This is a review of a study which indicates that diuretics cause gout. It is one of a growing number of gout studies that provide evidence of reasons for gouty arthritis.
I have extracted the main ideas from the published gout investigation to present these in a more readable format suitable for unqualified gout sufferers. Inevitably, such scientific reporting will still include technical references. I will refer to my gout glossary for further explanation. If you encounter a term you do not understand, you should search for it using the search box above. If that does not provide an adequate explanation, then please ask in the gout forums, preferably by clicking the “Please tell me” button at the top or bottom of this page.
Diuretics Cause Gout Report Abstract
This is a layman’s summary of:
- Recent diuretic use and the risk of recurrent gout attacks: the online case-crossover gout study.
- Hunter DJ, York M, Chaisson CE, Woods R, Niu J, Zhang Y.
- J Rheumatol. 2006 Jul;33(7):1341-5. Epub 2006 Jun 1.
To assess several supposed risk factors, including thiazide and loop diuretics use, thought to trigger recurring gout attacks.
We conducted an internet-based case-crossover study involving subjects who had a gout attack within the past year. Patients were recruited online and asked to provide access to medical records. Data were obtained on specific diuretic use on each day over the 2-day period prior to a gout flare (hazard period) and on each day of 2 days between gout attacks (control period). We examined the relation of all diuretic use and use of specific diuretics, i.e., thiazide and loop, to the risk of recurrent gout attacks using a conditional logistic regression model adjusting for alcohol consumption and purine intake.
One hundred ninety-seven subjects completed both control and hazard period questionnaires. Participants were predominantly male (80%) and over half had a college education. The average time between onset of gout attack and logging on to the website was 2 days. Adjusting for alcohol consumption and purine intake, the odds ratio (OR) for recurrent gout attacks from all diuretic use over the last 48 h was 3.6 (95% confidence interval 1.4–9.7). OR of recurrent gout attacks were 3.2 and 3.8 for use of thiazide and loop, respectively.
Recent use of diuretics is associated with a significantly increased risk for recurring gouty arthritis. The increased risk of gout attacks from either thiazide or possibly loop diuretic therapies represents an important modifiable risk factor in patients with gout.
Diuretics Cause Gout Report
The report starts with background explanation of increasing incidence of gout, affecting around 1% of Americans[1 – 2]. It notes that gout often recurs, with progressive disability and joint damage[3 – 5]. Many previous studies have investigated risks of the onset of gout ,[6 – 10], but this one focuses on recurring attacks. In particular, it raises the known issues concerning medicines typically supplied for high blood pressure, especially thiazides and loop diuretics[11 – 22].
The gout research team recruited qualifying gout patients via the Internet. Subjects completed questionnaires for one year during gout attacks and gout-free (intercritical) periods. I.e. each case crosses over from one condition to another, eliminating variables introduced by having separate groups of subjects.
In addition to several gout questions, the questionnaires asked about use of other medications:
Did you take any of the following diuretics (‘water pills’) yesterday or the day before yesterday?
- For high blood pressure
- Hydrochlorothiazide or thiazide. Brand names including:
- For heart failure
- furosemide (“loop” diuretics). Brand names including:
- amiloride, spironolactone, or triamterene. Brand names including:
Other factors, such as purine and alcohol intake, were included. This may cloud the issue, but as this is a statistical study, their inclusion is valid[24 – 25].
The results show a big rise in the number of gout attacks when gout patients were taking diuretics compared to periods when they did not take them. The report includes odds ratio data, but my view is that such a detailed statistical view is not necessary here. We can see clearly that these diuretics are a reason for gout. Therefore, it makes sense to ask your doctor for an alternative treatment.
The report ends with a discussion of the points raised by the investigation. Most of these are of interest to the scientific community, but not valuable to the gout sufferer[26 – 28]. The significant point is that the problem of diuretics for gout sufferers is easily overcome because there are widely available alternatives.
The gout report concludes:
In summary, we found that recent use of thiazide and possibly loop diuretics was associated with a significantly increased risk for recurrent gouty arthritis. Despite the well-known association of gout and diuretics, a relatively large proportion of our patient population with preexisting gout was prescribed this class of antihypertensive therapy. Given the wide availability of alternative effective agents for the treatment of hypertension and congestive heart failure, clinicians have ample ability to individualize management for this population. So they could reduce the risk of recurrent gout attacks by avoiding the use of thiazide and possibly loop diuretics in persons with preexisting gout.
