Medical treatment of
ascites is aimed at reverting
sodium retention, that is, at creating a negative
sodium balance to relieve
ascites.
Bed rest and
low-sodium diet induce the disappearance of
ascites in about 10% of patients.
Loop diuretics and
aldosterone antagonists must be administered to the patients not responding to the previous regimen. Available evidence indicates that
aldosterone antagonists are the first-choice drugs, as these substances are more effective than
furosemide. Nevertheless,
loop diuretics potentiate the effects of
aldosterone antagonists. The reduced efficacy of
furosemide in these patients, when compared with that of
spironolactone, may be related to an impairment of both pharmacodynamics and pharmacokinetics. In fact, most
sodium not reabsorbed in Henle's loop, due to the action of
furosemide, is subsequently taken up in the distal nephron because of
hyperaldosteronism. A further mechanism of resistance may be related to an impaired excretion of
furosemide into the tubular lumen. The use of
diuretics in the treatment of
ascites is associated with several side effects, including prerenal
azotemia,
hepatic encephalopathy, and
electrolyte and
acid-base disorders. A stepped-care approach, together with careful monitoring of patients, is the best way to reduce the incidence of these complications.
Ethacrynic acid has been shown to be highly effective in the treatment of
ascites, even in patients refractory to other
diuretics, but its use is associated with a high incidence of
hypokalemia and hypochloremic
alkalosis.
Bumetanide and
piretanide are comparable to
furosemide, in terms of both efficacy and side effects.(ABSTRACT TRUNCATED AT 250 WORDS)