Is Hydrochlorothiazide (HCTZ) contraindicated in patients with gout?

HCTZ and Gout Management: Recommendations and Considerations

Hydrochlorothiazide (HCTZ) is not absolutely contraindicated in patients with gout, but should be discontinued if possible due to its effect on increasing serum urate levels and potentially worsening gout. 1

Mechanism and Effects

• HCTZ and other thiazide diuretics increase serum uric acid levels by:
  • Reducing urate excretion in the kidneys
  • Competing with uric acid for renal tubular secretion
  • Promoting volume depletion which enhances urate reabsorption

Evidence-Based Recommendations

For Patients Already on HCTZ Who Develop Gout:

1. Substitute the diuretic if possible 1

   • For hypertension management, consider alternative agents:
     • Losartan (has uricosuric properties)
     • Calcium channel blockers
     • Other antihypertensives without hyperuricemic effects

2. If HCTZ cannot be discontinued:

   • Implement appropriate urate-lowering therapy (ULT)
   • Monitor serum urate levels more frequently
   • Consider more aggressive ULT dosing to overcome the hyperuricemic effect of HCTZ

For Acute Gout Management in Patients on HCTZ:

• First-line options for acute flares remain the same 1:
  • Colchicine (within 12 hours of flare onset)
  • NSAIDs (with PPI if appropriate)
  • Oral corticosteroids
  • Intra-articular corticosteroid injection

Clinical Decision Algorithm

1. Assess necessity of HCTZ:

   • Is HCTZ essential for managing the patient's hypertension?
   • Are there suitable alternatives available?

2. If HCTZ can be discontinued:

   • Replace with losartan or calcium channel blockers for hypertension management 1
   • Monitor urate levels to assess improvement

3. If HCTZ must be continued:

   • Initiate or optimize ULT therapy
   • Target lower serum urate levels (<6 mg/dL or <5 mg/dL in severe cases) 2
   • Consider more frequent monitoring of serum urate levels (every 2-5 weeks during dose adjustment) 2

Important Considerations

• The American College of Rheumatology (ACR) specifically recommends eliminating prescription medications that elevate serum urate levels when they are non-essential for managing comorbidities, with thiazide diuretics being a prime example 1

• Febuxostat may be an appropriate ULT choice for patients who must remain on HCTZ, as studies have shown no significant pharmacokinetic interactions between febuxostat and HCTZ 3

• For patients with both gout and hypertension, a comprehensive approach addressing both conditions is essential, with medication choices that minimize negative effects on either condition

Pitfalls to Avoid

• Don't assume all diuretics have equal effects on urate levels - Loop diuretics also raise urate levels but may be necessary in certain clinical scenarios

• Don't overlook the importance of lifestyle modifications - Weight loss, limiting alcohol (especially beer), avoiding sugar-sweetened drinks, and limiting meat and seafood intake remain important regardless of medication choices 1

• Don't forget prophylaxis against flares when initiating ULT in patients who must remain on HCTZ, as they may be at higher risk of flares during ULT initiation

By carefully weighing the necessity of HCTZ against its effects on gout and implementing appropriate alternative strategies, clinicians can effectively manage both hypertension and gout in affected patients.