Diuretics Cause Gout: Next Steps
As you can see, diuretics are bad for gout. In extreme cases, they may be the sole cause of your gout, and changing your medication may be the only thing you need to do.
Do not stop taking them without consulting your doctor. There are many alternatives to diuretics for treating high blood pressure and heart disease. It is important to get your uric acid tested and ensure that you get it down to 5 mg/dL (0.30 mmol/L) or below. If switching diuretics to something else does not lower your uric acid low enough, then you should arrange for uric acid treatment. Details are in the Gout Treatment pages, and if you need personal help to understand your options, please ask in the gout forum.
Leave Diuretics Cause Gout to browse more evidence for causes of gouty arthritis.
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Common Terms: Most Helpful Gout Pages, patient, Reasons for Gout Set
Other posts that include these terms:
- High Alkaline Foods for Gout Diet Menu
- Gout Foods Table for Vegetables
- Gout Food List for GoutPal Foodies
- Foods High in Uric Acid Chart
- Purine Rich Foods
- Does Alcohol Affect Gout?
- Colchicine For Gout
Diuretics Cause Gout References
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|Gout: on the brink of novel therapeutic options for an ancient disease.||Bieber JD, Terkeltaub RA.||Arthritis Rheum 2004;50:2400-14.|
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|Review: systemic toxicity associated with the intravenous administration of colchicine — guidelines for use.||Wallace SL, Singer JZ.||J Rheumatol 1988;15:495-9.|
|Incidence and risk factors for gout in white men.||Roubenoff R, Klag MJ, Mead LA, Liang KY, Seidler AJ, Hochberg MC||JAMA 1991;266:3004-7.|
|Racial differences in the incidence of gout. The role of hypertension.||Hochberg MC, Thomas J, Thomas DJ, Mead L, Levine DM, Klag MJ.||Arthritis Rheum 1995;38:628-32.|
|Asymptomatic hyperuricemia. Risks and consequences in the Normative Aging Study.||Campion EW, Glynn RJ, DeLabry LO.||Am J Med 1987;82:421-6.|
|Alcohol intake and risk of incident gout in men: a prospective study.||Choi HK, Atkinson K, Karlson EW, Willett W, Curhan G.||Lancet 2004;363:1277-81.|
|Purine-rich foods, dairy and protein intake, and the risk of gout in men.||Choi HK, Atkinson K, Karlson EW, Willett W, Curhan G.||N Engl J Med 2004;350:1093-103.||High Purine Foods|
|Chlorothiazide (Diuril) as a hyperuricacidemic agent.||Oren B, Rich M, Belle M.||JAMA 1958;168:2128-9.|
|Physiologic and clinical observations on furosemide and ethacrynic acid.||Laragh JH, Cannon PJ, Stason WB, Heinemann HO.||Ann NY Acad Sci 1966;139:453-65.|
|Obesity, weight change, hypertension, diuretic use, and risk of gout in men: the health professionals follow-up study.||Choi HK, Atkinson K, Karlson EW, Curhan G.||Arch Intern Med 2005;165:742-8.||Obesity And Gout|
|Thiazide diuretics and the initiation of anti-gout therapy.||Gurwitz JH, Kalish SC, Bohn RL, et al.||J Clin Epidemiol 1997;50:953-9.|
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|Incidence of diabetes and gout in hypertensive patients during 8 years of follow-up. The General Practice Hypertension Study Group.||Grodzicki T, Palmer A, Bulpitt CJ.||J Hum Hypertens 1997;11:583-5.|
|Hypertension in the metabolic syndrome and diabetes: pathogenesis, clinical studies, and treatment.||Izzo JL Jr.||J Clin Hypertens 2003;5 Suppl 4:3-10.|
|Guidelines for antihypertensive treatment: an update after the ALLHAT study.||Salvetti A, Ghiadoni L.||J Am Soc Nephrol 2004;15 Suppl 1:S51-S54.|
|Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000.||Hajjar I, Kotchen TA.||JAMA 2003;290:199-206.|
|Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.||Chobanian AV, Bakris GL, Black HR, et al.||Hypertension 2003;42:1206-52.|
|Top 200 most prescribed drugs of 2003.||Mosby’s Drug Consult.||New York: Elsevier; 2003.|
|Preliminary criteria for the classification of the acute arthritis of primary gout.||Wallace SL, Robinson H, Masi AT, Decker JL, McCarty DJ, Yu TF.||Arthritis Rheum 1977;20:895-900.|
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|Evaluation of renal handling of uric acid in essential hypertension: hyperuricemia related to decreased urate secretion.||Tykarski A.||Nephron 1991;59:364-8.|
|The phlogistic potential of urate in solution: studies of the phagocytic process in human leukocytes.||Malawista SE, Van Blaricom G, Cretella SB, Schwartz ML.||Arthritis Rheum 1979;22:728-36.|
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If diuretic-induced gout occurs, it is usually treated with a urate-lowering drug such as allopurinol.
