Unfortunately, the commonly prescribed diuretic hydrochlorothiazide can disturb electrolytes, uric acid, sugars, and fats in the blood. For this reason, a lot of people with mild symptoms turn to natural diuretics. Read on to learn more, including a breakdown of the best natural alternatives and how effective they are.
Disclaimer: By writing this post, we are not recommending this drug. Some of our readers requested that we commission a post on it and we are providing a summary of the information available in the scientific and clinical literature, along with a list of evidence-based natural alternatives. Please discuss your medications with your doctor.
Hydrochlorothiazide is a diuretic mainly used for high blood pressure and water retention. It belongs to the class of thiazide diuretics (or benzothiadiazines). Thiazide diuretics promote the flushing of sodium and water in urine by blocking sodium uptake in the kidneys [1, 2, 3].
Hydrochlorothiazide has become the most commonly prescribed drug for high blood pressure since it was launched in 1959. In 2008, almost 48 million prescriptions for hydrochlorothiazide alone and over 87 million for its combination with other drugs were written in the US. Of these, 97% were for low-dose (12.5 or 25 mg/day) hydrochlorothiazide .
Hydrochlorothiazide is approved by the FDA for treating :
- High blood pressure
- Water retention (edema) due to kidney failure, heart failure, liver damage (cirrhosis), and corticosteroid or estrogen therapy
Although not approved by the FDA, doctors may prescribe hydrochlorothiazide for the following conditions :
- Kidney stones
- Diabetes insipidus
- Ménière’s disease, a disorder of the inner ear
- Acid buildup in the body from kidney dysfunction (renal tubular acidosis)
An important drawback of thiazide diuretics is an increased potassium excretion, which may alter the heart rate and cause serious complications. Their combination with potassium-sparing diuretics (triamterene, amiloride, spironolactone) can prevent this adverse effect .
For more about hydrochlorothiazide, how it works, and what it’s prescribed for, check out this post.
Hydrochlorothiazide may cause different side effects. Consult your doctor if these effects are severe or mild but persistent and carefully follow their recommendations.
- Muscle pain and cramps
- Irregular heart rate
- Constipation and reduced urine production
- Disturbed blood sugar balance
- Increased thirst and dry mouth
Potassium deficits are more common in women and increase the risk of heart disease. Hydrochlorothiazide was associated with potassium deficits in observational studies on over 36,000 people with high blood pressure [8, 9, 10, 11].
Potassium deficits can be compensated by taking potassium salts. In 3 clinical trials on 55 people on hydrochlorothiazide, potassium-magnesium-citrate prevented potassium deficits (unlike potassium chloride) [12, 6, 13].
Another option is combining hydrochlorothiazide with potassium-sparing diuretics such as:
Very high blood calcium can cause :
- Nausea, vomiting, stomach pain
- Excessive thirst
- Muscle weakness and fatigue
- Numbness and confusion
High blood calcium is a long-known side effect of hydrochlorothiazide. In an observational study on 22 people with high blood pressure taking hydrochlorothiazide long-term (2 – 12 years), 36% developed high blood calcium levels [36, 37, 38].
Severely high blood calcium is more likely with high doses of hydrochlorothiazide, especially in combination with calcium supplements and vitamin D or in those with specific health conditions (hyperparathyroidism and sarcoidosis) [35, 39, 40, 41, 42].
Hydrochlorothiazide is well known to increase blood calcium, which may be beneficial in people with osteoporosis, and may be detrimental if blood calcium increases too dramatically.
- Muscle weakness and cramps
- Nausea, vomiting, lack of appetite
- Confusion, memory loss, and sleepiness
The risk increases in combination with:
- Potassium-sparing diuretics (triamterene, amiloride) [49, 50]
- Angiotensin II receptor blockers (losartan, olmesartan, telmisartan) [51, 52, 53]
- Anti-seizure medication (carbamazepine) 
- Antidepressants (paroxetine, sertraline) 
Long-term hydrochlorothiazide therapy reduces the production of a protein responsible for magnesium uptake in the kidneys (Trpm6). This may lead to magnesium deficiency, which in severe cases can cause [56, 57]:
- Muscle cramps, tremors, and seizures
- Irregular heartbeat
- Low blood levels of calcium, potassium, and the parathyroid hormone
- Delirium, and even coma
In an observational study on almost 250 people on hydrochlorothiazide (50 mg/day), almost 20% developed low magnesium levels. Magnesium supplements (such as a potassium-magnesium-citrate formula) could correct the deficiency in most cases .
Hydrochlorothiazide use was linked to an increased risk of diabetes, especially in obese people, in an observational study on almost 400 people .
Diuretics may raise blood levels of total cholesterol, LDL-cholesterol, and triglycerides, increasing the risk of heart disease and stroke. Hydrochlorothiazide specifically can increase triglycerides and cholesterol levels, as seen in 2 clinical trials on over 700 people [66, 67, 68, 69].
