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Hydrochlorothiazide

Class
Diuretics
Subclass
Thiazide diuretics
Substance name
hydroCHLOROthiazide
Common formulations
Tablet, Capsule
Contained in
Amlodipine / valsartan / hydrochlorothiazide (Exforge HCT®)
Eprosartan (Teveten HCT®)
Lisinopril / hydrochlorothiazide (Zestoretic®)
Losartan / hydrochlorothiazide (Hyzaar®)
Olmesartan / amlodipine / hydrochlorothiazide (Tribenzor®)
Olmesartan / hydrochlorothiazide (Benicar HCT®)
Triamterene / hydrochlorothiazide
Valsartan / hydrochlorothiazide (Diovan HCT®)
Dosage and administration
Adults patients
Treatment
Hypertension
•
Maintenance: 12.5-25 mg PO daily
•
Maximum: 50 mg per day
Consider increasing dose based on response.
Alternative
•
Start at: 12.5-25 mg PO daily, in 1-2 divided doses
•
Maintenance: 25-50 mg PO daily, in 1-2 divided doses
Hypertension in pregnancy • Off-label
•
12.5-50 mg PO daily
Adjunctive treatment
Corticosteroid-induced edema
•
25-100 mg PO daily, in 1-2 divided doses
Edema in patients with congestive HF
•
25-100 mg PO daily, in 1-2 divided doses
Alternative
•
Maintenance: 25 mg PO q12-24h
•
Maximum: 200 mg per day
Edema in patients with liver cirrhosis
•
25-100 mg PO daily, in 1-2 divided doses
Estrogen-induced edema
•
25-100 mg PO daily, in 1-2 divided doses
Prevention
Prevention of nephrolithiasis in patients with hypercalciuria • Off-label
•
12.5-50 mg PO q12-24h
Other off-label uses
•
Treatment of hypercalciuria
•
Treatment of nocturnal enuresis
Indications for use
Labeled indications
Adults
•
Treatment of hypertension
•
Adjunctive treatment for corticosteroid-induced edema
•
Adjunctive treatment for edema in patients with congestive HF
•
Adjunctive treatment for edema in patients with liver cirrhosis
•
Adjunctive treatment for estrogen-induced edema
Off-label indications
Adults
•
Treatment of hypercalciuria
•
Treatment of hypertension in pregnancy
•
Treatment of nocturnal enuresis
•
Prevention of nephrolithiasis in patients with hypercalciuria
Safety risks
Contraindications
Hypersensitivity to hydrochlorothiazide or its components or to other sulfonamide derivatives
Anuria
Warnings and precautions
Acute angle-closure glaucoma, acute transient myopia
•
Maintain a high level of suspicion, as hydrochlorothiazide has been associated with an increased risk of acute transient myopia and acute angle-closure glaucoma, especially in patients with a history of sulfonamide or penicillin hypersensitivity.
Decreased serum potassium
•
Use caution in patients with brisk diuresis when severe cirrhosis is present or after prolonged therapy, inadequate oral electrolyte intake, or concomitant use of corticosteroids or ACTH. Consider prescribing potassium-sparing diuretics or potassium supplements to avoid hypokalemia. Monitor serum potassium levels periodically.
Decreased serum sodium
•
Use extreme caution in patients with edema during hot water. Monitor serum sodium levels periodically. Restrict water intake in case of dilutional hyponatremia.
Electrolyte and metabolic abnormalities
•
Maintain a high level of suspicion, as hydrochlorothiazide can cause hyperglycemia, hyperlipidemia, hypercalcemia, and hyperuricemia, potentially precipitating a gout attack in susceptible patients. Monitor serum electrolytes periodically.
Exacerbation of SLE
•
Use caution in patients with SLE.
Hepatic coma
•
Use caution in patients with sever liver disease.
Hypotension
•
Use caution in patients after sympathectomy.
Increased blood glucose
•
Use caution in patients with diabetes or prediabetes. Adjust the doses of insulin and/or other hypoglycemic agents.
Increased serum calcium, decreased serum phosphate
•
Use caution in all patients, especially with hyperparathyroidism or prolonged therapy. Discontinue thiazides before obtaining parathyroid function tests.
Metabolic alkalosis
•
Use caution in patients with renal or hepatic impairment.
Specific populations
Renal impairment
CrCl ≥ 10 mL/min
•
Use acceptable. No dose adjustment required. Monitor renal function. Monitor for electrolyte disturbances.
CrCl < 10 mL/min
•
Do not use.
Renal replacement therapy
Any modality
•
Do not use.
Hepatic impairment
Any severity
•
Use with caution.
Pregnancy and breastfeeding
Pregnancy
All trimesters • Australia Category: C
•
Use only if clearly needed. Evidence of fetal harm in humans. Consider using low doses (12.5-25 mg daily) to minimize metabolic effects, such as impaired glucose tolerance and hypokalemia.
Breastfeeding
Consider alternative agents that may be safer.
Undetectable levels in breastfed infants.
No overt adverse effects reported in breastfed infants.
Some adverse effects on lactation reported.
Adverse reactions
Unknown frequency
•
Acute angle-closure glaucoma, acute pancreatitis, acute transient myopia, anaphylaxis, aplastic anemia, color vision impairment, ↓ WBC count, ↓ platelet count, ↓ serum magnesium, ↑ serum total cholesterol, ↑ serum triglycerides, metabolic alkalosis, ↓ serum sodium, ↑ serum calcium, ↓ serum potassium, ↓ serum phosphate, hemolytic anemia, hepatic encephalopathy, hypersensitivity pneumonitis, ↑ blood glucose, ↑ serum uric acid, interstitial nephritis, jaundice, necrotizing vasculitis, orthostatic hypotension, hypotension, photosensitivity of skin, pulmonary edema, purpura, renal failure, blurred vision, constipation, diarrhea, dizziness, erectile dysfunction, fatigue, weakness, fever, hair loss, erythema multiforme, headache, loss of appetite, muscle spasms, myalgia, nausea, paresthesia, restlessness, skin rash, vertigo, vomiting, Stevens-Johnson syndrome, toxic epidermal necrolysis, urticaria
Interactions
Drug(s)
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