What is the starting dose of furosemide (Lasix) and spironolactone (Aldactone) for managing cirrhosis with ascites?

Starting Doses of Furosemide and Spironolactone for Cirrhosis with Ascites

For patients with cirrhosis and ascites, the recommended starting dose is spironolactone 100 mg once daily and furosemide 40 mg once daily, administered together as a single morning dose. 1, 2

Initial Diuretic Therapy Approach

First Presentation of Moderate Ascites

• Spironolactone monotherapy:
  • Starting dose: 100 mg once daily 1
  • Can be titrated up to 400 mg daily if needed

Recurrent or Severe Ascites

• Combination therapy:
  • Spironolactone: 100 mg once daily
  • Furosemide: 40 mg once daily
  • Both medications should be given as a single morning dose to maximize compliance 1, 2

Dose Titration Protocol

• Doses of both diuretics can be increased simultaneously every 3-5 days (maintaining the 100 mg:40 mg ratio) if weight loss and natriuresis are inadequate 1
• Maximum recommended doses:
  • Spironolactone: 400 mg/day
  • Furosemide: 160 mg/day

Monitoring and Adjustments

• Monitor for adverse events, which occur in approximately half of patients and may require dose reduction or discontinuation 1
• Check serum electrolytes and renal function regularly during dose adjustments
• Target weight loss:
  • Without peripheral edema: 0.5 kg/day 1
  • With peripheral edema: No specific limit, but should be monitored carefully 1

Special Considerations

Electrolyte Imbalances

• If hypokalemia occurs: Reduce or stop furosemide 1
• If hyperkalemia develops: Reduce or stop spironolactone 1

When to Discontinue Diuretics

Reduce or stop diuretics in cases of:

• Severe hyponatremia
• Acute kidney injury
• Overt hepatic encephalopathy
• Severe muscle spasms 1

Alternative Approaches

For patients not responding to diuretic therapy (refractory ascites):

• Consider large volume paracentesis with albumin replacement (8 g albumin/L of ascites removed) 1
• Evaluate for transjugular intrahepatic portosystemic shunt (TIPS) or liver transplantation 3

Clinical Pearl

While some evidence suggests that spironolactone monotherapy may be equally effective as combination therapy and require fewer dose adjustments for outpatient management 4, the most recent guidelines recommend combination therapy for recurrent or severe ascites 1, 2. The combination approach allows for more rapid diuresis while maintaining normokalemia.