What medication is used to treat edema?

Medication for Edema

Loop diuretics, particularly furosemide, are the primary medications for treating edema, with doses ranging from 20-40 mg initially up to 40-240 mg daily, and should be combined with ACE inhibitors and beta-blockers in heart failure patients rather than used as monotherapy. 1, 2

First-Line Diuretic Therapy

Loop diuretics are preferred over thiazides for most edema cases because they increase sodium excretion by 20-25% of filtered load, maintain efficacy even with impaired renal function, and produce more intense diuresis than thiazides. 1

Loop Diuretic Options and Dosing:

• Furosemide: 20-40 mg initial dose, usual daily dose 40-240 mg 1
• Bumetanide: 0.5-1.0 mg initial dose, usual daily dose 1-5 mg 1
• Torasemide: 5-10 mg initial dose, usual daily dose 10-20 mg 1
• Torasemide may be preferred in some patients due to superior absorption and longer duration of action compared to furosemide 1

Diuretics relieve dyspnea and edema within hours to days, providing symptomatic benefits more rapidly than any other heart failure medication, while ACE inhibitors or beta-blockers may require weeks to months to show clinical effects. 1

Combination Therapy for Resistant Edema

When loop diuretics alone fail to control edema, add a thiazide diuretic for sequential nephron blockade, as thiazides and loop diuretics act synergistically. 1

Thiazide Options for Combination:

• Hydrochlorothiazide: 25 mg initial dose, 12.5-100 mg usual daily dose 1
• Metolazone: 2.5 mg initial dose, 2.5-10 mg usual daily dose 1
• Bendroflumethiazide: 2.5 mg initial dose, 2.5-10 mg usual daily dose 1

Important caveat: Do not use thiazides if estimated glomerular filtration rate is <30 mL/min, except when prescribed synergistically with loop diuretics. 1

Mineralocorticoid Antagonists for Heart Failure

Add spironolactone 12.5-25 mg daily (up to 50 mg) for patients with NYHA class III-IV heart failure, as it reduces morbidity and mortality in addition to managing edema. 1, 3, 4

• Spironolactone is FDA-approved for treatment of NYHA Class III-IV heart failure with reduced ejection fraction to increase survival, manage edema, and reduce hospitalization 3
• Always preferred over other potassium-sparing diuretics (amiloride, triamterene) in heart failure patients 1
• Monitor potassium levels closely, especially when combined with ACE inhibitors or ARBs, due to hyperkalemia risk 1

Critical Dosing Principles

The goal is to achieve euvolemia (dry weight) with the lowest possible diuretic dose, requiring dose adjustment after restoration of dry body weight to avoid dehydration, hypotension, and renal dysfunction. 1

Start with low doses and titrate upward until urine output increases and weight decreases by 0.5-1.0 kg daily, then adjust frequency to twice-daily dosing if needed to maintain active diuresis. 1

Train patients to self-adjust diuretic doses based on daily weight monitoring and symptoms/signs of congestion. 1

Essential Warnings

Never use diuretics as monotherapy in heart failure—they must be combined with ACE inhibitors and beta-blockers, as diuretics alone cannot maintain long-term clinical stability. 1

Avoid these medications that worsen edema:

• Thiazolidinediones (glitazones) cause worsening heart failure and increase hospitalization risk (Class III recommendation) 1, 5
• NSAIDs and COX-2 inhibitors cause sodium/water retention and worsen heart failure (Class III recommendation) 1
• Most calcium channel blockers except amlodipine and felodipine have negative inotropic effects (Class III recommendation) 1

Inappropriately high diuretic doses lead to volume contraction, increasing hypotension risk with ACE inhibitors and renal insufficiency risk with ACE inhibitors/ARBs. 1

Inappropriately low diuretic doses result in fluid retention, diminishing ACE inhibitor response and increasing beta-blocker treatment risk. 1

Specific Edema Contexts

For cirrhosis with ascites: Use spironolactone as first-line when edema is unresponsive to fluid and sodium restriction 3

For nephrotic syndrome: Use spironolactone when other diuretics produce inadequate response, particularly useful when other diuretics have caused hypokalemia 3

For medication-induced edema (calcium channel blockers, TZDs): Consider switching the offending agent rather than adding diuretics—for calcium channel blocker edema, switch to an ACE inhibitor or ARB 5