Here is a question about changing lipids with diuretics and below is my response.

Hi Paul,

I have a 64 yo woman with following lipid profile. Between the two dates, she was diagnosed with severe osteoporosis and started on HCTZ 12.5mg daily for renal Calcium wasting by her endocrinologist. She also started exercising, changed her diet and lost 17 lbs. She and I were both surprised her numbers got worse, not better, with the lifestyle changes. She had a normal TSH last year, but I am checking again. Do you think this could be the HCTZ? Are all thiazides the same? Her endocrinologist increased HCTZ to 25mg b/c still having sig calcium wasting last month.

On 3/11/17, her TC was 182, TGs 183, HDL 72 and LDL direct 91.

On 1/5/19, her TC was 240, TGs 200, HDL 69, and LDL estimated 137.

Between the two dates, she was diagnosed with severe osteoporosis and started on HCTZ 12.5mg daily for renal Calcium wasting by her endocrinologist. She also started exercising, changed her diet and lost 17 lbs. She and I were both surprised her numbers got worse, not better, with the lifestyle changes. She had a normal TSH last year, but I am checking again. Do you think this could be the HCTZ? Are all thiazides the same? Her endocrinologist increased HCTZ to 25mg b/c still having sig calcium wasting last month.

MY RESPONSE — There is often a slight difference between directly measured LDL and the calculated LDL, but when I calculated LDL for both measurements her LDL increased. Here is the skinny:

1. Anything that changes plasma volume can change LDL, so diuretics increased LDL by hemoconcentration. All diruetics do this. Lying down increases total cholesterol about 10% in 30 minutes (Tan. NEJM. 1973) because the fluid from the legs dilutes the LDL. We showed years ago that women have lower LDL just before menstration from plasma expansion (Cullinane EM1, …Herbert PN, Thompson PD. Variations in plasma volume affect total and low-density lipoprotein cholesterol concentrations during the menstrual cycle. Metabolism. 1995 Aug;44(8):965–71).

2. Thiazides also worsen glucose metabolism, which reduces HDL and increases Triglyceride production. Beta blockade does the same thing. Increasing TG production can increase LDL in active people because the active folks make more lipoprotein lipase which converts the VLDL with its TGs to LDL, increasing the LDL level.

So, I suspect that some of her increase is the thiazide from plasma concentration, and the thiazide may have actually negatively some effects of her exercise program.

Paul D. Thompson, MD

Chief of Cardiology — Emeritus, Hartford Hospital

Professor of Medicine, University of Connecticut

Telephone: 860–972–1793

Blog — https://medium.com/@pthomps1947

Twitter — @pauldthompson5