Drug therapy of ascites
For symptomatic ascites (ie causing abdominal discomfort or distension), start treatment with a diuretic and increase the dose according to response. For patients without significant peripheral oedema, weight loss should not exceed 1 kg per day.
Use spironolactone for initial therapy of symptomatic ascites:
spironolactone 50 to 100 mg orally, daily. If needed, increase dose by 100 mg daily every 4 to 7 days, up to a maximum of 400 mg daily. ascites spironolactone
Start with a spironolactone dose of 50 mg in patients who are at risk of dehydration or electrolyte disturbance.
For patients who cannot tolerate spironolactone (eg due to painful gynaecomastia), use:
amiloride 10 mg orally, daily. If needed, increase dose up to 20 mg daily. ascites amiloride
If spironolactone or amiloride alone is inadequate, add:
furosemide (frusemide) 40 mg orally, daily. If needed, increase dose by 40 mg daily every 4 to 7 days, up to a maximum of 160 mg daily. ascites furosemide (frusemide) furosemide (frusemide) furosemide (frusemide)
Diuretics can cause hyponatraemia, changes in potassium concentration and kidney impairment; check serum electrolyte concentrations and kidney function regularly. If the patient develops hyponatraemia or an elevated serum creatinine concentration, reduce the dose of diuretics or consider stopping diuretics altogether. Diuretics may be reintroduced, or their doses increased, after resolution of electrolyte and creatinine abnormalities. Dilutional hyponatraemia in patients without kidney impairment may respond to fluid restriction of 800 to 1500 mL/day.
In selected high-risk patients who have persistent ascites despite diuretic therapy (spironolactone 200 mg daily or more, plus furosemide [frusemide] 25 mg daily or more), but who do not require regular large-volume paracentesis, regular albumin infusions can reduce mortality.