From the Guidelines
Management of edema depends on whether it's overfilled (hypervolemic) or underfilled (hypovolemic), with the primary approach for overfilled edema being fluid and sodium restriction combined with diuretic therapy, as recommended by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1.
Key Considerations
- For overfilled edema, loop diuretics like furosemide, bumetanide, or torsemide are first-line treatments, with combination therapy with thiazide diuretics considered in severe cases.
- For underfilled edema, the focus is on volume repletion and addressing the underlying cause, typically involving isotonic fluid administration at rates determined by the severity of hypovolemia.
- Clinical assessment, including vital signs, jugular venous pressure, and laboratory values like BUN/creatinine ratio, helps differentiate between these types and guide appropriate therapy.
Diuretic Therapy
- Loop diuretics are the preferred diuretic agents for use in most patients with heart failure, as stated in the 2022 AHA/ACC/HFSA guideline 1.
- The treatment goal of diuretic use is to eliminate clinical evidence of fluid retention, using the lowest dose possible to maintain euvolemia.
Volume Repletion
- Isotonic fluid administration, such as normal saline or lactated Ringer's, is used for volume repletion in underfilled edema, with rates determined by the severity of hypovolemia.
- Albumin infusion may be considered in cases of severe hypoalbuminemia.
Guiding Principles
- The distinction between overfilled and underfilled edema is crucial, as treating underfilled edema with diuretics can worsen the condition by further depleting intravascular volume.
- Clinical guidelines, such as those from the AHA/ACC/HFSA, provide recommendations for fluid management in adults with sepsis and heart failure, emphasizing the importance of careful fluid management to avoid fluid overload and pulmonary edema 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 FDA drug label does not answer the question.
From the Research
Management of Edema
The management of edema, whether overfilled or underfilled, involves a systematic approach to determine the underlying diagnosis and treatment of the underlying disorder.
- Sodium restriction and diuretic use are common treatments for edema, as they help regulate fluid balance in the body 2.
- Loop diuretics, such as furosemide, are often used alone or in combination with other medications to treat edema 2, 3.
- In patients with heart failure, torsemide may be a primary choice for treating edema due to its efficacy and pharmacological qualities 4.
- Leg elevation may be helpful in some patients with edema, particularly those with venous obstruction or increased capillary permeability 2.
Treatment of Overfilled Edema
Overfilled edema is often associated with fluid overload, which can be treated with diuretics and other medications.
- Intravenous diuretic day-care treatment has been shown to be effective in improving symptoms and reducing hospital admissions in patients with heart failure and fluid overload 3.
- The use of hyperoncotic albumin in addition to diuretics may also be beneficial in treating edema, particularly in critically ill patients 5.
Treatment of Underfilled Edema
Underfilled edema, on the other hand, may require a different approach, focusing on addressing the underlying cause of the edema.
- Correction of the primary disorder should be the main goal in the management of underfilled edema, with diuretics aiding in promoting increased excretion of salt and water 6.
- Compression garments and range-of-motion exercises may be helpful in patients with lymphedema, a type of underfilled edema characterized by protein-rich fluid accumulation in the interstitium 2.