From the Guidelines
Hydrochlorothiazide should be avoided in patients with gout who also have hypertension, and instead, alternative antihypertensive medications such as losartan should be considered. This recommendation is based on the 2020 American College of Rheumatology guideline for the management of gout, which conditionally recommends switching hydrochlorothiazide to an alternate antihypertensive when feasible for patients with gout, regardless of disease activity 1. The guideline also conditionally recommends choosing losartan preferentially as an antihypertensive agent when feasible for patients with gout, regardless of disease activity 1.
Key Considerations
- Hydrochlorothiazide can raise uric acid levels in the blood, potentially triggering or worsening gout attacks.
- Losartan, an angiotensin receptor blocker, has uricosuric properties that can help lower uric acid levels.
- Other alternative antihypertensive medications, such as calcium channel blockers like amlodipine or ACE inhibitors like lisinopril, may also be considered.
- If a diuretic is absolutely necessary, a low dose of hydrochlorothiazide (12.5 mg daily) may be used while monitoring uric acid levels closely, or a loop diuretic like furosemide may be considered as an alternative.
Lifestyle Modifications
- Patients with both hypertension and gout should focus on lifestyle modifications, including:
- Weight loss
- Reduced alcohol intake
- Limiting purine-rich foods to help manage both conditions.
The mechanism behind hydrochlorothiazide's effect on gout involves increased reabsorption of uric acid in the proximal tubule of the kidney, leading to hyperuricemia 1. Therefore, alternative antihypertensive medications that do not exacerbate gout should be prioritized.
From the FDA Drug Label
Hyperuricemia Hyperuricemia or acute gout may be precipitated in certain patients receiving thiazide diuretics.
- Hyperuricemia and gout are potential risks associated with thiazide diuretics, including hydrochlorothiazide.
- The use of hydrochlorothiazide in patients with hypertension and gout should be approached with caution, as it may precipitate or worsen gout.
- Patients with a history of gout should be closely monitored for signs of hyperuricemia or acute gout when taking hydrochlorothiazide 2.
From the Research
Hydrochloride Use in Hypertension Patients with Gout
- The use of hydrochloride in patients with hypertension and gout is a complex issue, as certain antihypertensive drugs can affect uric acid metabolism and exacerbate gout symptoms 3, 4.
- Diuretics, beta-blockers, and alpha-1 blockers have been shown to increase serum uric acid levels and reduce glomerular filtration rate, which can worsen gout symptoms 3.
- On the other hand, calcium channel blockers, ACE inhibitors, and angiotensin receptor blockers, such as losartan, do not increase serum uric acid levels and may be safer options for patients with hypertension and gout 3, 4.
- Losartan, in particular, has been found to have mild uricosuric properties, making it a potential option for treating hypertensive patients with gout 4.
- There is no direct evidence on the use of hydrochloride in patients with hypertension and gout, but it is likely that the use of diuretics, which can increase serum uric acid levels, should be avoided or used with caution in these patients 3, 4.
Alternative Treatment Options
- Calcium channel blockers and ACE inhibitors may be alternative treatment options for patients with hypertension and gout, as they do not increase serum uric acid levels 3, 5.
- Losartan, an angiotensin receptor blocker, may also be a suitable option due to its mild uricosuric properties 4.
- Lifestyle modifications, such as regular exercise and a healthy diet, can also help manage hypertension and reduce the risk of gout symptoms 6, 7.
Considerations for Treatment
- When treating patients with hypertension and gout, it is essential to consider the potential effects of antihypertensive drugs on uric acid metabolism and gout symptoms 3, 4.
- A thorough evaluation of the patient's medical history, lifestyle, and current medications is necessary to determine the best course of treatment 6, 7.