Can I continue to use a diuretic to treat hypertension in a patient with hyperuricemia and add allopurinol (Zyloprim) for his uric acid elevation?
—Masoud Shahidi, MD, Dedham, Mass.
It would be preferable to use a calcium channel blocker rather than a diuretic. However, if the calcium channel blocker doesn’t do the job and a diuretic is needed, a diuretic should definitely be prescribed. The lowest effective dose should be employed. Studies are not good enough to say that one class of diuretics is a worse offender than another. Loop diuretics seem more benign, but they were studied in patients with heart failure whereas thiazides were studied in hypertensive patients, so results should not be extrapolated. We can say only that if the dose of any diuretic used in treating hypertensive patients is sufficient to reduce intravascular volume, uric acid will increase.
Asymptomatic hyperuricemia need not be treated pre-emptively. However, if gout develops and recurs, allopurinol should be added. The strategy of adding a second medication to combat the side effect of the first medication seems undesirable, but in many cases, hypertension cannot be controlled without a diuretic, and the diuretic should not be withheld.
—Samuel J. Mann, MD (105-10)