Will torsemide (loop diuretic) and eplerenone (aldosterone antagonist) alleviate severe wrist pain in a patient with existing edema (fluid retention) and mildly elevated blood pressure (hypertension) after taking mefenamic acid (nonsteroidal anti-inflammatory drug)?

Will Torsemide and Eplerenone Relieve Wrist Pain?

No, torsemide and eplerenone will not relieve wrist pain—these medications treat fluid retention and hypertension, not musculoskeletal pain. The severe wrist pain is likely caused by the mefenamic acid (an NSAID) or represents an underlying inflammatory/mechanical condition that requires appropriate analgesic therapy, not diuretics.

Why This Approach is Misguided

Diuretics Do Not Treat Pain

• Loop diuretics like torsemide are indicated exclusively for managing fluid overload in heart failure, renal disease, hepatic cirrhosis, and hypertension—not for pain relief 1, 2.
• The American College of Cardiology clearly states that diuretics work by inhibiting sodium and chloride reabsorption in the loop of Henle to promote water excretion, with no analgesic properties whatsoever 1.
• Eplerenone is an aldosterone antagonist used primarily as adjunctive therapy in heart failure and hypertension, not for pain management 3.

The Real Clinical Problem

The patient's wrist pain after taking mefenamic acid suggests either:

• NSAID-induced adverse effects (though wrist pain is not a typical NSAID side effect)
• Worsening of pre-existing inflammatory arthritis or mechanical joint pathology
• Coincidental acute injury or inflammatory condition

NSAIDs and Fluid Retention: A Critical Interaction

The American College of Cardiology explicitly warns that NSAIDs, including COX-2 inhibitors, can block diuretic effects and cause diuretic resistance 1.

• NSAIDs should be avoided or withdrawn in patients with fluid retention, as they adversely affect clinical status 1.
• If the patient already had edema, adding mefenamic acid was contraindicated and may have worsened the fluid retention 1.

What Should Actually Be Done

Immediate Management of Wrist Pain

• Discontinue mefenamic acid immediately given the pre-existing edema and slightly elevated blood pressure 1.
• Evaluate the wrist pain with focused examination: assess for trauma, inflammatory arthritis (swelling, warmth, erythema), mechanical derangement, or referred pain.
• Provide appropriate analgesia: acetaminophen (paracetamol) up to 4 grams daily is safer in patients with edema and hypertension, or consider topical NSAIDs if localized inflammation is present.

Managing the Pre-Existing Edema

• Torsemide is appropriate for treating the edema, as it has superior bioavailability (80-90%), longer duration of action (12-16 hours), and more predictable absorption compared to furosemide 4, 5, 6.
• Start torsemide 10-20 mg once daily, targeting weight loss of 0.5-1.0 kg daily until edema resolves 1, 2.
• Eplerenone may be appropriate if the patient has heart failure or resistant hypertension, but its role here is unclear without knowing the underlying cause of edema 3.

Critical Monitoring

• Monitor daily weights, blood pressure, and serum electrolytes (potassium, sodium, creatinine) during diuretic therapy 1, 2.
• The American Heart Association recommends continuing diuresis even if mild azotemia develops, as long as the patient remains asymptomatic, since persistent volume overload worsens outcomes 1, 2.
• Restrict dietary sodium to 3-4 grams daily to prevent recurrent fluid retention 2, 4.

Common Pitfalls to Avoid

• Do not use diuretics to treat pain—this represents a fundamental misunderstanding of pharmacology.
• Do not continue NSAIDs in patients with pre-existing edema or heart failure, as they cause sodium retention and diuretic resistance 1.
• Do not delay appropriate evaluation of acute joint pain—inflammatory arthritis, septic arthritis, or fracture require specific diagnosis and treatment.
• Do not stop diuretics prematurely if creatinine rises modestly, as persistent congestion is more harmful than mild azotemia 1, 7.