyperuricemia and

23

Intern Med 54: 17-24, 2015

6.
7.
8.
9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

DOI: 10.2169/internalmedicine.54.2931

eastern Chinese provinces. BMC Public Health 13: 664, 2013.

25. Lant AF, McNabb RW, Noormohamed FH. Kinetic and metabolic
aspects of enalapril action. J Hypertens Suppl 2: S37-S42, 1984.
26. Naidoo DP, Sareli P, Marin F, et al. Increased efficacy and tolerability with losartan plus hydrochlorothiazide in patients with uncontrolled hypertension and therapy-related symptoms receiving
two monotherapies. Adv Ther 16: 187-199, 1999.
27. Fernandez R, Puig JG, Rodriguez-Perez JC, Garrido J, Redon J.
Effect of two antihypertensive combinations on metabolic control
in type-2 diabetic hypertensive patients with albuminuria: a randomised, double-blind study. J Hum Hypertens 15: 849-856, 2001.
28. Lewis AS, Murphy L, McCalla C, Fleary M, Purcell S. Inhibition
of mammalian xanthine oxidase by folate compounds and
amethopterin. J Biol Chem 259: 12-15, 1984.
29. Ramirez G, Chen M, Boyce HJ, et al. The plasma and red cell vitamin B levels of chronic hemodialysis patients: a longitudinal
study. Nephron 42: 41-46, 1986.
30. Lwin H, Yoshiike N, Yokoyama T, Saito K, Date C, Tanaka H.
The relationships between plasma total homocysteine and selected
atherosclerotic risk factors according to the C677T methylenetetrahydrofolate reductase gene in Japanese. Eur J Cardiovasc Prev Rehabil 12: 182-184, 2005.
31. Uehara SK, Rosa G. Association of homocysteinemia with high
concentrations of serum insulin and uric acid in Brazilian subjects
with metabolic syndrome genotyped for C677T polymorphism in
the methylenetetrahydrofolate reductase gene. Nutr Res 28: 760766, 2008.
32. Areekul S, Hathirat P, Churdchu K. Folic acid, vitamin B12 and
vitamin B12 binding proteins in patients with neuroblastoma.
Southeast Asian J Trop Med Public Health 17: 184-188, 1986.
33. Oster KA. Folic acid and xanthine oxidase. Ann Intern Med 86:
367, 1977.
34. Akram M, Mohiuddin E, Owais Khan M, et al. Hyperuricemia
and gout: a review article. Int J Family Pract 9: 2009.
35. Zumoff B. Failure of folic acid to affect uric acid metabolism in a
case of gout. Metabolism 4: 80-81, 1955.
36. Boss GR, Ragsdale RA, Zettner A, Seegmiller JE. Failure of folic
acid (pteroylglutamic acid) to affect hyperuricemia. J Lab Clin
Med 96: 783-789, 1980.
37. Mierzecki A, Bukowska H, Honczarenko K, Jastrzebska M, Naruszewicz M. Effect of low doses of folic acid on selected biochemical atherosclerosis risk factors: preliminary study. Pol
Merkur Lekarski 19: 57-62, 2005.
38. Health Guidance Organization. Diets that reduce uric acid [Internet]
[cited 2009 Oct 10]. Available from: http://www.healthguidance.
org/entry/13483/1/Diets-That-Reduce-Uric-Acid.html
39. Forman JP, Rimm EB, Stampfer MJ, Curhan GC. Folate intake
and the risk of incident hypertension among US women. JAMA
293: 320-329, 2005.
40. van Dijk RA, Rauwerda JA, Steyn M, Twisk JW, Stehouwer CD.
Long-term homocysteine-lowering treatment with folic acid plus
pyridoxine is associated with decreased blood pressure but not
with improved brachial artery endothelium-dependent vasodilation
or carotid artery stiffness: a 2-year, randomized, placebocontrolled trial. Arterioscler Thromb Vasc Biol 21: 2072-2079,
2001.
41. Albert CM, Cook NR, Gaziano JM, et al. Effect of folic acid and
B vitamins on risk of cardiovascular events and total mortality
among women at high risk for cardiovascular disease: a randomized trial. JAMA 299: 2027-2036, 2008.

