What is the role of Lasix (furosemide) and Aldactone (spironolactone) in managing ascites and edema in patients with cirrhosis?

From the Guidelines

Lasix (furosemide) and Aldactone (spironolactone) are essential diuretics used together to manage fluid accumulation in cirrhosis patients, with spironolactone as the primary diuretic, typically started at 100 mg daily and increased as needed to 400 mg daily, and furosemide added as a supplementary diuretic, usually starting at 40 mg daily and increased as needed to 160 mg daily, as recommended by the most recent guidelines 1. The use of these diuretics is based on the pathophysiology of cirrhosis, which involves increased aldosterone levels and sodium retention, leading to fluid accumulation.

• Spironolactone, an aldosterone antagonist, addresses the underlying cause of sodium retention and is the primary diuretic used in the management of ascites in cirrhosis patients.
• Furosemide, a loop diuretic, is added to enhance sodium excretion through a different mechanism in the kidney's loop of Henle, and its use is recommended in combination with spironolactone to achieve a synergistic effect and minimize the risk of complications like electrolyte imbalances or kidney injury. The recommended ratio of spironolactone to furosemide is generally 100 mg to 40 mg, respectively, to maintain electrolyte balance, as supported by recent guidelines 1. Treatment with these diuretics requires careful monitoring of kidney function, electrolytes (particularly potassium), and blood pressure, with dose adjustments to achieve a weight loss of 0.5-1 kg/day, as recommended by the guidelines 1. It is also important to note that diuretics should be used in as small a dose as possible when the ascites is controlled to prevent complications, and should be stopped or reduced in cases of hepatic encephalopathy, hyponatremia, acute kidney injury, or lack of response to treatment, as recommended by the guidelines 1.

From the FDA Drug Label

Spironolactone acts both as a diuretic and as an antihypertensive drug by this mechanism. It may be given alone or with other diuretic agents that act more proximally in the renal tubule. Edematous states in which secondary aldosteronism is usually involved include congestive heart failure, hepatic cirrhosis, and nephrotic syndrome By competing with aldosterone for receptor sites, Spironolactone provides effective therapy for the edema and ascites in those conditions. Furosemide tablets are indicated in adults and pediatric patients for the treatment of edema associated with congestive heart failure, cirrhosis of the liver, and renal disease, including the nephrotic syndrome.

The role of Lasix (furosemide) and Aldactone (spironolactone) in managing ascites and edema in patients with cirrhosis is to provide diuretic therapy.

• Spironolactone is a potassium-sparing diuretic that acts as an aldosterone antagonist, which helps to reduce edema and ascites in patients with cirrhosis by increasing the excretion of sodium and water while retaining potassium 2.
• Furosemide is a loop diuretic that is particularly useful when an agent with greater diuretic potential is desired, and it is indicated for the treatment of edema associated with cirrhosis of the liver 3. Key points:
• Both Lasix (furosemide) and Aldactone (spironolactone) can be used to manage edema and ascites in patients with cirrhosis.
• Spironolactone is often used as first-line therapy for edema and ascites in patients with cirrhosis, while furosemide may be added if necessary to achieve adequate diuresis 2.

From the Research

Role of Lasix and Aldactone in Cirrhosis

• Lasix (furosemide) and Aldactone (spironolactone) are commonly used diuretics in the management of ascites and edema in patients with cirrhosis 4, 5, 6, 7, 8.
• The primary mechanism of action of these diuretics is to enhance sodium excretion, which is essential in treating ascites, as sodium and water retention is the basic abnormality leading to ascites formation 4.

Treatment Guidelines

• The recommended initial dose of spironolactone is 100-200 mg/d, and furosemide is 20-40 mg/d, with maximum doses of 400 mg/d and 160 mg/d, respectively 4.
• Patients with cirrhosis and ascites should limit sodium intake to 2 grams per day, and diuretic therapy should be adjusted based on the patient's response 4.
• Spironolactone alone or in combination with furosemide can be effective in treating moderate ascites in non-azotemic cirrhosis, with similar response rates and safety profiles 6.

Comparison of Furosemide and Spironolactone

• Studies have shown that spironolactone is more effective than furosemide in non-azotemic cirrhosis with ascites, particularly in patients with higher renin and aldosterone levels 8.
• The diuretic response to furosemide and spironolactone is influenced by the activity of the renin-aldosterone system, with spironolactone being more effective in patients with hyperaldosteronism 8.

Refractory Ascites

• Refractory ascites is defined as fluid overload that is unresponsive to sodium-restricted diet and high-dose diuretic treatment, and has a poor prognosis 4.
• Treatment options for refractory ascites include serial therapeutic paracentesis, transjugular intrahepatic stent-shunt (TIPS), peritoneovenous shunt, and liver transplantation, with TIPS being considered in patients who repeatedly fail large-volume paracentesis and have relatively preserved liver function 4.