From the Guidelines
For patients with edema, therapies beyond diuretics that can be recommended include compression therapy, elevation of the affected limb, lifestyle modifications, and physical therapy. These approaches can be used alone for mild cases or as complementary treatments alongside medication for more severe edema. Key considerations include:
- Compression therapy with graduated compression stockings (20-30 mmHg for mild edema, 30-40 mmHg for moderate to severe cases) or pneumatic compression devices used for 1-2 hours daily 1.
- Elevation of the affected limb above heart level for 30 minutes several times daily to improve venous return.
- Lifestyle modifications such as sodium restriction (limiting intake to 2,000-2,300 mg daily), regular physical activity to improve circulation, and weight management for patients with obesity-related edema.
- Physical therapy incorporating manual lymphatic drainage techniques for localized edema.
- Nutritional support with adequate protein intake (1.2-1.5 g/kg/day) to maintain oncotic pressure in cases of protein-losing conditions causing edema 1. It's essential to tailor these therapies to the individual patient's needs and underlying condition, and to monitor their effectiveness and potential side effects closely. In patients with severely symptomatic fluid overload, vasodilators such as intravenous nitroglycerin, nitroprusside, or nesiritide can be beneficial when added to diuretics and/or in those who do not respond to diuretics alone 1. Overall, a comprehensive approach to edema management that incorporates both pharmacological and non-pharmacological therapies can help improve patient outcomes and quality of life.
From the FDA Drug Label
During major surgery, patients can lose over half of their circulating albumin with the attendant complications of oncotic deficit.(2,4,5) A similar situation can occur in sepsis or intensive care patients. Treatment with Plasbumin-25 may be of value in such cases. Acute Nephrosis(2) Certain patients may not respond to cyclophosphamide or steroid therapy. The steroids may even aggravate the underlying edema In this situation a loop diuretic and 100 mL Plasbumin-25 repeated daily for 7 to 10 days may be helpful in controlling the edema and the patient may then respond to steroid treatment.
Other therapies that could be recommended to a patient with edema other than a diuretic include:
- Albumin administration, such as Plasbumin-25, to help maintain plasma colloid osmotic pressure and control edema 2
- Steroid therapy, which may be used in combination with albumin administration to control edema in certain cases, such as acute nephrosis 2
- Colloid and crystalloid administration to restore depleted extracellular fluid volume, particularly in the first 24 hours after sustaining thermal injury 2
From the Research
Alternative Therapies for Edema
Other than diuretics, several alternative therapies can be recommended to patients with edema, including:
- Angiotensin II receptor antagonists, which have been shown to have haemodynamic effects similar to ACE inhibitors, but with different mechanisms of action and adverse effects 3
- ACE inhibitors, such as lisinopril, which have been demonstrated to reduce mortality and morbidity in patients with heart failure 4
- Aldosterone antagonists, such as spironolactone, which have been shown to prevent deaths in patients with heart failure and incapacitating dyspnea despite ACE inhibitor + diuretic combination therapy 3
- Ultrafiltration by semipermeable membranes, which can be effective in achieving targeted fluid removal in patients with advanced heart failure who are refractory to diuretic therapy 5
Combination Therapies
Combination therapies, such as the use of continuous infusions of loop diuretics, sometimes combined with carbonic anhydrase inhibitors and/or aldosterone antagonists and/or thiazide diuretics, can also be effective in patients with advanced heart failure 5
- The combination of diuretic therapy and/or ultrafiltration can achieve volume control in essentially all patients with heart failure 5
Timing of Therapy
The timing of diuretic therapy can also impact its effectiveness, with evening dosing appearing to lower cardiovascular events relative to morning dosing 6