What is the treatment for edema?

From the Guidelines

Edema treatment should prioritize addressing the underlying cause while managing symptoms, with the most recent and highest quality study recommending compression therapy as a helpful initial treatment for venous leg ulcers, with a minimum pressure of 20 to 30 mm Hg 1.

Key Considerations

• For mild edema, lifestyle modifications are the first step, including reducing salt intake to less than 2,300 mg daily, elevating affected limbs above heart level when possible, and wearing compression stockings to improve circulation.
• Diuretics are the primary medication treatment, with furosemide (Lasix) 20-80 mg daily being commonly prescribed, and other options include hydrochlorothiazide 12.5-50 mg daily or spironolactone 25-100 mg daily.
• For edema caused by heart failure, ACE inhibitors like lisinopril (10-40 mg daily) or ARBs such as losartan (25-100 mg daily) may be added, and severe cases might require combination therapy.

Treatment Approach

• Regular monitoring of electrolytes, especially potassium and sodium, is essential when using diuretics as they can cause imbalances.
• Physical therapy and lymphatic drainage massage can benefit patients with lymphedema.
• Treatment duration varies based on the underlying cause, with some conditions requiring long-term management while others resolve once the primary issue is addressed.

Recent Evidence

• A 2023 study published in the Journal of the American College of Radiology found that compression therapy has value in preventing ulcer recurrence and healing ulcers, with 30 to 40 mm Hg inelastic compression being better than elastic bandaging for wound healing 1.
• Another study found that anti-VEGF agents are effective in treating macular edema with central retinal vein occlusion, with intravitreal ranibizumab, aflibercept, and bevacizumab being commonly used treatments 1.

From the FDA Drug Label

In patients with cirrhosis, initiate therapy in a hospital setting and titrate slowly [see Use in Specific Populations (8. 7)] . The recommended initial daily dosage is 100 mg of spironolactone tablets administered in either single or divided doses, but may range from 25 mg to 200 mg daily. Metolazone tablets, USP, are indicated for the treatment of salt and water retention including: edema accompanying congestive heart failure; edema accompanying renal diseases, including the nephrotic syndrome and states of diminished renal function

Edema Treatment:

• Spironolactone can be used to treat edema, with an initial daily dosage of 100 mg, which can range from 25 mg to 200 mg daily 2.
• Metolazone is also indicated for the treatment of edema accompanying congestive heart failure and renal diseases 3.

From the Research

Edema Treatment Overview

• Edema is the result of an imbalance in the filtration system between the capillary and interstitial spaces, and its treatment depends on the underlying cause 4.
• A systematic approach is warranted to determine the underlying diagnosis, and treatment includes sodium restriction, diuretic use, and appropriate management of the underlying disorder 4.
• Loop diuretics are often used alone or in combination, and spironolactone has been found to reduce morbidity and mortality rates in patients with New York Heart Association class III and IV congestive heart failure 4.

Specific Treatment Options

• Leg elevation may be helpful in some patients, and compression garments and range-of-motion exercises may be helpful in patients with lymphedema 4.
• Ruscus extract and horse chestnut seed demonstrate moderate-quality evidence to improve edema from chronic venous insufficiency, and compression therapy is effective for most causes of edema 5.
• Diuretics are effective but should be used only for systemic causes of edema, and the choice of appropriate diuretic is essential for successful management and is mainly guided by patient clinical situations and the presence of other co-morbidities 6.

Diuretic Use in Heart Failure

• Diuretics induce sodium and water excretion, leading to decreased cardiac preload and wall tension, and an effective decrease of symptomatic pulmonary and systemic congestion 7.
• Azosemide and torasemide have been shown to cause a significant reduction in brain natriuretic peptide (BNP) level, and torasemide also causes a significant decrease in collagen volume fraction (CVF) and edema 6.
• No significant difference between diuretics was observed in terms of hospital readmission and mortality rates, and the choice of diuretic should be guided by patient clinical situations and the presence of other co-morbidities 6.

Investigation and Diagnosis

• Investigation of the causes of edema is essential for appropriate therapy, and a basic metabolic panel, liver function tests, thyroid function testing, brain natriuretic peptide levels, and a urine protein/creatinine ratio should be obtained 5.
• Validated decision rules, such as the Wells and STOP-Bang criteria, can guide decision-making regarding the possibility of venous thromboembolic disease and obstructive sleep apnea, respectively 5.
• Lymphedema is often a clinical diagnosis, and lymphoscintigraphy can be performed if the diagnosis is unclear 5.