How is edema managed?

Management of Edema

The initial treatment for edema should include moderate sodium restriction (2 g or 90 mmol/day) and diuretic therapy, with loop diuretics (furosemide) as first-line treatment for most types of edema. 1

Diagnostic Approach

Before initiating treatment, determine the underlying cause of edema:

• Chronicity and laterality: Acute unilateral edema warrants immediate evaluation for deep venous thrombosis with d-dimer or compression ultrasonography 2
• Laboratory evaluation: Basic metabolic panel, liver function tests, thyroid function testing, brain natriuretic peptide levels, and urine protein/creatinine ratio 2
• Common causes:
  • Venous insufficiency (most common in older adults)
  • Idiopathic edema (common in women between menarche and menopause)
  • Pulmonary hypertension (often associated with sleep apnea)
  • Medication-induced (antihypertensives, anti-inflammatory drugs, hormones)
  • Systemic conditions (heart failure, cirrhosis, nephrotic syndrome)

Treatment Algorithm

1. General Measures

• Sodium restriction: Limit to 2 g or 90 mmol/day 1
• Leg elevation: Helpful for venous insufficiency 3
• Address underlying cause: Treat the primary condition causing edema

2. Diuretic Therapy

• First-line: Loop diuretics (furosemide 40 mg/day) 1
• Add-on therapy: Spironolactone when loop diuretics alone are insufficient 1
  • For heart failure: Start spironolactone 25 mg once daily (if serum potassium ≤5.0 mEq/L and eGFR >50 mL/min/1.73 m²) 4
  • For cirrhosis with ascites: Spironolactone 100 mg/day with or without furosemide 1

3. Condition-Specific Management

Heart Failure Edema

• Start with furosemide 40 mg/day 1
• Add spironolactone 25 mg daily (shown to reduce morbidity and mortality in NYHA class III-IV heart failure) 4, 3
• Monitor for hyperkalemia; reduce to 25 mg every other day if hyperkalemia develops 4

Cirrhosis with Ascites

• Spironolactone 100 mg/day as first-line therapy 1
• For tense ascites: Large-volume paracentesis with albumin, followed by diuretic therapy 1
• Initiate therapy in hospital setting and titrate slowly 4

Venous Insufficiency

• Compression therapy (stockings or devices) 2
• Leg elevation 3
• Consider Ruscus extract or horse chestnut seed (moderate evidence for efficacy) 2

Lymphedema

• Compression garments and range-of-motion exercises 3
• Pneumatic compression devices 5

Cerebral Edema

• Avoid antiparasitic drugs if present 6
• For increased intracranial pressure: Mannitol 0.25-0.5 g/kg IV over 20 minutes, every 6 hours (max 2 g/kg) 1
• Additional measures: Restrict free water, avoid excess glucose administration, minimize hypoxemia and hypercarbia, treat hyperthermia 6

Monitoring and Dose Adjustment

• Regular monitoring of body weight, serum creatinine, and electrolytes (especially sodium and potassium) 1
• Taper diuretics to lowest effective dose once edema is adequately mobilized 1
• Fluid restriction only necessary with moderate or severe hyponatremia (serum sodium ≤125 mmol/L) 1

Managing Complications

• Hypokalemia: Add spironolactone or potassium supplements 1
• Hyperkalemia: Reduce spironolactone dose or switch to alternate-day dosing if serum potassium >5.0 mEq/L 1
• Renal impairment: In chronic kidney disease, higher doses of loop diuretics and lower doses of aldosterone antagonists are typically needed 1

Cautions and Pitfalls

• Diuretics should only be used for systemic causes of edema, not for localized edema 2
• Avoid fluid overload in patients with peritonitis as it may aggravate gut edema and increase intra-abdominal pressure 1
• In patients with eGFR between 30-50 mL/min/1.73 m², consider initiating spironolactone at 25 mg every other day due to risk of hyperkalemia 4
• Antihypertensive agents that induce cerebral vasodilation should be avoided in cerebral edema 6