In rare cases, hydrochlorothiazide therapy followed by sun exposure may cause skin conditions such as:
- Rash [70, 71, 72]
- Redness and sunburn-like eruptions [71, 73, 74]
- Blistering and swelling [75, 76]
- Skin lupus [77, 78, 79, 80]
- Decreased skin pigmentation 
- Skin fragility 
- Lip inflammation 
Other reported adverse effects of hydrochlorothiazide therapy include:
- Fluid buildup in the lungs [93, 94, 95]
- Allergic reactions [96, 97, 98]
- Fever [99, 100]
- Acute respiratory distress syndrome (ARDS) 
- Diabetes insipidus 
- Heart inflammation 
- Hearing disorders 
- Impotence 
Hydrochlorothiazide increases the frequency of urination. To avoid having to get up at night to go to the toilet, it’s better not to take it in the evening.
According to the FDA, the risk of hydrochlorothiazide use during pregnancy cannot be ruled out (category C). Thus, it is recommended in pregnancy only if its potential benefits outweigh the risks .
Small amounts of hydrochlorothiazide can pass into breast milk. Breastfeeding women should consult their doctors before taking hydrochlorothiazide .
Because elderly people may break down and excrete hydrochlorothiazide slower, they may need a lower dose or a different dosing schedule .
Hydrochlorothiazide is excreted through the kidneys. People with kidney failure should take hydrochlorothiazide with caution, since the drug may build up in their body and cause adverse effects .
Hydrochlorothiazide may worsen the following conditions and should be taken with caution by people who suffer them:
Importantly, hydrochlorothiazide should be avoided by people with the following conditions:
To help avoid interactions, your doctor should manage all of your medications carefully. Be sure to tell your doctor about all medications, vitamins, or herbs you’re taking. Talk to your healthcare provider to find out how hydrochlorothiazide might interact with something else you are taking.
Hydrochlorothiazide may enhance the blood pressure-lowering effect of drugs such as:
- Renin-angiotensin system blockers (zofenopril, losartan, atenolol, aliskiren) [114, 115, 116]
- Calcium channel blockers (amlodipine) 
- Anti-anxiety drugs (phenobarbital) 
- Sedatives (morphine, codeine) 
- Alcohol 
This can be desirable in some cases (e.g., fixed-dose combinations with renin-angiotensin system blockers) but may cause blood pressure to drop too much in others.
The effects of hydrochlorothiazide on water, electrolyte, and uric acid excretion may be enhanced in combination with drugs such as:
- Carbonic anhydrase blockers (acetazolamide) 
- Loop diuretics (furosemide) 
- Potassium-sparing diuretics (triamterene, amiloride, spironolactone) [122, 19]
- Vasopressin blockers (tolvaptan) 
- Anti-gout medication (probenecid) 
Hydrochlorothiazide increases lithium uptake in the kidneys, which raises its concentration in the blood and slows its elimination. Indeed, several cases of lithium intoxication due to hydrochlorothiazide use have been reported [125, 126].
Anti-inflammatory glucocorticoids such as prednisone have a strong diuretic effect. Their combination with hydrochlorothiazide may cause an excessive loss of electrolytes, especially potassium [130, 131].
The blood pressure-lowering effect of hydrochlorothiazide may be reduced in people taking NSAID anti-inflammatory drugs such as naproxen or ibuprofen .
These are some substances and herbs that have some of the same mechanisms of action hydrochlorothiazide. You may try the herbal remedies listed below if you and your doctor determine that they could be appropriate. None of them should ever be done in place of what your doctor recommends or prescribes.
Most importantly, these substances haven’t been sufficiently tested. The effects of horsetail, black cumin, dandelion, coffee, and pomegranate have been evaluated in few clinical trials with small numbers of people, while those of tea, garlic, caraway, parsley, raspberry, and oregano have only been tested in animals. Additionally, only roselle and horsetail have been compared to hydrochlorothiazide in humans, each one in one clinical trial [133, 134].
To sum up, while some of these remedies may help in people with mild symptoms of high blood pressure and water retention, none of them can be considered a realistic alternative to hydrochlorothiazide based on the existing evidence.
Roselle (Hibiscus sabdariffa) tea is used worldwide for high blood pressure. This species of Hibiscus contains two polyphenols identified as ACE inhibitors and the flavonoid quercetin, which contributes to blood vessel relaxation [135, 136, 137].
Roselle tea 1x – 2x/day for up to 6 weeks lowered blood pressure in 3 clinical trials on almost 200 people with moderately high blood pressure, but only caused a slight effect in another (on 75) [138, 139, 140, 141].
In a clinical trial on 80 people with mildly high blood pressure, roselle tea (150 mg/kg per day) was more effective than hydrochlorothiazide (25 mg/day) at lowering blood pressure and didn’t cause sodium, potassium, and chloride imbalance .
In rats and rabbits, the combination of roselle extract (20 – 40 mg/kg) with hydrochlorothiazide (10 mg/kg) increased urine production and reduced sodium, chloride, and bicarbonate excretion. Because it also slowed hydrochlorothiazide elimination, the combination may not be safe .
