In a 42‑year‑old man (BMI ≈ 67) with hypertension on lisinopril‑hydrochlorothiazide, prediabetes, vitamin D deficiency, mild transaminitis, chronic bilateral lower‑extremity edema, and a longstanding hyperpigmented dry patch on the left anterior shin after a presumed brown‑recluse bite, what is the optimal management for his edema (including addition of a loop diuretic) and for the chronic wound?

Management of Chronic Wound and Edema in Morbidly Obese Patient with Prediabetes

For the chronic wound with delayed healing, optimize vascular assessment, ensure adequate off-loading, address vitamin D deficiency, and consider multidisciplinary wound care consultation; for the bilateral edema, add a loop diuretic (furosemide 20–40 mg daily or torsemide 10–20 mg daily) to the current thiazide-containing regimen, with close monitoring of renal function and electrolytes. 1, 2

Wound Management

Immediate Assessment Priorities

• Evaluate for arterial insufficiency by obtaining ankle-brachial index (ABI) measurements bilaterally, as PAD is present in 20–30% of persons with diabetes and up to 40% of those with diabetic foot infections, and the absence of pedal pulses suggests PAD. 1 An ABI of 0.90–1.30 is normal; 0.60–0.89 indicates mild arterial obstruction; 0.40–0.59 moderate obstruction; and <0.40 severe obstruction requiring urgent vascular consultation. 1

• Assess for venous insufficiency, which may cause edema that impedes wound healing, particularly given the chronic bilateral lower extremity swelling and history of cellulitis. 1

• Rule out osteomyelitis if the wound has not healed after 6 weeks of appropriate care and off-loading, especially since bone may be palpable with a sterile probe in chronic wounds overlying bony prominences. 1 Consider plain radiographs initially, followed by MRI if osteomyelitis is suspected and plain films are inconclusive. 3

Wound Care Interventions

• Ensure strict off-loading of the anterior tibial wound, as altered biomechanics from morbid obesity (BMI 66.72) predispose to foot wounds and impair healing. 1 Consider total contact cast or irremovable walker for plantar wounds if applicable. 3

• Optimize metabolic factors: Correct the severe vitamin D deficiency (10 ng/mL) with aggressive repletion, as this may impair wound healing. 3 Maintain tight glycemic control despite the currently acceptable A1c of 5.9%, as the patient is prediabetic and at high risk for progression. 3

• Seek wound care specialist consultation for advanced dressing techniques and pressure off-loading strategies, particularly given the 4-month healing timeline and decreased vascularity. 1 The IDSA recommends that clinicians unfamiliar with these techniques consult specialists. 1

Monitoring for Infection

• Watch for signs of infection recurrence, including increased erythema, warmth, purulent drainage, or systemic symptoms, given the history of secondary infection requiring cephalexin. 4, 3 Mark the borders of any erythema to track progression. 4

• Do not use topical antibiotics, as they have no role in established wounds and may increase resistance risk. 4

Edema Management

Addition of Loop Diuretic

• Add a loop diuretic to the current lisinopril-hydrochlorothiazide 20/12.5 mg regimen rather than increasing the thiazide dose, as loop diuretics are more efficient at inducing diuresis and natriuresis in patients with significant fluid overload. 1

• Start with furosemide 20–40 mg once daily or torsemide 10–20 mg once daily. 1, 2 Torsemide offers advantages of longer duration of action, once-daily dosing, and more reliable bioavailability compared to furosemide. 2

• Titrate the loop diuretic dose upward until clinical improvement in edema is achieved, then adjust to maintain "dry weight" with the lowest achievable dose to avoid renal dysfunction and dehydration. 1

Monitoring Requirements

• Check renal function and serum electrolytes before initiating loop diuretic therapy and monitor frequently during titration. 1 This is critical given the baseline creatinine of 0.69 mg/dL and the risk of hypokalemia, hyponatremia, and worsening renal function with combination diuretic therapy.

• Monitor for signs of dehydration or hypovolemia, including orthostatic symptoms, decreased urine output, or rising creatinine. 1

• Consider short-term combination therapy with the thiazide if edema proves resistant, but use this potent combination for only a few days with careful monitoring to avoid severe electrolyte derangements. 1

Patient Education

• Encourage self-adjustment of diuretic dose based on daily weight measurements and clinical signs of fluid retention, with appropriate patient education on when to increase or decrease the dose. 1

• Emphasize sodium restriction and leg elevation to complement diuretic therapy in managing chronic venous edema.

Common Pitfalls to Avoid

• Do not assume the wound is "just healing slowly" without ruling out arterial insufficiency, venous stasis, or occult osteomyelitis, as these will prevent healing regardless of time. 1, 3

• Avoid aggressive diuresis without monitoring, as the combination of ACE inhibitor, thiazide, and loop diuretic increases risk of acute kidney injury, particularly in the setting of obesity and potential renal hyperfiltration. 1

• Do not overlook the elevated ALT (69 U/L) in the context of morbid obesity and prediabetes, as this likely represents non-alcoholic fatty liver disease (NAFLD), which may worsen with certain medications and requires monitoring. 5

• Recognize that the hyperpigmented shin patch likely represents chronic venous stasis dermatitis (hemosiderin deposition) rather than diabetic dermopathy, given the history of cellulitis and chronic edema. 1 This reinforces the need for aggressive edema management and compression therapy once wounds heal.