From the Guidelines
Thiazide diuretics are contraindicated in patients with a history of gout, diabetes, hyperlipidaemia, or creatinine clearance (CrCL) <30 mL/min, as well as in elderly patients with ankle oedema without signs of heart failure or as first-line therapy for hypertension. This is based on the most recent and highest quality study available, which highlights the potential adverse effects of thiazide diuretics in these patient populations 1.
Key Contraindications
- History of gout: Thiazides can reduce uric acid excretion, exacerbating gout symptoms.
- Diabetes: Thiazides can worsen hyperglycemia and increase the risk of diabetic complications.
- Hyperlipidaemia: Thiazides can increase lipid levels, further worsening cardiovascular risk.
- CrCL <30 mL/min: Thiazides become ineffective at this level of kidney dysfunction and may worsen electrolyte imbalances.
- Elderly patients with ankle oedema without heart failure: Thiazides may not be effective in this population and may increase the risk of adverse effects.
- Elderly patients as first-line therapy for hypertension: Thiazides may not be the best initial choice due to the potential for adverse effects and the availability of alternative agents.
Rationale
Thiazide diuretics work by inhibiting sodium and chloride reabsorption in the distal convoluted tubule, which can affect electrolyte balance and worsen certain pre-existing conditions. The contraindications listed above are based on the potential for thiazides to exacerbate these conditions or increase the risk of adverse effects.
Monitoring and Precautions
Patients taking thiazide diuretics should be monitored for signs of adverse effects, including hypovolaemia, postural hypotension, falls, poor sleep, nocturia, dehydration, electrolyte disturbances, and metabolic disturbances. Caution should be exercised in patients with poor mobility, urinary incontinence, acute kidney injury, and electrolyte disturbances. Excessive diuresis should be avoided in elderly patients with heart failure with preserved ejection fraction (HFpEF) 1.
From the FDA Drug Label
Hydrochlorothiazide capsules are contraindicated in patients with anuria. Hypersensitivity to this product or other sulfonamide derived drugs is also contraindicated. Thiazide diuretics, such as hydrochlorothiazide, are contraindicated in the following situations:
- Anuria: patients with no urine production
- Hypersensitivity: patients with a known allergy to the drug or other sulfonamide-derived drugs 2
From the Research
Contraindications of Thiazide Diuretics
Thiazide diuretics are contraindicated in certain conditions, including:
- Advanced chronic kidney disease (CKD), specifically stage 4 CKD, as they are deemed ineffective in this population 3, 4, 5
- Hypersensitivity to thiazide diuretics or sulfonamides
- Anuria or severe renal impairment
- Electrolyte imbalances, such as hyponatremia or hypokalemia, which can be exacerbated by thiazide diuretics 6
Special Considerations
Thiazide diuretics should be used with caution in:
- Elderly patients, as they are at increased risk of electrolyte disorders, syncope, and falls 6
- Patients with gout or hyperuricemia, as thiazide diuretics can increase uric acid levels
- Patients with diabetes mellitus, as thiazide diuretics can impair glucose tolerance
Monitoring Requirements
Patients taking thiazide diuretics require regular monitoring of: