Should Hydrochlorothiazide Be Discontinued in a Patient with Frequent Gout Attacks?
Yes, hydrochlorothiazide should be discontinued and replaced with losartan-based therapy in this patient with frequent gout attacks and resistant hypertension. The American College of Rheumatology conditionally recommends switching patients with gout from hydrochlorothiazide to alternative antihypertensives, regardless of current gout disease activity, because diuretic prescribing contributes to rising gout prevalence 1.
Why Hydrochlorothiazide Must Be Stopped
Thiazide diuretics directly cause hyperuricemia by inducing volume contraction and competing with uric acid for renal tubular secretion, making them a modifiable risk factor that should be eliminated when alternatives exist 1, 2.
The patient already has frequent gout attacks, indicating that the hydrochlorothiazide is actively contributing to disease burden and impairing quality of life 1.
Stopping the diuretic does not necessarily mean losing blood pressure control in this patient who is already on benazepril and amlodipine—two agents that can be optimized further 3.
Recommended Alternative Regimen for Resistant Hypertension with Gout
First-Line Replacement: Losartan
Replace benazepril with losartan 100 mg daily as the preferred ARB for this patient 1, 4.
Losartan uniquely lowers serum uric acid by increasing urinary uric acid excretion by approximately 25% and reducing serum uric acid by 20-47 μmol/L, making it the only antihypertensive that simultaneously treats both hypertension and gout 1, 4.
Titrate to the target dose of 100 mg once daily for optimal cardiovascular and urate-lowering benefits 1.
Second Step: Add Spironolactone for Resistant Hypertension
Spironolactone 25-100 mg daily is the preferred add-on agent for resistant hypertension and does not increase gout risk (odds ratio 1.06, not statistically significant) 3, 4.
Aldosterone antagonists are specifically recommended for resistant hypertension and provide additional blood pressure reduction without the hyperuricemic effects of thiazides 3.
Monitor potassium levels closely when combining spironolactone with losartan, especially given the patient's diabetes and likely chronic kidney disease 5, 4.
Optimizing Existing Therapy
Maximize amlodipine dose to 10 mg daily if not already at this dose, as calcium channel blockers do not raise serum uric acid and may modestly attenuate gout risk 3, 4.
Calcium channel blockers are metabolically neutral and appropriate for this obese diabetic patient 6.
What Happens When You Stop the Hydrochlorothiazide
Blood pressure may initially rise by 5-21 mmHg systolic when discontinuing hydrochlorothiazide, but this can be managed by optimizing the alternative regimen before stopping the diuretic 3, 7.
Serum uric acid will decrease and potassium will rise after stopping hydrochlorothiazide, which are both beneficial changes for this patient 7.
Metabolic parameters improve: discontinuation leads to significant decreases in serum lipids and hemoglobin A1C, which is particularly important for this diabetic patient 7.
Critical Monitoring After the Switch
Check electrolytes (sodium, potassium, magnesium) and creatinine within 2-4 weeks after starting losartan and spironolactone to detect hyperkalemia 5, 4.
Monitor blood pressure weekly for the first month to ensure adequate control during the transition 3.
Measure serum uric acid at 4-6 weeks to document improvement and guide gout prophylaxis therapy 4.
Common Pitfalls to Avoid
Do not continue hydrochlorothiazide "because the patient needs a diuretic"—this patient's resistant hypertension is better managed with spironolactone, which targets aldosterone-mediated sodium retention common in obesity without raising uric acid 3, 1.
Do not use loop diuretics as an alternative—furosemide and other loop diuretics also increase gout risk (though less than thiazides) and should only be reserved for significant fluid overload or advanced renal failure 1, 2.
Do not abruptly stop hydrochlorothiazide without having the alternative regimen in place—transition the patient by starting losartan and optimizing doses before discontinuing the thiazide 1.
Do not forget that this patient likely needs urate-lowering therapy (allopurinol or febuxostat) given the history of frequent gout attacks, which should be initiated or optimized regardless of the antihypertensive changes 2.
Why This Approach Prioritizes Morbidity, Mortality, and Quality of Life
Frequent gout attacks severely impair quality of life through acute pain, disability, and chronic joint damage 1.
Losartan-based therapy addresses both cardiovascular mortality (through blood pressure control) and gout morbidity (through uric acid lowering) simultaneously 1, 4.
Spironolactone provides superior blood pressure reduction in resistant hypertension compared to continuing thiazides, potentially reducing cardiovascular events 3.
Metabolic improvements from stopping hydrochlorothiazide (better glucose control, improved lipids) reduce long-term diabetes complications in this high-risk patient 7, 8.