From the Guidelines
The most effective treatment for lower leg edema is compression therapy, with a minimum pressure of 20 to 30 mm Hg, as it reduces venous stasis, improves lymphatic drainage, and increases venous blood flow velocity 1. When using compression therapy, it is essential to consider the severity of the disease, with pressures of 30 to 40 mm Hg recommended for more severe cases 1. The type of compression device used can also impact the effectiveness of treatment, with inelastic compression bandages showing better results than elastic bandaging for wound healing 1. Some key points to consider when implementing compression therapy include:
- Proper fitting and education on the use of compression devices to improve adherence 1
- Graduated compression, with higher pressures at the calf and lower pressures at the distal ankle, to improve ejection fraction and reduce blood pooling 1
- Regular monitoring and adjustment of compression pressures to ensure optimal treatment and minimize the risk of adverse effects 1 It is also important to note that compression therapy may not be sufficient on its own to improve quality of life, and additional treatments may be necessary to address underlying conditions or comorbidities 1.
From the FDA Drug Label
Edema Therapy should be individualized according to patient response to gain maximal therapeutic response and to determine the minimal dose needed to maintain that response. The usual initial dose of Furosemide tablets is 20 to 80 mg given as a single dose. The dose may be raised by 20 or 40 mg and given not sooner than 6 to 8 hours after the previous dose until the desired diuretic effect has been obtained.
The best way to treat lower leg edema is to use Furosemide tablets with a dose that is individualized according to patient response. The usual initial dose is 20 to 80 mg given as a single dose, and the dose may be increased by 20 or 40 mg every 6 to 8 hours until the desired diuretic effect is obtained 2.
- Key considerations:
- The dose should be titrated to achieve the desired effect.
- Careful clinical observation and laboratory monitoring are advisable when doses exceeding 80 mg/day are given for prolonged periods.
- Geriatric patients should be started at the low end of the dosing range.
- Indications: Furosemide tablets are indicated for the treatment of edema associated with congestive heart failure, cirrhosis of the liver, and renal disease 2.
From the Research
Treatment Options for Lower Leg Edema
- Compression therapy is effective for most causes of edema, including chronic venous insufficiency and lymphedema 3, 4.
- Diuretics can be used to treat systemic causes of edema, but their use may be associated with failure to relieve lower extremity swelling despite combined endovascular therapy for chronic venous insufficiency 5.
- Ruscus extract and horse chestnut seed have moderate-quality evidence to improve edema from chronic venous insufficiency 3.
- Pneumatic compression devices or compression stockings may be helpful in cases of lymphedema 4.
Diagnostic Considerations
- Evaluation of lower leg edema should begin with obtaining a basic metabolic panel, liver function tests, thyroid function testing, brain natriuretic peptide levels, and a urine protein/creatinine ratio 3.
- Validated decision rules, such as the Wells and STOP-Bang criteria, can guide decision-making regarding the possibility of venous thromboembolic disease and obstructive sleep apnea, respectively 3.
- Duplex ultrasonography with reflux can help diagnose chronic venous insufficiency in patients with chronic bilateral lower-extremity edema 3.
Special Considerations
- Heart failure is a common comorbidity in patients with lower leg edema, and compression therapy may be safe in patients with stable and compensated heart failure if appropriate precautionary measures are undertaken 6.
- Obstructive sleep apnea may cause bilateral leg edema even in the absence of pulmonary hypertension 4.
- Lymphedema can present in one or both lower extremities, and possible secondary causes include tumor, trauma, previous pelvic surgery, inguinal lymphadenectomy, and previous radiation therapy 4, 7.