Is Hydrochlorothiazide (HCTZ) contraindicated in patients with gout?

Hydrochlorothiazide in Patients with Gout

Hydrochlorothiazide (HCTZ) should be avoided in patients with gout whenever possible, as it can precipitate acute gout attacks by increasing serum uric acid levels. 1, 2

Mechanism and Concerns

• Thiazide diuretics, including HCTZ, can precipitate hyperuricemia or acute gout attacks in susceptible patients 3
• HCTZ increases serum uric acid levels by reducing renal excretion of urate, which can worsen existing gout or trigger new attacks 4
• Studies have shown that patients switching to HCTZ-containing formulations experience significant increases in serum uric acid levels, even when combined with medications like losartan 4

Management Recommendations for Hypertension in Gout Patients

• When gout occurs in a patient receiving thiazide diuretics, substitute the diuretic if possible 1
• For hypertension management in gout patients, consider alternative antihypertensives such as:
  • Losartan (which has uricosuric properties) 1
  • Calcium channel blockers 1
• For hyperlipidemia in gout patients, consider statins or fenofibrate rather than medications that might increase uric acid 1

Evidence-Based Approach to Medication Selection

• The European League Against Rheumatism (EULAR) specifically recommends substituting thiazide diuretics when managing patients with gout 1
• The American College of Rheumatology guidelines recommend elimination of prescription medications that elevate serum urate levels when not essential for management of comorbidities, with thiazide diuretics specifically mentioned 1
• When treating hypertension in gout patients, medications that don't increase serum uric acid levels should be preferred 4

Clinical Considerations

• If HCTZ must be used due to compelling indications (when benefits outweigh risks):
  • Monitor serum uric acid levels regularly 3
  • Consider prophylactic therapy with colchicine or other appropriate medications to prevent gout flares 1
  • Use the lowest effective dose of HCTZ 3
• Patients with gout should receive comprehensive lifestyle advice including weight loss if appropriate, avoiding alcohol (especially beer and spirits), and reducing intake of sugar-sweetened drinks 1

Alternative Approaches

• For patients requiring diuretic therapy, consider loop diuretics in lower doses if clinically appropriate, though these can also affect uric acid levels 1
• Urate-lowering therapy may need dose adjustment if diuretic therapy cannot be discontinued 1
• Angiotensin receptor blockers, particularly losartan, may be preferred in hypertensive patients with gout due to their uricosuric effect 5

Common Pitfalls

• Failing to recognize the relationship between thiazide diuretics and gout exacerbations 3
• Not considering medication-induced hyperuricemia as a potential cause of recurrent gout attacks 5
• Inadequate monitoring of serum uric acid levels in patients who must remain on thiazide diuretics 3
• Overlooking the importance of treating to target serum uric acid levels (<6 mg/dL) in gout patients, regardless of concurrent medications 6