What are the treatment options for oedema?

Treatment of Edema

The treatment of edema depends critically on the underlying cause: loop diuretics (furosemide 20-80 mg daily) are first-line for systemic fluid overload from heart failure, cirrhosis, or renal disease, while compression therapy and leg elevation are preferred for venous insufficiency and lymphedema where diuretics are ineffective. 1, 2

Systemic Edema (Cardiac, Renal, Hepatic)

Loop diuretics are the cornerstone of treatment for edema associated with congestive heart failure, cirrhosis, and renal disease including nephrotic syndrome. 1

Furosemide Dosing

• Initial dose: 20-80 mg as a single dose 1
• If inadequate response, increase by 20-40 mg increments, given no sooner than 6-8 hours after the previous dose 1
• May be titrated up to 600 mg/day in severe edematous states with careful monitoring 1
• For maintenance, give once or twice daily (e.g., 8 AM and 2 PM) 1
• Most efficient mobilization occurs with 2-4 consecutive days of treatment per week 1

Heart Failure-Specific Considerations

• In NYHA class III-IV heart failure, add spironolactone to reduce morbidity and mortality 2
• For acute pulmonary edema, vasodilatation is more important than diuresis to reduce cardiac filling pressures 3
• Patients with pure pulmonary edema have acute hemodynamic derangement without excess total body fluid 3

Cirrhosis with Ascites

• Spironolactone is the preferred diuretic 2
• Paracentesis for symptomatic relief 2

Peripheral/Venous Edema

Diuretics should NOT be used for peripheral edema from venous insufficiency or lymphedema—they are ineffective and potentially harmful. 2, 4

Non-Pharmacologic Management (First-Line)

• Compression therapy is effective for most causes of peripheral edema 5
• Leg elevation can be helpful, particularly for chronic peripheral edema 2, 6
• Range-of-motion exercises for lymphedema 2

Pharmacologic Options for Venous Insufficiency

• Ruscus extract and horse chestnut seed have moderate-quality evidence for improving chronic venous insufficiency edema 5

Medication-Induced Edema

Dihydropyridine calcium channel blocker-induced edema should be treated with an ACE inhibitor or angiotensin-receptor blocker, not diuretics. 2

Adjunctive Measures

Sodium Restriction

• Fundamental for all systemic causes of edema 2
• The kidneys regulate extracellular fluid volume by adjusting sodium and water excretion 2

Special Populations

• Elderly patients: start at the low end of dosing range 1
• Pediatric patients: initial dose 2 mg/kg, may increase by 1-2 mg/kg increments, maximum 6 mg/kg 1

Critical Pitfalls to Avoid

• Never use diuretics for lymphedema or isolated venous insufficiency—these conditions result from mechanical obstruction, not fluid overload 2, 4
• Avoid topical carbonic anhydrase inhibitors as first-line for corneal edema with endothelial dysfunction due to interference with the endothelial pump 7
• In acute pulmonary edema, prioritize vasodilators over aggressive diuresis to avoid hemodynamic collapse 3
• Monitor carefully when furosemide doses exceed 80 mg/day for prolonged periods with clinical observation and laboratory testing 1

Complications Requiring Treatment

Cellulitis is a common complication of chronic edema and requires antibiotics 4