Should diuretics (e.g. spironolactone or furosemide) be held before paracentesis?

Diuretics Do Not Need to Be Held Before Paracentesis

Diuretics should be continued through paracentesis and are essential immediately after the procedure to prevent rapid reaccumulation of ascites. The evidence consistently shows that diuretic therapy must be maintained or initiated following paracentesis, with no guideline recommendations to hold these medications periprocedurally.

Evidence Supporting Continuation of Diuretics

Post-Paracentesis Diuretic Requirements

• Following large-volume paracentesis, diuretics should be started immediately to prevent early ascites recurrence, as demonstrated in a randomized trial where 93% of patients receiving placebo (no diuretics) developed recurrent ascites within 4 weeks compared to only 18% receiving spironolactone 1
• More than 50% of patients not receiving diuretics after paracentesis developed recurrent ascites within the first 2 weeks, emphasizing the critical need for immediate diuretic therapy 1
• The American Association for the Study of Liver Diseases explicitly recommends that "a single large-volume paracentesis followed by diet and diuretic therapy is appropriate treatment for patients with tense ascites" 2

Mechanism and Rationale

• Paracentesis addresses only the symptom (fluid accumulation) but does nothing to correct the underlying pathophysiology of sodium retention that causes ascites in cirrhosis 2
• Diuretics are required to increase urinary sodium excretion and prevent fluid reaccumulation after the mechanical removal of ascites 2
• Following initial paracentesis for tense ascites, maintenance diuretic therapy should be initiated or optimized, typically starting with spironolactone 50-100 mg/day and furosemide 20-40 mg/day 3, 4

Optimal Diuretic Management Around Paracentesis

Before Paracentesis

• No evidence supports holding diuretics before the procedure
• Patients already on diuretics should continue their regimen

After Paracentesis

• Diuretics must be started immediately post-paracentesis in patients not already receiving them 1
• For patients already on diuretics, doses should be optimized by titrating upward every 3-5 days to achieve natriuresis and appropriate weight loss 2, 3
• The standard spironolactone:furosemide ratio of 100:40 mg should be maintained to preserve normokalemia 2, 4
• Maximum doses before considering ascites refractory are spironolactone 400 mg/day and furosemide 160 mg/day 2, 3

Safety Considerations

No Increased Risk with Diuretics

• A randomized trial specifically demonstrated that administering spironolactone 225 mg/day immediately after paracentesis does not increase the incidence of post-paracentesis circulatory dysfunction compared to placebo 1
• Post-paracentesis circulatory dysfunction occurred in similar rates (2 patients in spironolactone group vs 3 in placebo group) 1

Monitoring Requirements

• Regular monitoring of weight, electrolytes, and renal function is essential during diuretic therapy 3, 5
• Target weight loss should not exceed 0.5 kg/day in patients without peripheral edema to avoid rapid fluid shifts 3, 4
• Watch for complications including hepatic encephalopathy, renal impairment (creatinine >2.0 mg/dL), hyponatremia (<120 mmol/L), or hyperkalemia (>6.0 mmol/L) 2

Common Pitfalls to Avoid

• Do not perform serial paracenteses without diuretic therapy in diuretic-sensitive patients, as this approach is inappropriate and fails to address sodium retention 2, 3
• Avoid NSAIDs, which can reduce diuretic efficacy and convert diuretic-sensitive patients to refractory status 2, 3
• Do not restrict fluids unless serum sodium falls below 120-125 mmol/L 2, 3