What is the recommended dose of Furosemide (Lasix) and Spironolactone for treating ascites?

From the Guidelines

For managing ascites, a typical starting regimen combines Lasix (furosemide) 40 mg once daily with spironolactone 100 mg once daily, with doses adjusted to achieve a weight loss of 0.5-1 kg/day, as recommended by the most recent guidelines 1. The medications should be taken in the morning to avoid nighttime urination. Key points to consider when managing ascites include:

• Starting with spironolactone 100 mg and increasing to 400 mg/day as needed, with furosemide 40 mg added and increased to 160 mg/day if there is a suboptimal response 1
• Monitoring for diuretic adverse events, such as electrolyte imbalance, worsening hypokalaemia, hyperkalaemia, serum creatinine, hepatic encephalopathy, and muscle cramps, and temporarily discontinuing diuretics if necessary 1
• Reducing diuretic dose to the lowest possible once ascites has resolved 1
• Maintaining a salt intake of 5-6.5 g/day and monitoring urine sodium/potassium ratio if there is a suboptimal diuretic response 1 The combination of furosemide and spironolactone works synergistically to manage the sodium and fluid retention that characterizes ascites, with furosemide blocking sodium reabsorption in the loop of Henle and spironolactone blocking aldosterone receptors in the distal tubule, preventing sodium retention and potassium loss. Regular monitoring of electrolytes, particularly potassium, sodium, and renal function, is crucial, as these medications can cause hypokalemia (furosemide) or hyperkalemia (spironolactone), as well as renal impairment. It is also important to note that the maximal diuretic doses are often not achieved in clinical practice, and the doses should be adjusted based on the patient's response and tolerance. Overall, the goal of treatment is to achieve a weight loss of 0.5-1 kg/day, while minimizing the risk of adverse events and maintaining the patient's quality of life.

From the FDA Drug Label

2.4 Treatment of Edema In patients with cirrhosis, initiate therapy in a hospital setting and titrate slowly [see Use in Specific Populations (8. 7)] . The recommended initial daily dosage is 100 mg of spironolactone tablets administered in either single or divided doses, but may range from 25 mg to 200 mg daily.

The recommended dose of spironolactone for ascites due to cirrhosis is 100 mg daily, which can be administered in single or divided doses, and may range from 25 mg to 200 mg daily 2.

• The dose should be titrated slowly in a hospital setting.
• The initial dose is 100 mg daily.
• The dose range is 25 mg to 200 mg daily.

From the Research

Medication Dose for Ascites

The recommended initial dose for treating ascites is:

• Spironolactone: 100-200 mg/d 3
• Furosemide (also known as Lasix): 20-40 mg/d 3

Maximum Doses

The usual maximum doses are:

• Spironolactone: 400 mg/d 3
• Furosemide: 160 mg/d 3

Treatment Approach

The treatment of ascites typically involves:

• Sodium restriction: limiting sodium intake to 2 grams per day 3
• Diuretic therapy: using medications like spironolactone and furosemide to enhance sodium excretion 3, 4, 5, 6, 7
• Large-volume paracentesis: removing excess fluid from the abdominal cavity, often with intravenous albumin infusion 4, 6, 7

Monitoring and Adjustments

Patients with ascites should be monitored for:

• Daily weight changes: aiming for a weight loss of 300-500 g/d in patients without peripheral edema 3
• Serum electrolytes and renal function: to assess the effectiveness and potential adverse effects of diuretic therapy 5