What diuretics are suitable for patients with gout?

From the Guidelines

For patients with gout, losartan and calcium channel blockers are the preferred antihypertensive medications with diuretic properties, as they do not increase uric acid levels and can help prevent gout flares. Traditional diuretics like hydrochlorothiazide, chlorthalidone, and furosemide should be avoided when possible as they can increase uric acid levels and trigger gout flares 1. If a diuretic is absolutely necessary, losartan (25-100 mg daily) is recommended as it has the unique property of increasing uric acid excretion while controlling blood pressure 1. Calcium channel blockers like amlodipine (5-10 mg daily) are also uric acid neutral and safe options. For patients already on thiazide or loop diuretics who develop gout, consider switching to these alternatives rather than simply adding urate-lowering therapy. The mechanism behind traditional diuretics worsening gout involves increased uric acid reabsorption in the proximal tubule of the kidney, while losartan blocks this reabsorption through effects on the URAT1 transporter 1. When managing patients with both hypertension and gout, medication choice should balance cardiovascular benefits with the risk of exacerbating gout symptoms.

Some key points to consider when choosing a diuretic for patients with gout include:

• Avoiding traditional diuretics like hydrochlorothiazide, chlorthalidone, and furosemide
• Using losartan or calcium channel blockers as alternative antihypertensive medications
• Considering the patient's individual needs and medical history when selecting a diuretic
• Monitoring uric acid levels and adjusting medication as needed to prevent gout flares

It's also important to note that the 2017 updated EULAR evidence-based recommendations for the management of gout suggest that diuretics should be stopped if possible in patients with gout, and alternative antihypertensive treatment without diuretics should be considered 1. Additionally, the 2018 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults recommends using losartan or other ARBs as first-line treatment for hypertension in patients with gout 1.

From the FDA Drug Label

Hyperuricemia or acute gout may be precipitated in certain patients receiving thiazide diuretics. Hyperuricemia may occur; it has been asymptomatic in cases reported to date

Diuretics to use in gout:

• None of the above diuretics are recommended for use in gout, as they may precipitate or worsen hyperuricemia or acute gout 2, 3.
• Thiazide diuretics, such as hydrochlorothiazide, and loop diuretics, such as bumetanide, may increase uric acid levels and trigger gout attacks.
• Alternative diuretics that do not increase uric acid levels, such as potassium-sparing diuretics, may be considered in patients with gout.

From the Research

Diuretics in Gout Treatment

• The use of diuretics in patients with gout is a complex issue, as some diuretics can increase the risk of gout attacks 4.
• Loop diuretics, such as furosemide, and thiazide diuretics, such as hydrochlorothiazide, can increase urate reabsorption and decrease urate excretion, which can worsen gout 5, 4.
• However, some diuretics, such as ticrynafen, have been shown to increase urate excretion and may be beneficial in treating gout, but its use is limited due to hepatotoxicity and nephrotoxicity 5.
• Potassium-sparing diuretics, such as amiloride, may not increase the risk of gout and can be used as an alternative to loop and thiazide diuretics 4.

Types of Diuretics

• Loop diuretics:
  • Furosemide: increases urate reabsorption and decreases urate excretion 5.
  • Torasemide: has a similar effect to furosemide, but with a longer half-life 6.
• Thiazide diuretics:
  • Hydrochlorothiazide: increases urate reabsorption and decreases urate excretion 5.
  • Chlorthalidone: has a longer half-life and is more potent than hydrochlorothiazide 7.
• Potassium-sparing diuretics:
  • Amiloride: does not increase the risk of gout and can be used as an alternative to loop and thiazide diuretics 4.

Considerations for Diuretic Use in Gout

• Patients with gout should be monitored closely for signs of worsening gout when starting diuretic therapy 4.
• Alternative treatments, such as potassium-sparing diuretics or urate-lowering therapies, should be considered in patients with gout who require diuretic therapy 8.
• The use of diuretics in patients with gout should be individualized and based on the patient's specific needs and medical history 7.