What is the treatment for edema (+1) or pulmonary edema?

From the Guidelines

Edema treatment should prioritize addressing the underlying cause while managing symptoms, with loop diuretics like furosemide being the most effective for edema, as recommended by the European Society of Cardiology guidelines 1.

Key Considerations

• For mild edema, lifestyle modifications are the first step: elevate the affected area above heart level when possible, reduce salt intake to less than 2,300mg daily, wear compression stockings (15-20 mmHg for mild cases, 20-30 mmHg for moderate cases), and engage in regular physical activity.
• Diuretic therapy may be necessary if lifestyle modifications are insufficient, with loop diuretics like furosemide (20-40mg once or twice daily) being the most effective for edema.
• For maintenance therapy, thiazide diuretics such as hydrochlorothiazide (12.5-25mg daily) may be used.
• Potassium-sparing diuretics like spironolactone (25-100mg daily) are particularly useful in cases with liver disease or heart failure.
• Diuretics work by increasing sodium and water excretion by the kidneys, reducing fluid volume in the body.
• Monitor for side effects including electrolyte imbalances, particularly hypokalemia with loop and thiazide diuretics.

Specific Recommendations

• For patients with acute heart failure, an i.v. loop diuretic is recommended to improve breathlessness and relieve congestion, with symptoms, urine output, renal function, and electrolytes monitored regularly during use of i.v. diuretic 1.
• In patients with resistant peripheral oedema (and ascites), a combination of a loop and a thiazide (e.g. bendroflumethiazide) may be used 1.

Important Considerations

• The optimum dose and route of administration (bolus or continuous infusion) of diuretics are uncertain, but a high-dose strategy may be associated with greater improvement in symptoms but at the expense of more transient worsening of renal function 1.
• Diuretic therapy should be carefully titrated to promote effective diuresis while avoiding worsening renal function, particularly in patients with acute heart failure syndromes 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. When given as the sole agent for diuresis, administer for at least five days before increasing dose to obtain desired effect. Edema during pregnancy may arise from pathological causes or from the physiologic and mechanical consequences of pregnancy. Diuretics are indicated in pregnancy when edema is due to pathologic causes, just as they are in the absence of pregnancy

The treatment for edema can be managed with spironolactone at an initial daily dosage of 100 mg, which may range from 25 mg to 200 mg daily 2.

• Hydrochlorothiazide may also be used in the management of edema in pregnancy when the edema is due to pathologic causes 3.
• It is essential to note that diuretics should be used with caution in pregnant women and only when the edema is due to pathologic causes.
• In cases of extreme discomfort due to edema in pregnancy, a short course of diuretics may be appropriate 3.

From the Research

Edema Treatment

• Edema is the result of an imbalance in the filtration system between the capillary and interstitial spaces, and its treatment includes sodium restriction, diuretic use, and appropriate management of the underlying disorder 4.
• A systematic approach is warranted to determine the underlying diagnosis, and evaluation 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.
• Treatment of edema is specific to the etiology, and diuretics are effective but should be used only for systemic causes of edema 5.
• Loop diuretics often are used alone or in combination, and in patients with New York Heart Association class III and IV congestive heart failure, spironolactone has been found to reduce morbidity and mortality rates 4.
• The optimal dose of furosemide and spironolactone can significantly improve the clinical symptoms of elderly diastolic heart failure patients and ameliorate their long-term prognosis 6.
• 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 have an essential role in the management of heart failure, but each drug has its own benefit and side effect, and the choice of appropriate diuretic is essential for successful management 7.

Specific Treatments

• Leg elevation may be helpful in some patients with edema 4.
• In patients with cirrhosis, ascites is treated with paracentesis and spironolactone 4.
• Dihydropyridine-induced edema can be treated with an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker 4.
• Lymphedema occurs when a protein-rich fluid accumulates in the interstitium, and compression garments and range-of-motion exercises may be helpful in patients with this condition 4.
• Azosemide and torasemide caused a significant reduction in brain natriuretic peptide level, and torasemide also caused a significant decrease in collagen volume fraction and edema 7.