What medications can contribute to gout?

Medications That Can Contribute to Gout

Thiazide and loop diuretics, niacin, calcineurin inhibitors, low-dose aspirin, and certain cytotoxic drugs are the main medications that can contribute to gout by elevating serum urate levels. 1

Common Medications That Increase Gout Risk

Diuretics

• Thiazide diuretics (e.g., hydrochlorothiazide) and loop diuretics (e.g., furosemide) are among the most common medications that contribute to hyperuricemia and gout 1
• These medications reduce uric acid excretion by the kidneys, leading to elevated serum urate levels 2
• Furosemide can specifically increase the risk of gouty arthritis, especially when used concomitantly with cyclosporine 3

Immunosuppressants

• Calcineurin inhibitors (e.g., cyclosporine, tacrolimus) commonly used in organ transplant recipients can elevate serum urate levels 1
• The combination of cyclosporine and furosemide is particularly problematic, as it significantly increases the risk of gouty arthritis 3

Cardiovascular Medications

• Low-dose aspirin (≤325 mg daily) can elevate serum urate levels, though the ACR guidelines do not recommend discontinuation when used for cardiovascular prophylaxis 1
• Beta-blockers and ACE inhibitors can reduce renal function and contribute to reduced uric acid elimination 4

Other Medications

• Niacin (vitamin B3), commonly used for hyperlipidemia, can increase serum urate levels 1
• Cytotoxic drugs used in cancer treatment can increase uric acid production through cell breakdown 5

Management Strategies for Medication-Induced Gout

Medication Adjustments

• Consider discontinuing thiazide or loop diuretics if possible and not essential for managing comorbidities 1
• When treating hypertension in gout patients, consider using losartan preferentially as it has uricosuric effects 1
• For hyperlipidemia, fenofibrate has uricosuric effects, though guidelines recommend against switching cholesterol-lowering agents to fenofibrate solely for gout management 1

Alternative Approaches

• If diuretics cannot be discontinued, consider adding a urate-lowering therapy such as allopurinol or febuxostat 1
• For patients on low-dose aspirin for cardiovascular protection, continue the medication as the benefits outweigh the modest effects on serum urate 1

Clinical Pearls and Pitfalls

• When evaluating a patient with gout, always review their medication list for potential contributors to hyperuricemia 1, 6
• Patients with renal impairment are at higher risk for medication-induced hyperuricemia and gout, as many medications that raise uric acid levels affect renal excretion 1, 5
• Avoid the common pitfall of focusing solely on dietary factors while overlooking medications as potential causes of gout 6, 4
• When prescribing medications known to increase serum urate levels, consider monitoring uric acid levels, especially in patients with a history of gout or risk factors 5

Special Considerations

• In patients with gout and hypertension, consider using calcium channel blockers or losartan, which do not adversely affect uric acid levels 1, 6
• For patients requiring diuretics, be aware that the uricosuric effects of certain medications (like losartan or fenofibrate) may help counteract the hyperuricemic effects of diuretics 1
• In patients with gout and organ transplants who require calcineurin inhibitors, more aggressive urate-lowering therapy may be needed 1, 5