- Diuretics (see below)
- Aspirin low dose (less than 300 mg daily)
- Nicotinic acid.
A dose of ≥50 mg of hydrochlorothiazide or chlorthalidone led to an average increase of 1.53 mg/dL of uric acid in one study, and in several other studies of hydrochlorothiazide 25 mg, an average increase of 0.8 mg/dL was observed.
Furosemide (20 mg) decreased the urinary excretion of uric acid by 40% (P < . 01), oxypurinol by 39% (P < . 05), and xanthine by 43% (P < . 05) and the fractional clearance of uric acid by 45% (P < .
Diuretics, particularly thiazide diuretics, are associated with an increase in serum urate levels (3–6). Moreover, hyperuricemia is the leading risk factor for gout (7).
Answer From April Chang-Miller, M.D. Yes. Diuretics can increase your risk of developing gout, a type of arthritis caused by the buildup of uric acid crystals in a joint. This may happen because diuretics increase urination, which reduces the amount of fluid in your body.
Thiazides may be used in patients with asymptomatic hyperuricemia because they are not associated with an increased risk of gout in these patients.
- Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs include over-the-counter options such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve), as well as more-powerful prescription NSAIDs such as indomethacin (Indocin, Tivorbex) or celecoxib (Celebrex). ...
- Colchicine. ...
It is known that some antihypertensive agents, such as thiazide, increase serum uric acid levels, while other medications, including losartan, fenofibrate, and sodium–glucose cotransporter-2 (SGLT2) inhibitors, decrease serum uric acid levels.
What causes gout? Gout is caused by a condition known as hyperuricemia, where there is too much uric acid in the body. The body makes uric acid when it breaks down purines, which are found in your body and the foods you eat.
Lesinurad works in a novel way to lower blood levels of uric acid, a bodily waste product responsible for gout.
Our results showing increased XOR activity with omeprazole is consistent with increased conversion of hypoxanthine to xanthine and xanthine to uric acid in patient taking omeprazole, thus increasing the risk of acute gout.
Allopurinol is a medicine used to lower levels of uric acid in your blood. If you produce too much uric acid or your kidneys do not filter enough out, it can build up and cause tiny, sharp crystals to form in and around your joints. Allopurinol is used to treat gout and kidney stones.
If you're taking a diuretic such as furosemide, it's important not to have too much salt in your food because this can stop it working. Do not eat foods that have a lot of salt in them, such as processed foods or ready-meals. Do not add extra salt when you're cooking or at the table.
A high-salt diet has been found to lower blood levels of uric acid, a recognised trigger of gout, according to a study by US researchers.
Diuretics are one of the most important causes of secondary hyperuricaemia. The use of loop diuretics, thiazide diuretics and thiazide-like diuretics was associated with an increased risk of incident gout [5, 6].
Do not use aspirin, because it can alter uric acid levels and potentially prolong and intensify an acute attack. Low-dose aspirin alters uric acid levels, increasing the risk of gout attacks and requiring close uric acid monitoring when aspirin is added to a uric acid/gout treatment regimen.
Beer and distilled liquors are associated with an increased risk of gout and recurring attacks. Moderate consumption of wine doesn't appear to increase the risk of gout attacks. Avoid alcohol during gout attacks, and limit alcohol, especially beer, between attacks. Sugary foods and beverages.
