From the Guidelines
Thiazide diuretics can increase the risk of gout attacks, and patients with a history of gout or elevated uric acid levels should be cautious when taking these medications. According to the 2017 updated EULAR evidence-based recommendations for the management of gout 1, thiazide diuretics can raise uric acid levels in the blood by reducing uric acid excretion in the kidneys. This occurs because these medications compete with uric acid for elimination through the same transport channels in the kidney tubules, causing uric acid to accumulate in the bloodstream. The elevated uric acid levels (hyperuricemia) can lead to the formation of urate crystals in joints, triggering painful gout attacks.
Some key points to consider:
- Thiazide diuretics, such as hydrochlorothiazide (HCTZ), chlorthalidone, and indapamide, can increase the risk of gout attacks by raising uric acid levels in the blood.
- Patients with a history of gout or elevated uric acid levels should inform their healthcare provider before starting thiazide diuretics.
- If a patient is taking a thiazide diuretic and experiences symptoms of gout, they should contact their doctor, who may consider alternative blood pressure medications or prescribe medications to prevent gout attacks, such as allopurinol or febuxostat.
- Staying well-hydrated and limiting alcohol and purine-rich foods can also help reduce the risk of gout while on these medications.
- 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 monitoring uric acid levels and considering alternative treatments for patients with a history of gout or elevated uric acid levels 1.
In terms of management, the 2017 updated EULAR evidence-based recommendations for the management of gout suggest that patients with gout should receive advice regarding lifestyle modifications, including weight loss, avoidance of alcohol and sugar-sweetened drinks, and regular exercise 1. Additionally, the use of urate-lowering therapy (ULT) should be considered for patients with recurrent flares, tophi, urate arthropathy, and/or renal stones.
Overall, thiazide diuretics should be used with caution in patients with a history of gout or elevated uric acid levels, and alternative treatments should be considered to minimize the risk of gout attacks.
From the FDA Drug Label
Hyperuricemia Hyperuricemia or acute gout may be precipitated in certain patients receiving thiazide diuretics.
Thiazide diuretics may increase the risk of gout attacks by precipitating hyperuricemia or acute gout in certain patients.
- Key points:
- Thiazide diuretics can precipitate hyperuricemia or acute gout.
- This may lead to an increased risk of gout attacks in certain patients. 2
From the Research
Thiazide Diuretics and Gout Attacks
- Thiazide diuretics have been associated with an increased risk of gout attacks, as evidenced by several studies 3, 4, 5.
- A population-based case-control study found that current use of thiazide diuretics was associated with an increased risk of incident gout, with an adjusted odds ratio (OR) of 1.70 (95% CI 1.62-1.79) 3.
- Another study found that recent use of thiazide diuretics was associated with a significantly increased risk of recurrent gout attacks, with an odds ratio of 3.2 (95% CI not specified) 4.
- A retrospective cohort study found that use of thiazide diuretics in doses of 25 mg/day or higher was associated with a significantly increased risk for initiation of anti-gout therapy, with an adjusted relative risk of 1.99 (95% CI 1.21-3.26) 5.
Mechanism of Thiazide Diuretics and Gout
- Thiazide diuretics can increase the risk of gout by inducing hyperuricemia, which is a result of volume contraction and competition with uric acid for renal tubular secretion 6.
- The use of thiazide diuretics can also lead to hypokalemia, which can increase the risk of gout attacks 6.
Clinical Implications
- The use of thiazide diuretics should be carefully considered in patients with a history of gout, and alternative treatments should be explored if possible 3, 4, 5.
- Combining thiazide diuretics with potassium-sparing diuretics may help to minimize the risk of hypokalemia and hyperglycemia, while also providing effective blood pressure control 7.