Can hydrochlorothiazide (HCTZ) worsen underlying gouty arthropathy and is vitamin B12 injection helpful for controlling pain besides dexamethasone and ketorolac injections?

Management of Hydrochlorothiazide in Gouty Arthropathy and Role of Vitamin B12 Injections for Pain Control

Hydrochlorothiazide should be switched to an alternative antihypertensive medication in patients with gout, as it can worsen underlying gouty arthropathy by increasing serum uric acid levels. 1

Effect of Hydrochlorothiazide on Gout

• Hydrochlorothiazide decreases the excretion of uric acid, leading to increased serum uric acid levels that can exacerbate gouty arthritis 2
• The 2020 American College of Rheumatology (ACR) gout management guidelines specifically recommend switching hydrochlorothiazide to an alternate antihypertensive medication in patients with gout 1
• Losartan is preferentially recommended as an alternative antihypertensive for patients with gout due to its uricosuric properties 1
• Clinical studies have shown that thiazide diuretics can increase uric acid levels in many patients, potentially triggering gout flares in those with underlying gouty arthropathy 1

Pain Management Options for Gouty Arthritis

• For acute gout flares, the ACR strongly recommends oral colchicine, NSAIDs, or glucocorticoids (oral, intraarticular, or intramuscular) as first-line therapy 1
• Dexamethasone and ketorolac injections are appropriate choices for managing acute gouty arthritis pain, especially in patients who cannot take oral medications 1
• For patients who may receive nothing by mouth (NPO), glucocorticoids (intramuscular, intravenous, or intraarticular) are strongly recommended 1

Role of Vitamin B12 Injections in Gout Pain Management

• There is no evidence in the current ACR guidelines or other high-quality research supporting the use of vitamin B12 injections specifically for controlling pain in gouty arthritis 1
• The 2020 ACR guidelines do not mention vitamin B12 as a recommended therapy for gout pain management 1
• First-line treatments for acute gout pain should be colchicine, NSAIDs, or glucocorticoids based on patient-specific factors 1
• For patients with contraindications to standard therapies, topical ice is conditionally recommended as an adjuvant treatment 1, but vitamin B12 is not mentioned

Clinical Approach for Patients with Gout on Hydrochlorothiazide

1. Evaluate the necessity of continuing hydrochlorothiazide therapy 1
2. Consider switching to losartan as an alternative antihypertensive agent 1
3. For acute gout flare pain management, continue using dexamethasone and ketorolac injections as appropriate 1
4. Do not rely on vitamin B12 injections for pain control as there is no evidence supporting this approach 1
5. Consider implementing lifestyle modifications including limiting alcohol intake, purine intake, and high-fructose corn syrup consumption 1
6. For overweight/obese patients, recommend weight loss to help reduce gout flares 1

Pitfalls and Caveats

• Continuing hydrochlorothiazide in patients with recurrent gout can lead to increased frequency and severity of gout attacks 1, 2
• When switching antihypertensives, ensure adequate blood pressure control is maintained with the alternative agent 1
• Do not stop hydrochlorothiazide abruptly without having an alternative antihypertensive plan in place 1
• Vitamin B12 injections should not be relied upon for gout pain management as they lack evidence for efficacy in this condition 1
• Patients with chronic kidney disease require special consideration when selecting both antihypertensives and gout treatments 3