Hyperuricemia Associated with Thiazide Diuretics in Hypertensive Adults

Prescribing cascades of antigout medications from thiazide diuretics in gout-naïve hypertensive adults receiving first-line pharmacological management

Prescribing cascade is a significant clinical problem but is often overlooked. We explore the incidence of the prescribing cascades of antigout medications related to thiazide treatment in gout-naïve hypertensive adults newly exposed to the pharmacological treatment. This population-based, retrospective cohort study used the Taiwan National Health Insurance Registry Database. Gout-naïve hypertensive adults who were newly dispensed first-line antihypertensive drugs between January 1, 2000, and December 31, 2016, were enrolled. Patients were divided into the thiazide group (n = 4192) and the non-thiazide group (n = 81,083). The non-thiazide group included patients who received an angiotensin-converting enzyme inhibitor, angiotensin II receptor blocker, calcium channel blocker, or beta-blocker. The study utilized propensity score matching and multivariable Cox regression models to investigate the prescribing cascade of antigout agents following antihypertensive treatment, adjusting for factors like age, sex, comorbidities, and concurrent medications. After propensity score matching, each group consisted of 4045 patients, with the thiazide group exhibiting a higher risk of being prescribed antigout medications across different time intervals post-treatment initiation. Specifically, adjusted hazard ratios (aHRs) for the thiazide group were 2.23, 2.07, and 2.41 for < 30 days, 31-180 days, and > 180 days, respectively, indicating a sustained and significant risk over time. Comparative analyses revealed thiazide diuretics were associated with a higher risk of antigout medication prescriptions compared to other antihypertensive classes, particularly evident after 180 days. Subgroup analyses across various demographics and comorbidities consistently showed an increased risk in the thiazide cohort. Gout-naïve hypertensive adults newly dispensed thiazide had a higher risk of subsequently adding antigout agents than those taking other first-line antihypertensive medications. The awareness and interruption of these prescribing cascades are critical to improving patient safety.

Giant Tophaceous Gout: The Importance of Therapeutic Compliance

Gout is a metabolic disease resulting from the deposition of monosodium urate crystals in joints, tissues, and organs. Nowadays, the treatment of hyperuricemia is easily accessible and widespread and mainly consists of xanthine oxidase inhibitors and uricosurics. In refractory and advanced cases of gout, amputation surgery may be required. The authors present the case of an 85-year-old man who is non-compliant with hypouricemic medication, has exuberant gout, and has refused amputation surgery several times. The patient went to the emergency department with a triad of acute kidney injuries, acute gout, and poorly controlled pain. Cases of tophaceus gout such as the one presented are very rare nowadays.

Machine Learning Insights Into Uric Acid Elevation With Thiazide Therapy Commencement and Intensification

Background Elevated serum uric acid, associated with cardiovascular conditions such as atherosclerotic heart disease, hypertension, and heart failure, can be elevated by thiazide or thiazide-like drugs (THZ), essential in hypertension management. Identifying clinical determinants affecting THZ-related uric acid elevation is critical. Methods In this retrospective cross-sectional study, we explored the clinical determinants influencing uric acid elevation related to THZ, focusing on patients where THZ was initiated or the dose escalated. A cohort of 143 patients was analyzed, collecting baseline and control uric acid levels, alongside basic biochemical studies and clinical data. Feature selection was conducted utilizing criteria based on mean squared error increase and enhancement in node purity. Four machine learning algorithms - Random Forest, Neural Network, Support Vector Machine, and Gradient Boosting regressions - were applied to pinpoint clinical influencers. Results Significant features include uncontrolled diabetes, index estimated Glomerular Filtration Rate (eGFR) level, absence of insulin, action of indapamide, and absence of statin treatment, with absence of Sodium-glucose cotransporter 2 inhibitors (SGLT2i), low dose aspirin exposure, and older age also being noteworthy. Among the applied models, the Gradient Boosting regression model outperformed the others, exhibiting the lowest Mean Absolute Error (MAE), Mean Squared Error (MSE), Root Mean Squared Error (RMSE) values, and the highest R2 value (0.779). While Random Forest and Neural Network regression models were able to fit the data adequately, the Support Vector Machine demonstrated inferior metrics. Conclusions Machine learning algorithms are adept at accurately identifying the factors linked to uric acid fluctuations caused by THZ. This proficiency aids in customizing treatments more effectively, reducing the need to unnecessarily avoid THZ, and providing guidance on its use to prevent instances where uric acid levels could become problematic.

Current state and prospects of gout treatment in Korea

Effective management of gout includes the following: appropriate control of gout flares; lifestyle modifications; management of comorbidities; and long-term urate-lowering therapy (ULT) to prevent subsequent gout flares, structural joint damage, and shortening of life expectancy. In addition to traditional treatments for gout, novel therapies have been introduced in recent years. Indeed, new recommendations for the management of gout have been proposed by various international societies. Although effective and safe medications to treat gout have been available, management of the disease has continued to be suboptimal, with poor patient adherence to ULT and failure to reach serum urate target. This review outlines recent progress in gout management, mainly based on the latest published guidelines, and specifically provides an update on efficient strategies for implementing treatment, efficacy and safety of specific medications for gout, and cardiovascular outcomes of ULT. In particular, we reviewed gout management approaches that can be applied to a Korean population.

