Is it necessary to stop Hydrochlorothiazide (HCTZ) in patients with gout?

From the Guidelines

It is not always necessary to stop hydrochlorothiazide (HCTZ) in patients with gout, but it should be considered as HCTZ can worsen gout symptoms. HCTZ increases uric acid levels by reducing renal excretion of urate, which can trigger or exacerbate gout attacks. For patients with recurrent or severe gout attacks, switching from HCTZ to an alternative antihypertensive medication that doesn't affect uric acid levels is recommended, as suggested by the 2016 updated EULAR evidence-based recommendations for the management of gout 1. Options include losartan (which has uricosuric properties), calcium channel blockers like amlodipine, or ACE inhibitors like lisinopril. If HCTZ must be continued due to compelling indications or lack of suitable alternatives, adding prophylactic medication such as allopurinol (starting at 100mg daily and titrating based on uric acid levels) or febuxostat can help manage gout while continuing HCTZ, as indicated in the management of gout 1. The decision should balance the benefits of HCTZ for blood pressure control against the risk of worsening gout, considering the frequency and severity of gout attacks, availability of alternative medications, and the patient's overall health status. Some key points to consider when making this decision include:

• The patient's renal function, as HCTZ can worsen renal impairment 1
• The presence of other comorbidities, such as hypertension, hyperlipidaemia, or heart failure, which may influence the choice of antihypertensive medication 1
• The patient's lifestyle and dietary habits, which can also impact gout management, as suggested by the 2016 updated EULAR evidence-based recommendations for the management of gout 1. In general, the management of gout should be individualized, taking into account the patient's specific needs and circumstances, as recommended by the EULAR guidelines 1.

From the Research

Gout and Hydrochlorothiazide (HCTZ) Use

• The use of diuretics, such as HCTZ, has been associated with an increased risk of recurrent gout attacks 2.
• A study found that recent use of diuretics, including thiazide diuretics like HCTZ, was associated with a significantly increased risk of recurrent gouty arthritis, with an odds ratio of 3.6 2.
• Another study noted that drugs, particularly diuretics, could potentially contribute to the development of hyperuricemia and gout 3.

Management of Gout

• The management of gout involves treating acute attacks and lowering excess stores of uric acid to achieve dissolution of monosodium urate crystals through a long-term reduction of serum urate concentrations 4.
• The treatment of acute gout attacks can be achieved with non-steroidal anti-inflammatory agents, colchicine, or corticosteroid-based therapies 5.
• Long-term management of gout involves the reduction and maintenance of serum urate levels in a goal range, usually defined as less than 6.0 mg/dL, which can be achieved with urate-lowering therapy such as allopurinol or febuxostat 4.

Considerations for Patients with Gout

• Patients with gout often have comorbid conditions, such as hypertension, lipid disorders, and diabetes mellitus, which may influence the clinical course and outcome of gout 3.
• The use of certain medications, including diuretics like HCTZ, may need to be reassessed in patients with gout to minimize the risk of recurrent gout attacks 2.
• The selection of agents used for acute gout management and long-term urate-lowering therapy should be individualized according to patient and agent cardiovascular risk factors 6.