What is the treatment for edema?

From the Guidelines

Edema treatment should prioritize addressing the underlying cause while managing symptoms, with lifestyle modifications and compression therapy being the first line of treatment, as supported by the most recent and highest quality study 1.

Key Considerations

• For mild edema, lifestyle modifications such as 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 are essential.
• Compression therapy, with a minimum pressure of 20 to 30 mm Hg, is recommended for patients with venous leg ulcers, as it reduces venous stasis and improves lymphatic drainage 1.
• Diuretics, such as furosemide (Lasix) 20-80 mg daily, may be prescribed to increase urine output and reduce fluid retention, but their use should be judicious due to potential associations with worsening renal function and long-term mortality 1.

Treatment Options

• For edema associated with heart failure, ACE inhibitors like lisinopril 5-40 mg daily or ARBs such as losartan 25-100 mg daily may be included in the regimen.
• Severe cases may require combination therapy with loop and thiazide diuretics, but regular monitoring of electrolytes, especially potassium and sodium, is crucial to prevent imbalances.
• Physical therapy and lymphatic drainage massage may benefit patients with lymphedema, and treatment duration varies based on the underlying cause.

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 in patients with chronic venous disease 1.
• Another study published in 2020 in the journal Ophthalmology found that anti-VEGF agents are effective in treating macular edema secondary to central retinal vein occlusion, with a significant improvement in visual acuity 1.

From the FDA Drug Label

2.4 Treatment of Edema 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. When given as the sole agent for diuresis, administer for at least five days before increasing dose to obtain desired effect.

INDICATIONS AND USAGE 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

The treatment for edema can be managed with spironolactone or metolazone.

• Spironolactone dosage for edema treatment is 100 mg daily, which can be administered in single or divided doses, and may range from 25 mg to 200 mg daily 2.
• Metolazone is indicated for the treatment of salt and water retention, including edema accompanying congestive heart failure and edema accompanying 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.

Diagnosis and Management

• Evaluation of edema should begin with obtaining a basic metabolic panel, liver function tests, thyroid function testing, brain natriuretic peptide levels, and a urine protein/creatinine ratio 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.
• Acute unilateral lower-extremity edema warrants immediate evaluation for deep venous thrombosis with a d-dimer test or compression ultrasonography, and patients with pulmonary edema or elevated brain natriuretic peptide levels should undergo echocardiography to assess for heart failure 5.

Congestive Heart Failure Treatment

• Diuretics, direct vasodilators, and angiotensin-converting enzyme (ACE) inhibitors can be used to reduce symptoms, prolong life, or both, in patients with congestive heart failure (CHF) 7.
• ACE inhibitors can cause hemodynamic and neurohormonal changes that lead to a reduction of preload and afterload, decreasing symptoms of heart failure, and significantly decrease CHF mortality 7.