Roselle has also been traditionally used for kidney stones. One clinical trial on 18 men found that roselle tea increased uric acid excretion, while the extract decreased the buildup of stone-forming substances in the kidneys (such as calcium and oxalate) in rat studies [143, 144, 145, 146].
Horsetail (Equisetum spp.) has long been used as a diuretic and is currently sold as a tea and in capsules for this purpose. In a clinical trial on 25 healthy people, the extract of the Andean horsetail (0.75 g/day for 2 days) had diuretic effects. It slightly increased sodium, potassium, and chloride flushing .
In a clinical trial on 36 healthy men, 900 mg/day of field horsetail (Equisetum arvensis) extract had the same diuretic effect as 25 mg hydrochlorothiazide but a much lower risk of potassium and sodium deficits .
In a study in rats, the extracts of four different Mexican horsetail species (Equisetum fluviatile, E. hiemale var. affine, E. giganteum, and E. myriochaetum) were as effective as hydrochlorothiazide and had a similar mechanism of action .
Caution: Horsetail should be avoided by people with HIV, since it reduced the effect of antiviral drug combinations (lamivudine/ zidovudine/efavirenz and emtricitabine/tenofovir) in two cases .
Black cumin (Nigella sativa) has been traditionally used for cooking and to improve a wide range of diseases, including high blood pressure .
In a clinical trial on 76 elderly people with high blood pressure, black cumin seed extract (300 mg 2x/day) only caused a very mild reduction in blood pressure .
In a study in rats, black cumin oil (5 ml/kg for 28 days) reduced blood and urine levels of calcium, phosphate, and oxalate. It increased urine production and reduced the risk of developing kidney stones. Both black cumin extract and its main active compound (thymoquinone) reduced calcium oxalate buildup in rat kidneys [154, 155, 156].
Dandelion (Taraxacum officinale) and related plants have been cherished for their diuretic benefits in both traditional Chinese and Ayurvedic medicine for over 2,000 years. Its potassium-rich leaves may account for its diuretic activity [157, 158].
A commercial dandelion leaf extract (8 mL 3x/day) increased urination in a clinical trial on 17 people .
Moderate doses of caffeine (at least 300 mg) increase urination in people who don’t drink coffee regularly. In contrast, a moderate coffee intake (4 mg/kg caffeine 4x/day) had no effect on water balance in a clinical trial on 52 men used to the effects of caffeine [163, 164].
Some people are sensitive to caffeine, while coffee can also worsen inflammation. For these reasons, we don’t generally recommend coffee as a diuretic for most people.
In a clinical trial on 30 people, pomegranate extract reduced calcium oxalate buildup in urine, which might prevent kidney stones. In rats, pomegranate extract reduced kidney damage and the buildup of calcium, oxalate, and phosphate in the urine [165, 166].
Scientists are also investigating the effectiveness of other natural substances traditionally used as diuretics or for kidney stones. Because the research is still at the animal and cell stage, there is no evidence to support their purported benefits.
Both black (300 – 2,400 mg/kg) and green tea (100 – 500 mg/kg) had diuretic effects in two studies in rats. The combination of green tea with hydrochlorothiazide (10 mg/kg) increased the effects and reduced potassium loss [167, 168].
Garlic extract acted as a diuretic in animals, increasing urine production. In dogs, it also reduced blood pressure, slowed heart rate, and increased sodium and chloride flushing [173, 174, 175, 176, 177].
Caraway (Carum carvi) is a spice that has long been traditionally used for high blood pressure, water retention, and digestive disorders in countries such as Morocco and India .
In rats, caraway extract (100 mg/kg) was as effective as the diuretic furosemide (10 mg/kg) at increasing urine production. The extract also enhanced sodium and potassium flushing .
Parsley (Petroselinum sativum) has been used as a diuretic in folk medicine for centuries. Although no studies have been done in humans, parsley extract increased urine production in 2 studies in rats [180, 173].
Raspberry is a popular fruit with the capacity to release kidney stones from the urinary tract. In animal studies, raspberry extract increased urine production, reduced the oxalate, calcium, and phosphorus buildup in the urine. Overall, it helped prevent kidney stones [143, 181, 182].
Oregano is a spice that has traditionally been used for water retention and kidney stones. In rats, oregano extract prevented kidney stone formation. It also reduced stone-forming calcium oxalate crystals in test tubes .
Hydrochlorothiazide is a diuretic mostly used to treat high blood pressure and water retention. Side effects such as mineral (sodium, potassium, or magnesium) deficiency, high blood calcium, high blood uric acid, increases in blood fats and sugars, skin sensitivity to light, and even vision problems are not uncommon.
Many natural alternatives to hydrochlorothiazide exist. Natural remedies will most benefit people with mildly increased blood pressure or slight water retention. Herbs such as Roselle, horsetail, and black cumin are safe diuretics that support general wellness. However, they should never be used in place of something your doctor recommends or prescribes.