Diuretics lessen swelling that usually happens in the legs. High blood pressure. Thiazide diuretics lower blood pressure. That lowers your chance of a stroke or heart attack.
Statins Differ with Respect to Gout:
We did some sleuthing, though and discovered that while atorvastatin (Lipitor) lowers uric acid levels (a cause of gout), pitavastatin (Livalo) may actually raise these levels (Nucleosides, Nucleotides & Nucleic Acids, June, 2010).
Nonsteroidal anti-inflammatory drugs and colchicine are recommended first-line treatments for acute gouty arthritis attacks. However, in patients with CKD, nonsteroidal anti-inflammatory drugs are not recommended because their use can exacerbate or cause acute kidney injury.
A loop diuretic is generally the diuretic of choice in patients with renal insufficiency. Although a thiazide-type diuretic will initiate diuresis in patients with mild renal insufficiency, the response in patients with a GFR of <50 ml/min/1.73 m2 is less than that seen with a loop diuretic.
Diuretics (both loop agents and thiazides) can increase SU levels but also interfere with allopurinol, enhancing the renal clearance of its active metabolite oxypurinol and increasing the dose needed to ensure effectiveness .
There is no proof that consuming or using apple cider vinegar can help prevent or treat gout. However, certain chemicals in apple cider vinegar, namely acetic acid, may lower the risk of developing conditions that can increase the likelihood of gout, such as obesity, diabetes, and high blood pressure.
Cranberry juice or extract helps to increase the clearance of uric acid from the body. Uric acid causes gout. It is a waste product in the blood that becomes stuck in joints and forms painful uric acid crystals.
Bananas are low in purines and high in vitamin C, which makes them a good food to eat if you have gout. Changing your diet to include more low-purine foods, like bananas, can lower the amount of uric acid in your blood and reduce your risk of recurrent gout attacks.
A growing body of evidence indicates that serum zinc may be associated with the level of serum uric acid. A report revealed that oral zinc therapy can produce an improvement in hypouricemia in patients with Wilson's disease by increasing uric acid synthesis in the liver .
“More than 70 percent of people with gout have high blood pressure,” Juraschek says. “If one was to consume more sodium to improve uric acid, it could worsen blood pressure.”
Hyperuricemia is common in people who present with primary hypertension, and tends to be especially common in those with accelerated (or malignant) hypertension. Some of the hyperuricemia might represent coexistent CKD or the use of thiazide diuretics that increase serum uric acid levels.
Drink at least 10-12 eight-ounce glasses of non-alcoholic fluids daily, especially if you have had kidney stones. This will help flush the uric acid crystals out of your body.
Eat: Citrus Fruits
Grapefruit, oranges, pineapples, and strawberries are all great sources of vitamin C, which lowers your uric acid levels and helps prevent gout attacks.
- Drinking plenty of water. When a person has gout, they can experience significant swelling and inflammation. ...
- Applying ice to affected joints. ...
- Reducing stress. ...
- Elevating the affected joints. ...
- Taking over-the-counter pain relievers. ...
- Drinking coffee. ...
- Eating a balanced diet. ...
- Drinking lemon water.
The drugs of first choice for acute gouty arthritis are nonsteroidal anti-inflammatory drugs (NSAID), corticosteroids, and colchicine. Treatment with xanthine oxidase inhibitors (XOI) or uricosuric drugs is indicated for patients with a recurrent or severe course; the target uric acid value is <6 mg/dL.
Allopurinol is used for the long-term treatment and prevention of gout. Taken regularly, it can stop attacks of gout and help prevent damage to your joints. Gout occurs in people who have high levels of urate in their blood.
Allopurinol (Zyloprim) is the recommended first-line agent for urate-lowering therapy.
Fructose is a “simple sugar” found in honey, fruit, some vegetables and sweeteners. Fructose increases purine metabolism, raising blood uric acid levels. Avoid sweeteners high in fructose such as honey, brown sugar, high-fructose corn syrup, golden syrup and palm sugar.
Uric acid is known to contribute to endothelial dysfunction by impairing nitric oxide production, which could lead to damage to the heart. Another possibility is that high uric acid levels cause inflammation that eventually result in heart failure.
