In a patient experiencing an acute gout flare, should thiazide diuretics be discontinued and what antihypertensive or heart‑failure medications can be used as alternatives?

Management of Diuretics During Acute Gout Flare

In patients experiencing an acute gout flare, thiazide and loop diuretics should be switched to alternative antihypertensives when possible, with losartan as the preferred first-line alternative due to its unique uricosuric properties. 1

Should Diuretics Be Discontinued During Acute Flare?

The American College of Rheumatology conditionally recommends switching from hydrochlorothiazide or other diuretics (including loop diuretics like furosemide) to alternative antihypertensive agents in gout patients, regardless of current disease activity. 1, 2 This recommendation reflects that widespread diuretic prescribing contributes to rising gout prevalence. 1

Critical Exception - When Diuretics Cannot Be Stopped:

• Do not abruptly discontinue diuretics in patients with compelling cardiovascular indications (heart failure with volume overload, severe edema requiring diuresis). 1, 2
• In these cases, carefully balance cardiovascular benefits against gout risk, optimize urate-lowering therapy with higher allopurinol doses, and monitor serum uric acid closely. 1
• For heart failure patients specifically, the European Society of Cardiology advises using colchicine for symptomatic gout relief while continuing necessary diuretic therapy, explicitly avoiding NSAIDs. 3

Preferred Antihypertensive Alternatives

First-Line: Losartan

Losartan is the preferred alternative for hypertension in patients with gout, offering dual benefits of blood pressure control and uric acid lowering. 1

• Mechanism: Increases urinary uric acid excretion by approximately 25% and reduces serum uric acid by 20-47 µmol/L. 1, 2
• Dosing: Target 100 mg once daily for optimal cardiovascular and urate-lowering benefits, though uricosuric effect plateaus around 50 mg daily. 1
• Monitoring: Check potassium levels and renal function regularly, particularly in patients with chronic kidney disease. 1

Second-Line: Calcium Channel Blockers

• Calcium channel blockers do not raise serum uric acid and may modestly attenuate gout risk when combined with diuretics. 1, 2
• Preferred when losartan is contraindicated or not tolerated (e.g., persistent cough, hyperkalemia). 1

Additional Consideration: Fenofibrate

• For patients with concurrent hyperlipidemia and gout, fenofibrate demonstrates uricosuric effects, reducing serum uric acid by approximately 20% and increasing renal uric acid clearance by about 30%. 1

If Diuretic Therapy Is Absolutely Necessary

Least Harmful Diuretic Options:

Potassium-sparing diuretics (spironolactone, amiloride, triamterene) have an odds ratio of 1.06 for gout (not statistically significant), meaning they do not meaningfully increase gout risk. 2

• Monitor for hyperkalemia, especially with concurrent ACE inhibitors/ARBs or chronic kidney disease. 2

Diuretics to Avoid:

• Thiazide diuretics: Odds ratio 1.72 for gout. 4
• Loop diuretics: Also increase gout risk through reduced renal uric acid excretion. 1, 5
• Gout occurrence is uncommon when hydrochlorothiazide ≤50 mg/day or chlorthalidone ≤25 mg/day, though serum uric acid still rises. 2

Treatment of the Acute Flare Itself

While managing diuretics, treat the acute flare appropriately:

• Colchicine is safe and potentially reduces myocardial infarction risk in patients with cardiovascular disease. 6
• Short-duration, low-dose glucocorticoids are efficacious and may be safe if colchicine is not tolerated. 6
• NSAIDs should be avoided in patients with cardiovascular disease or heart failure. 3, 6
• For heart failure patients specifically, use colchicine for pain relief during acute flares. 3

Common Pitfalls to Avoid

• Do not stop diuretics abruptly without an alternative antihypertensive plan in patients requiring blood pressure control. 1
• Do not continue hydrochlorothiazide in gout patients when alternatives exist, as it is a modifiable risk factor. 1
• Do not forget that serum uric acid levels may be normal during acute attacks, so hyperuricemia does not confirm or exclude gout during a flare. 5
• Greatest electrolyte shifts occur within the first 3 days of diuretic therapy changes, requiring close monitoring. 2