Evaluation of uric acid disorders and associated factors in essential hypertensive patients at Wolkite University specialized hospital, Southern Ethiopia

BACKGROUND

Essential hypertension is a condition characterized by a rise in blood pressure of undetermined cause, includes 90% of all hypertensive cases and is a highly important public health challenge with major modifiable cause of morbidity and mortality. Uric acids disorders in particular hyperuricemia are significant problems in essential hypertensive patients and can cause substantial morbidity and mortality. Determination of uric acid disorders may play a major role in the management and early aversion of complications in hypertensive patient. Therefore, this study aimed to determine uric acid disorders and associated factors among essential hypertensive adults in the outpatient department at Wolkite University specialized Hospital, Southern Ethiopia from November 1 to February 30, 2021.

METHODS AND MATERIALS

An institional based cross sectional study was conducted on 270 essential hypertensive adults on follow-up in outpatient department from November 1 to February 30, 2021. Structured questionnaires through face to face interviews and participants' medical records were used to collect information on determinants related with uric acid disorders. The blood specimen was collected and level of serum uric acid, blood sugar and lipid profile was measured using standard principles and procedures with an ABX Pentra 400 automated chemistry analyzer. Bivariate and multivariate logistic regression analyses were done to identify factors associated with hyperuricemia. The p-value was set at <0.05 with a 95% confidence interval of the adjusted odds ratio.

RESULTS

A total of 270 adult essential hypertensive patients were participated in the study, among those 196(27.4%) of study participants were hyperuricemic with 95%CI (21.9, 33.3). Being alcoholic [(AOR: 15.68, 95% CI: (5.93, 21.41)], taking antihypertensive medication [(AOR: 11.56, 95% CI: (3.94, 23.80)], BMI > = 30 [(AOR: 4.89, 95% CI: (1.46, 25.5)] and being centrally obese [(AOR: 6.87, 95% CI: (2.53, 18.63)] were factors significantly associated with hyperuricemia.

CONCLUSION

In this study, the high burden of hyperuricemia (27.4%) was observed in essential hypertensive patients with follow-up in outpatient department. Taking alcohol and antihypertensive medication, being overweight and centrally obese were identified factors of uric acid disorders. The finding of this study should be taken into consideration to implement preventive interventions on identified predictors in hypertensive patients. Taking fruit and vegetable, and promoting physical exercise and determinations of serum uric acid level in adult essential hypertensive patients was recommended to minimize the emergence of hyperuricemia.

Treatment of Acute Gout Flares in the Emergency Department: Prescribing Patterns and Revisit Rates

BACKGROUND

The incidence and health care costs of gout flares have increased in the United States. The increased costs may be a result of a lack of adherence to treatment guidelines and medication knowledge. Identifying causes for this trend is vital to mitigate inappropriate resource use.

OBJECTIVES

The aim was to identify pharmacotherapy use related to gout treatment before, during hospital visit or stay, and on discharge in patients presenting to the emergency department (ED) with gout flares. Secondary end points included opioid use, revisit rates, and associated risk factors.

METHODS

We performed a retrospective cohort study at a community teaching hospital ED. All consecutive patients visiting the ED from January 2016 to July 2019 with a primary diagnosis of gout flare were included. Data were extracted from the electronic medical records.

RESULTS

The analysis included 214 patients. Anti-inflammatory medication was not prescribed in 33.6% during the hospital visit and 29.6% of patients on discharge. History of opioid use (odds ratio [OR] = 3.3; 95% CI = 1.3-8.6; P = 0.014) and gastroesophageal reflux disease (OR = 3.5; 95% CI = 1.09-10.9; P = 0.035) were associated with opioid prescription on discharge. ED revisits within 90 days for any gout-related or non-gout-related cause were recorded in 16.8% of patients.

CONCLUSION AND RELEVANCE

Roughly 30% of patients did not receive an anti-inflammatory on discharge, and opioids were frequently overused in gout management in the ED. There is an opportunity for further education of health care providers regarding gout treatment.

Hydrochlorothiazide and Indapamide bind the NADPH binding site of bacterial Dihydrofolate Reductase: results of an in-silico study and their implications

Hypertension is a public health concern. Low dose thiazide diuretics are known to effectively control blood pressure compared to that of other classes of antihypertensive drugs. In this context, we have performed an in-silico study and found that the two Sulphonamide Diuretics Hydrochlorothiazide and Indapamide bound the NADPH binding region of bacterial Dihydrofolate Reductase. Therefore, akin to Sulphonamide Antibiotics, Sulphonamide Diuretics may have antibiotic activity and thereby have the potential to modulate the gut microbiome in a way beneficial to vascular health. The in-silico experiment results were analyzed in the context of the relevant literature. We postulate that Sulphonamide Diuretics exert their antihypertensive role by modulating the gut microbiome, specifically by increasing butyrate-producing taxa in the gut. We recommend extending such work as it is plausible that Indapamide and other Sulphonamide Diuretics may be beneficial for both diabetes and hypertension.