From the Guidelines
Alternatives to spironolactone for managing ascites include other diuretics such as furosemide (20-40mg daily), torsemide (10-20mg daily), or bumetanide (0.5-1mg daily), as well as potassium-sparing diuretics like amiloride (5-10mg daily) or triamterene (100-300mg daily) 1. When considering alternatives to spironolactone, it's essential to evaluate the patient's renal function, electrolyte balance, and the severity of liver disease.
- Loop diuretics, such as furosemide and torsemide, work by inhibiting sodium reabsorption in the loop of Henle, while potassium-sparing diuretics like amiloride block sodium channels in the distal tubule without the anti-androgenic side effects of spironolactone.
- For patients with refractory ascites, therapeutic paracentesis may be necessary, removing up to 5-6 liters of fluid at once, followed by albumin replacement (6-8g per liter of fluid removed) to prevent circulatory dysfunction 1.
- Transjugular intrahepatic portosystemic shunt (TIPS) is a more invasive option for severe cases, reducing portal pressure and ascites formation.
- Vasopressin V2 receptor antagonists like tolvaptan can also be considered in specific situations. The choice of alternative depends on the patient's individual needs and medical history, and should be guided by the most recent and highest quality evidence, such as the 2021 guidelines on the management of ascites in cirrhosis 1.
- It is also important to monitor patients for adverse events, such as hypovolaemic hyponatraemia, and to adjust diuretic therapy accordingly 1.
- In cases of severe hyponatraemia, acute kidney injury, or worsening hepatic encephalopathy, diuretics should be discontinued 1.
- The dose of diuretics should be reduced to the lowest effective dose once ascites has largely resolved 1.
From the Research
Alternatives to Spironolactone for Treating Ascites
- Furosemide: can be used in combination with spironolactone to increase the natriuretic effect and diminish the effects on potassium metabolism 2
- Therapeutic paracentesis: can be used to eliminate ascitic fluid, especially in patients with tense ascites, and is often associated with intravenous albumin infusion to prevent complications 2, 3
- Transjugular intrahepatic portosystemic shunt (TIPS): can be considered in patients who repeatedly fail large-volume paracentesis and have relatively preserved liver function 4, 3
- Peritoneovenous shunt: can be used to treat ascites in cirrhosis, especially in patients who do not respond to diuretics and develop repeated episodes of ascites despite adequate treatment 2
- Liver transplantation: is the only modality that is associated with improved survival in patients with refractory ascites 4, 3
Combination Therapies
- Spironolactone and furosemide: can be used in combination to treat moderate ascites in nonazotemic cirrhosis, with similar response rates and incidence of complications as spironolactone alone 5
- Diuretics and paracentesis: can be used in combination to treat ascites, with diuretics given after the elimination of ascites by paracentesis to avoid reaccumulation of the abdominal fluid 2, 6
Other Treatment Options
- Serial therapeutic paracentesis: can be used to treat refractory ascites, especially in patients who are not candidates for TIPS or liver transplantation 4, 3
- Albumin infusion: can be used to prevent complications associated with paracentesis, such as hepatic encephalopathy, renal impairment, and hyponatremia 2, 3