Management of Ascites in Liver Cirrhosis

Introduction to Diuretic Therapy

The American Association for the Study of Liver Diseases (AASLD) recommends spironolactone monotherapy as the initial treatment for cirrhotic ascites, typically initiated at 50-100mg/day and can be increased up to 400mg/day 1
When spironolactone alone is insufficient, a loop diuretic should be added, as supported by the Clinical and Molecular Hepatology and Hepatology guidelines 1, 2, 3

Bumetanide is similar to furosemide in action and efficacy, with 0.5mg of bumetanide equivalent to approximately 20mg of furosemide, which is within the recommended starting dose range of 20-40mg/day for furosemide 1, 2, 3
The AASLD Practice Guidance notes that torsemide or bumetanide may improve natriuresis in patients with suboptimal response to furosemide 2

The combination of an aldosterone antagonist and loop diuretic helps maintain electrolyte balance, with loop diuretics counteracting hyperkalemia from spironolactone, and spironolactone counteracting hypokalemia from loop diuretics 1, 4
Monitor serum electrolytes, creatinine, and weight regularly, and watch for signs of hyponatremia, acute kidney injury, hepatic encephalopathy, and excessive weight loss 1
If the patient doesn't respond adequately, consider increasing spironolactone before increasing the bumetanide dose, as aldosterone antagonists are more effective for sodium retention in cirrhosis 1

Overdiuresis can lead to intravascular volume depletion, renal impairment, hepatic encephalopathy, and hyponatremia 3
Medication interactions can worsen ascites, and patients should not take NSAIDs, ACE inhibitors, or angiotensin receptor blockers while on diuretic therapy 1
Electrolyte disturbances, such as hyperchloremic normal anion gap metabolic acidosis, can occur with spironolactone and may be partially offset by loop diuretics 4

Start by adding bumetanide 0.5mg daily to current spironolactone 25mg daily, and monitor electrolytes, renal function, and weight after 3-7 days 1
Adjust the dose as needed, considering increasing spironolactone to 50-100mg daily before increasing bumetanide, and evaluate for therapeutic paracentesis if ascites remains tense despite optimized medical therapy 1, 2