Are there any diuretics that do not increase the risk of gout (hyperuricemia)?

Diuretics and Gout: Alternatives to Reduce Risk

Calcium channel blockers and losartan are the preferred alternatives to diuretics for patients at risk of gout, as they do not increase serum uric acid levels and may even have modest uricosuric effects. 1, 2

Diuretics and Their Impact on Gout Risk

• All thiazide and loop diuretics increase the risk of gout through elevation of serum uric acid levels 3
• Loop diuretics carry the highest risk (adjusted OR 2.64), followed by thiazide-like diuretics (adjusted OR 2.30) and thiazide diuretics (adjusted OR 1.70) 3
• Combined use of loop and thiazide diuretics presents the highest risk (adjusted OR 4.65) 3
• Potassium-sparing diuretics do not significantly increase gout risk (adjusted OR 1.06) 3
• Higher doses of thiazides (≥25 mg/day of hydrochlorothiazide equivalent) significantly increase the risk of gout, while lower doses show no significant increase 4

Recommended Alternatives to Diuretics

For Hypertension Management:

• Losartan is the preferred alternative for hypertension in patients with or at risk of gout 1, 2

  • Has unique uricosuric properties that increase urinary excretion of uric acid
  • Can lower both blood pressure and serum uric acid levels simultaneously

• Calcium channel blockers are excellent alternatives 3, 2

  • Do not increase serum uric acid levels
  • Current use may slightly attenuate the risk of gout in patients who must take diuretics 3

For Hyperlipidemia Management:

• Fenofibrate should be considered for patients with hyperlipidemia and gout 1
  • Demonstrated uricosuric and serum urate-lowering effects
  • Can reduce serum uric acid by approximately 20% 1
  • Increases renal uric acid clearance by about 30% 1

Management Algorithm for Patients with or at Risk of Gout

1. For patients with existing gout:

   • Stop diuretic therapy if possible 1
   • Switch to losartan for hypertension management 1
   • Consider fenofibrate for hyperlipidemia 1

2. For patients at high risk of gout without current diagnosis:

   • Avoid thiazide and loop diuretics if possible 3, 2
   • If diuretics are necessary, use lowest effective dose of thiazides (<25 mg/day hydrochlorothiazide equivalent) 4
   • Consider potassium-sparing diuretics if a diuretic is absolutely necessary 3

3. For patients requiring diuretic therapy despite gout risk:

   • Add calcium channel blockers or losartan to the regimen to attenuate risk 3
   • Monitor serum uric acid levels regularly 1
   • Consider prophylactic urate-lowering therapy if diuretics cannot be discontinued 2

Important Caveats and Considerations

• While the association between diuretics and gout is well-established, some research suggests that underlying cardiovascular conditions requiring diuretics may be confounding factors 5
• The clinical value and cost-effectiveness of losartan and fenofibrate specifically for gout management remain unclear despite their uricosuric effects 1
• Environmental and dietary factors also contribute to hyperuricemia and should be addressed alongside medication changes 6
• When diuretics cannot be discontinued due to compelling indications, the benefits of diuretic therapy must be carefully weighed against the risk of gout 1