incident hypertension: a systematic review and meta-analysis. Arthritis Care Res 63: 102-110, 2011.
Gibson TJ. Hypertension, its treatment, hyperuricaemia and gout.
Curr Opin Rheumatol 25: 217-222, 2013.
Burns CM, Wortmann RL. Gout therapeutics: new drugs for an
old disease. Lancet 377: 165-177, 2011.
Reyes AJ. Cardiovascular drugs and serum uric acid. Cardiovasc
Drugs Ther 17: 397-414, 2003.
Wang Y, Li X, Qin X, et al. Prevalence of hyperhomocysteinaemia
and its major determinants in rural Chinese hypertensive patients
aged 45-75 years. Br J Nutr 109: 1284-1293, 2013.
Li JP, Huo Y, Liu P. Efficacy and safety of Enalapril-Folate acid
tablets in lowering blood pressure and plasma homocysteine. Beijing Da Xue Xue Bao [Journal of Peking University (Health Sciences)] 39: 614-618, 2007 (in Chinese, Abstract in English).
Sutton-Tyrrell K, Bostom A, Selhub J, Zeigler-Johnson C. High
homocysteine levels are independently related to isolated systolic
hypertension in older adults. Circulation 96: 1745-1749, 1997.
Lip GY, Edmunds E, Martin SC, Jones AF, Blann AD, Beevers
DG. A pilot study of homocyst(e)ine levels in essential hypertension: relationship to von Willebrand factor, an index of endothelial
damage. Am J Hypertens 14: 627-631, 2001.
Ozkan Y, Yardim-Akaydin S, Imren E, Torun M, Simsek B. Increased plasma homocysteine and allantoin levels in coronary artery disease: possible link between homocysteine and uric acid
oxidation. Acta Cardiol 61: 432-439, 2006.
Itou S, Goto Y, Suzuki K, et al. Significant association between
methylenetetrahydrofolate reductase 677T allele and hyperuricemia among adult Japanese subjects. Nutr Res 29: 710-715, 2009.
Malinow MR, Levenson J, Giral P, et al. Role of blood pressure,
uric acid, and hemorheological parameters on plasma homocyst(e)
ine concentration. Atherosclerosis 114: 175-183, 1995.
Motti C, Gnasso A, Bernardini S, et al. Common mutation in
methylenetetrahydrofolate reductase. Correlation with homocysteine and other risk factors for vascular disease. Atherosclerosis
139: 377-383, 1998.
Pigozzi F, Rizzo M, Fagnani F, et al. Endothelial (dys)function:
the target of physical exercise for prevention and treatment of cardiovascular disease. J Sports Med Phys Fitness 51: 260-267, 2011.
Collaboration HLT. Dose-dependent effects of folic acid on blood
concentrations of homocysteine: a meta-analysis of the randomized trials. Am J Clin Nutr 82: 806-812, 2005.
Hao L, Ma J, Zhu J, et al. High prevalence of hyperhomocysteinemia in Chinese adults is associated with low folate, vitamin B-12,
and vitamin B-6 status. J Nutr 137: 407-413, 2007.
Botto LD, Yang Q. 5,10-Methylenetetrahydrofolate reductase gene
variants and congenital anomalies: a HuGE review. Am J Epidemiol 151: 862-877, 2000.
Lyu LC, Hsu CY, Yeh CY, Lee MS, Huang SH, Chen CL. A casecontrol study of the association of diet and obesity with gout in
Taiwan. Am J Clin Nutr 78: 690-701, 2003.
Mao G, Hong X, Xing H, et al. Efficacy of folic acid and
enalapril combined therapy on reduction of blood pressure and
plasma glucose: a multicenter, randomized, double-blind, parallelcontrolled, clinical trial. Nutrition 24: 1088-1096, 2008.
Johnson RJ, Gaucher EA, Sautin YY, Henderson GN, Angerhofer
AJ, Benner SA. The planetary biology of ascorbate and uric acid
and their relationship with the epidemic of obesity and cardiovascular disease. Med Hypotheses 71: 22-31, 2008.
Qiu L, Cheng XQ, Wu J, et al. Prevalence of hyperuricemia and
its related risk factors in healthy adults from Northern and North-

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