What is the treatment for ascites?

From the Guidelines

Treatment for ascites involves a combination of dietary sodium restriction, diuretics, and addressing the underlying cause, with the primary medication regimen including spironolactone and furosemide, as recommended by the most recent guidelines 1. The management of ascites requires a multifaceted approach, considering the patient's overall health, liver function, and potential complications.

• Dietary sodium restriction is essential, with a recommended intake of no more than 5 g of salt per day, equivalent to 2000 mg of sodium per day 1.
• The primary medication regimen includes spironolactone, an aldosterone antagonist, starting at 100 mg daily, and furosemide, a loop diuretic, starting at 40 mg daily, with doses adjusted as needed to achieve a maximum of 400 mg and 160 mg daily, respectively, while maintaining a 2.5:1 ratio (spironolactone:furosemide) 1.
• Weight loss should be limited to 0.5 kg/day for patients without edema and 1 kg/day for those with edema to prevent complications, as excessive weight loss can lead to dehydration and electrolyte imbalances 1.
• Large-volume paracentesis may be necessary for tense ascites, removing up to 5-6 liters of fluid while administering intravenous albumin (6-8 g per liter of fluid removed) to prevent circulatory dysfunction, as recommended by recent guidelines 1.
• For refractory ascites, options include serial paracentesis, transjugular intrahepatic portosystemic shunt (TIPS), or liver transplantation evaluation, with the choice of treatment depending on the patient's overall health, liver function, and potential risks and benefits of each option 1.
• Regular monitoring of electrolytes, renal function, and weight is essential during treatment, as diuretics can cause complications like hyponatremia, hypokalemia, or renal impairment, and patients should be advised to avoid NSAIDs, which can worsen sodium retention and renal function 1.

From the FDA Drug Label

By competing with aldosterone for receptor sites, Spironolactone provides effective therapy for the edema and ascites in those conditions.

The treatment for ascites includes Spironolactone as an effective therapy, as it competes with aldosterone for receptor sites, providing relief for edema and ascites in conditions such as hepatic cirrhosis 2.

• Key points:
  • Spironolactone acts as a diuretic and antihypertensive drug.
  • It is used to treat edema and ascites in conditions like hepatic cirrhosis and nephrotic syndrome.
  • The use of Furosemide may also be considered in the treatment of ascites, especially in a hospital setting for patients with hepatic cirrhosis and ascites 3.

From the Research

Treatment Options for Ascites

• The treatment of ascites depends on the underlying cause, with cirrhosis being the most common cause, accounting for almost 85% of all cases 4.
• The mainstay of treatment for ascites is restriction of sodium intake and enhancement of sodium excretion, which can be achieved through dietary changes and the use of oral diuretics 4, 5, 6.
• Patients with cirrhosis and ascites should limit sodium intake to 2 grams per day, and diuretics such as spironolactone and furosemide can be used to enhance sodium excretion 4.

Medical Therapy for Ascites

• 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.
• About 90% of patients respond well to medical therapy for ascites, but refractory ascites, which is defined as fluid overload that is unresponsive to sodium-restricted diet and high-dose diuretic treatment, has a poor prognosis 4, 5.
• Treatment options for patients with refractory ascites include serial therapeutic paracentesis, transjugular intrahepatic stent-shunt (TIPS), peritoneovenous shunt, and liver transplantation 4, 5, 6.

Therapeutic Paracentesis and Other Interventions

• Large-volume paracentesis (LVP) is a effective treatment for cirrhotic patients with tense ascites, and it is associated with a lower incidence of complications compared to diuretic therapy 5, 6.
• Post-paracentesis circulatory dysfunction (PPCD) may occur after LVP, and it can be prevented by administration of albumin intravenously along with LVP 5.
• TIPS should be considered in patients who repeatedly fail large-volume paracentesis and have relatively preserved liver functions, but it is contraindicated in patients with advanced liver failure 4, 5.
• Liver transplantation is the only modality that is associated with improved survival in patients with refractory ascites 4, 5.

Pharmacotherapy and Other Considerations

• Octreotide may be of value in the management of refractory ascites in cirrhotic patients, as it can improve renal function and hemodynamics, and diuretic response 7.
• Spontaneous bacterial peritonitis (SBP) is a common complication of cirrhotic ascites, and it can be treated with intravenous third-generation cephalosporins, and patients at risk should receive prophylaxis with orally administered quinolones or cotrimoxazole 5, 8.
• Cirrhotic patients with ascites are prone to develop renal failure when treated with certain pharmacological agents, such as aminoglycosides and nonsteroidal anti-inflammatory drugs, and these agents should be used with caution 8.