Our findings suggest that the increase in plasma uric acid noted with warfarin administration is probably due to an increase in uric acid production and may predispose to gout those patients who are on long-term therapy with warfarin.
Exercises that work the body's cardiovascular system are best for managing uric acid levels and help to manage body weight ( 4 ). Examples of these types of exercises include walking, cycling, and swimming.
For milder gout pain, an over-the-counter (OTC) pain reliever, such as Tylenol (acetaminophen ) can ease some pain. Keep in mind that people with kidney disease should avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs), including Advil (ibuprofen) and Bayer (aspirin).
Therapeutic Flare-Up Relief Cream with Arnica Extract, Ilex Leaf Extract, Aloe Vera and Tea Tree Oil will provide you with immediate, lasting and quick relief! Cream is non-greasy, non-staining and fast absorbing that will get you back on your feet!
Moreover, furosemide increased the plasma concentration of uric acid by 6% at 1.5 hours after administration. These results indicate that furosemide may decrease the urinary excretion of uric acid and oxypurinol by acting on their common renal transport pathway(s).
Furosemide is included in the World Anti-Doping Agency's (WADA) list of prohibited substances because it can be used by athletes to mask the presence of performance-enhancing drugs in urine and/or excrete water for rapid weight loss.
Sweet potatoes are a great source of dietary fibre, helping to keep the digestive system healthy and regular. Gout sufferers may want to take it easy on how much sweet potato they eat however, as they contain oxalates which, when eaten in excess, could potentially cause kidney stones.
The management of gout is focused on decreasing uric acid levels. Medication can be effect at doing this, but also avoiding anything that may increase uric acid levels (or the body's ability to excrete uric acid) can be helpful as well. Carbohydrates such as bread, pizza, and pasta do not increase uric acid levels.
Modifiable risk factors for gout include obesity, the use of certain medications, high purine intake, and consumption of purine-rich alcoholic beverages.
Conclusion: The interaction between allopurinol and furosemide results in increased SU and plasma oxypurinol. The exact mechanisms remain unclear but complex interactions that result in attenuation of the hypouricaemic effects of oxypurinol are likely.
Laxatives, oral antidiabetic agents, non-steroidal anti-inflammatory drugs, adenylate cyclase activators, mineralocorticoids, hypolipidaemic agents, neuromuscular blockers, chloral hydrate, carbenoxolone, drugs likely to produce the syndrome of inappropriate secretion of antidiuretic hormone and some antibiotics may be ...
medicines used to treat mental health problems, such as amisulpride, lithium, pimozide or risperidone. painkillers known as non-steroidal anti-inflammatory drugs (NSAIDs), including diclofenac, ibuprofen or naproxen. medicines that treat high blood pressure, or those that have a side effect of low blood pressure.
Some medicines and allopurinol can interfere with each other and increase the chances of you having side effects. Tell a doctor or pharmacist if you're taking any of these medicines before you start taking allopurinol: aspirin or medicines used to thin your blood (anticoagulants), such as warfarin. any antibiotics.
Side effects include increased urination and sodium loss. Diuretics can also affect blood potassium levels. If you take a thiazide diuretic, your potassium level can drop too low (hypokalemia), which can cause life-threatening problems with your heartbeat.
Don't take diuretics if you have trouble urinating, or if you're allergic to the active or inactive ingredients found in the medication. Ask your doctor if you should avoid or be cautious using diuretics if you: Have severe liver or kidney disease. Are dehydrated.
Conclusion: Withdrawal of long-term diuretic treatment in elderly patients leads to symptoms of heart failure or increase in blood pressure to hypertensive values in most cases. Any attempt to withdraw diuretic therapy requires careful monitoring conditions, notably during the initial four weeks.
Diuretics are banned in all sports because they can cause rapid weight loss and can act as masking agents (to hide the effects of other prohibited substances) both in and out of competition.
Water pills can affect your routine.
Your kidneys will make more urine (pee). You will need to use the bathroom more often. To avoid getting up at night, take your medication at least six hours before bedtime.
Replenish Depleted Nutrients
Until more is known, it has been suggested that people taking potassium-depleting diuretics, including thiazide diuretics, should supplement both potassium and magnesium.