Hydrochlorothiazide alternatives: what to try when HCTZ isn't right

Hydrochlorothiazide (HCTZ) works for many people, but it can cause low potassium, high uric acid, or poor control for some. If you're having side effects, not getting the blood pressure drop you need, or have specific health issues (like gout or kidney disease), there are clear alternatives. Below I’ll walk through the main drug choices and practical steps to talk about with your prescriber.

Drug alternatives — quick comparison

Chlorthalidone: A thiazide-like diuretic that lasts longer and is often more powerful than HCTZ. Large trials (like ALLHAT) showed strong blood pressure and heart protection. It can lower potassium more, so expect closer monitoring. Typical starting doses are lower than HCTZ, and many doctors use 12.5–25 mg.

Indapamide: Another thiazide-type option. It often causes fewer changes in blood sugar and lipids, so clinicians prefer it for older patients or when metabolic side effects are a concern. It’s effective for lowering systolic pressure in older adults.

ACE inhibitors (e.g., lisinopril): Great if you have diabetes or protein in the urine. They protect the kidneys and lower blood pressure without the potassium loss linked to thiazides. Watch for cough and, rarely, angioedema.

ARBs (e.g., losartan): Similar benefits to ACE inhibitors but with less cough risk. Losartan also has a mild uric-acid–lowering effect, which can help if you have gout—useful when you want to avoid thiazides.

Calcium channel blockers (e.g., amlodipine): Very effective at lowering systolic BP, especially in older adults. They don’t reduce potassium and are often combined with an ACE/ARB or diuretic. Expect possible ankle swelling or flushing.

Beta-blockers and others: Beta-blockers are useful if you have coronary artery disease or certain arrhythmias, but they’re not first choice for simple hypertension in many older adults. Loop diuretics (e.g., furosemide) are better when kidney function is poor or you need fluid removal.

Practical tips: switching, monitoring, and lifestyle

Don’t stop or swap meds without your doctor. When switching, clinicians usually pick a new drug based on other health issues (diabetes, gout, CKD, heart disease). Expect blood tests 1–2 weeks after a change: basic metabolic panel (sodium, potassium, creatinine), and sometimes uric acid or glucose.

Simple habits help a lot: cut sodium, lose a little weight, move more, and follow the DASH-style eating pattern. These steps can lower pressure enough to need a lower drug dose or fewer meds overall.

Watch for signs of low blood pressure or electrolyte problems: dizziness, muscle cramps, increased urination, or irregular heartbeat. Avoid long runs of NSAIDs, which can blunt many blood pressure medicines.

If pregnancy is a concern, thiazides aren’t the go-to choice—doctors often use labetalol or methyldopa instead. Ask your provider what fits your health profile best and how often you need follow-up.

Got questions about a specific medication or a combo pill your doctor suggested? Ask here or bring a list to your next visit—small changes can make treatment safer and more effective.