From the Guidelines
For a patient presenting with swelling, the most appropriate initial evaluation includes complete blood count, comprehensive metabolic panel, and urinalysis to assess for infection, organ dysfunction, or protein loss, as well as consideration of the underlying cause to guide further testing and treatment. The approach to a patient with swelling should prioritize identifying the underlying cause, as this will significantly influence the choice of diagnostic tests and treatments. Initial laboratory testing may include a complete blood count, comprehensive metabolic panel, and urinalysis to assess for infection, organ dysfunction, or protein loss 1. Additional tests may be considered based on the clinical presentation, such as D-dimer for suspected deep vein thrombosis, brain natriuretic peptide for heart failure, thyroid function tests, and inflammatory markers like C-reactive protein and erythrocyte sedimentation rate.
Treatment of swelling depends on the underlying cause and may involve:
- NSAIDs like ibuprofen (400-600mg every 6-8 hours) or naproxen (250-500mg twice daily) for localized inflammatory swelling.
- Diuretics such as furosemide (20-40mg daily) or hydrochlorothiazide (12.5-25mg daily) for edema from fluid retention.
- Elevation of the affected area, compression garments, and limiting salt intake to less than 2g daily can provide additional benefit.
- For allergic swelling, antihistamines like diphenhydramine (25-50mg every 4-6 hours) or cetirizine (10mg daily) may be effective, with epinephrine (0.3-0.5mg IM) reserved for severe angioedema.
In cases of hereditary angioedema, C1INH concentrates, a plasma kallikrein inhibitor, or a bradykinin B2 receptor antagonist are recommended for the treatment of acute attacks 1. For patients with heart failure, initial diagnostic testing should be limited to those tests necessary to exclude etiologies requiring special therapeutic procedures, and treatment may include intravenous diuretic drugs, nitrates, oxygen, and morphine 1.
Given the variety of potential causes for swelling, a thorough clinical evaluation and targeted diagnostic approach are essential to guide effective treatment and improve patient outcomes. The most recent and highest quality evidence should be consulted to inform treatment decisions, particularly for specific conditions like hereditary angioedema 1 or heart failure 1.
From the FDA Drug Label
Spironolactone tablets are indicated for the management of edema in the following settings: Cirrhosis of the liver when edema is not responsive to fluid and sodium restriction Nephrotic syndrome when treatment of the underlying disease, restriction of fluid and sodium intake, and the use of other diuretics produce an inadequate response.
For a patient presenting with swelling, the indicated treatment is spironolactone.
- 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.
- Lab tests to monitor include serum potassium levels and eGFR, as spironolactone can increase serum potassium and the risk of hyperkalemia is higher in patients with impaired renal function 2.
- Treatment of edema should be initiated in a hospital setting and titrated slowly, especially in patients with cirrhosis 2.
From the Research
Labs Indicated for Swelling
- Complete Blood Count (CBC) to rule out infections or inflammatory conditions 3
- Electrolyte panel to assess sodium, potassium, and chloride levels 3, 4
- Blood Urea Nitrogen (BUN) and creatinine to evaluate renal function 5, 3
- Liver function tests to assess for liver disease 3
- Thyroid function tests to evaluate for thyroid disorders 3
Treatments for Swelling
- Sodium restriction to reduce fluid retention 5, 3, 6
- Diuretic use, such as loop diuretics, to promote fluid excretion 5, 3, 6
- Leg elevation to reduce swelling in the legs 3
- Compression garments and range-of-motion exercises for lymphedema 3
- Spironolactone for patients with New York Heart Association class III and IV congestive heart failure or cirrhosis 3
- Angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers for dihydropyridine-induced edema 3