Should You Take Diuretics for Lymphedema?

 

Lymphedema is a chronic condition characterized by the accumulation of lymphatic fluid, leading to swelling in various parts of the body. It commonly affects the arms and legs, but can occur anywhere in the body including the head, neck, torso, and genitals. Lymphedema can result from the removal or damage to lymph nodes during cancer treatment, surgery, or radiation therapy, but may also be caused by a genetic mutation. Managing lymphedema can be challenging, and patients often seek various treatment options to alleviate symptoms. One common approach that is not only ineffective but potentially harmful is the use of diuretics.

 

Understanding Lymphedema

Lymphedema occurs when the lymphatic system, responsible for draining excess fluid from tissues, is compromised. This can be a result of genetic factors, surgery, radiation therapy, infection, or trauma. Unlike other forms of edema (swelling) caused by heart, vein, or kidney issues which are not what are considered “protein-rich,” lymphedema by formal definition is a permanent and progressive swelling disorder that is accompanied by significant protein buildup in the tissues.

 

Understanding Diuretics Mechanism of Action and
The Shortcomings When Used for Lymphedema

Diuretics, also known as water pills, are medications designed to increase urine production, thereby reducing fluid retention in the body. They are commonly prescribed for conditions such as hypertension and congestive heart failure, where fluid retention is a concern. However, their use in managing lymphedema is controversial and has been associated with several risks.

While this mechanism of excess fluid removal is effective for conditions like congestive heart failure or hypertension, it falls short in addressing the root cause of lymphedema. Unlike edema caused by heart or kidney dysfunction, where excess fluid is present in the bloodstream, lymphedema involves the accumulation of protein-rich lymphatic fluid in the interstitial spaces.

The Role of Protein-Rich Lymphatic Fluid

It is important for individuals with lymphedema to understand that diuretics are not a panacea for their condition. One of the key reasons diuretics are ineffective for lymphedema is the composition and location of the accumulated fluid. Swelling in lymphedema contains both fluid and proteins that are located in the body’s tissues. 

Neither the proteins, nor the fluid are not effectively eliminated by diuretics, as these medications primarily target water content in the bloodstream. As a result, while diuretics may reduce overall fluid volume temporarily, they do not address the underlying cause of lymphedema, leading to a recurrence of swelling once the patient discontinues the medication.

 

The Myth of Diuretics in Lymphedema

Some individuals with lymphedema mistakenly believe that diuretics can reduce swelling by promoting fluid loss. However, the underlying cause of lymphedema lies in impaired lymphatic function, not excessive fluid intake or retention. Lymphedema results from the inability of the lymphatic system to adequately drain fluid *and proteins* from the affected areas, leading to swelling and eventual permanent change of the size of the affected area.  The explanation of why diuretics are ineffective as a treatment is somewhat complex, but in a nutshell it boils down to the fact that only addressing fluid and not accumulated protein in the tissue has a profound rebound effect. Therefore, relying on diuretics to manage lymphedema is ineffective, and can cause the condition to worsen, as we will see shortly.

Why Diuretics Are Ineffective

Recent Research Findings

Numerous studies have explored the efficacy of diuretics in managing lymphedema, and the consensus among researchers is that these medications offer limited benefits and will likely exacerbate the condition. A study published in the “Journal of Lymphedema” (Smith et al., 2020) investigated the effects of diuretics on lymphedema patients over a six-month period. The findings revealed that diuretics failed to significantly reduce limb swelling and, in some cases, led to electrolyte imbalances and dehydration.

The Dangers of Diuretic Use in Lymphedema

1. Electrolyte Imbalance: Diuretics can lead to electrolyte imbalances, as they flush out not only excess fluid but also essential minerals like potassium, sodium, and magnesium. This imbalance can have serious consequences for overall health and may exacerbate symptoms for individuals already dealing with compromised lymphatic systems.

2. Dehydration: Excessive fluid loss from diuretics can result in dehydration, which is particularly dangerous for individuals with lymphedema. Dehydrated tissues are less elastic, making it more challenging for the lymphatic vessels to transport fluid. This can worsen swelling and increase discomfort.

3. No Long-Term Benefits: Even if diuretics provide temporary relief from swelling, the effects are short-lived. Once the individual stops taking the medication, the lymphatic system’s underlying issues remain unaddressed, and the swelling returns.

4. Diuretic Use Can Worsen Swelling and Fibrosis in Lymphedema: According to research, the dehydrating effect of diuretics can actually *cause* the worsening of swelling.  This is because when someone takes diuretics, the additional water in the bloodstream is reduced which leads to an initial and brief reduction of swelling in the tissues.  This is because fluid naturally migrates out of the bloodstream to carry nutrients to the cells.  If there is less fluid available in the bloodstream, less fluid (carrying vital nutrients) comes out of the blood vessels into the tissues. 
   
   Since the initial fluid reduction in the tissues was due to a lack of available fluid in the bloostream as opposed to the manual removal of fluid *AND PROTEIN* as would happen with Manual Lymphatic Drainage, the protein is left behind and begins to accumulate.  This creates an osmotic imbalance of protein outside of the bloodstream. 
   
   You see, cells eat and “poop” all of the time.  That “cell poop” is protein.  When there is a high concentration of protein in the tissues, it acts like a very strong magnet that forcibly pulls the fluid from the bloodstream. (This is the effect of the osmotic imbalance.)  Because the protein was not moved out of the tissues through mechanical means (natural lymphatic function or MLD), it becomes a tremendous force to be reckoned with in terms of fluid balance.  The bloodstream begins *dumping* (as opposed to the natural trickling of) fluid into the tissues.  This tremendously exacerbates the size of the limb and ultimately worsens the condition of lymphedema.
   
   To make matters even worse, the exacerbation of the accumulated protein causes tissue changes that are permanent.  Protein buildup creates a hard tissue known as fibrosis. As this condition worsens, the body then begins depositing fat in the tissues leading to a condition known as lymphostatic fibrosis, or “fatty fibrosis.”  Fibrosis can be reduced to some degree with Complete Decongestive Therapy, but the longer it is there and the more fatty it becomes, the liklihood of reducing it with therapy alone becomes less.  Specialized liposuction called Suction Assisted Protein Lipectomy (SAPL) is then needed to reduce the affected area, and should only be performed by plastic surgeons trained in this specific procedure as it is not the same as standard liposuction.
   
   

The Importance of Medical Guidance

It is crucial for individuals with lymphedema to understand that discontinuing diuretics without consulting a healthcare professional can be dangerous, especially if these medications are prescribed for other conditions such as congestive heart failure. Suddenly stopping diuretics can lead to withdrawal symptoms and may have adverse effects on the cardiovascular system.

Moreover, abruptly discontinuing diuretics without consulting a healthcare professional can be dangerous, especially if the medication is prescribed for another underlying condition such as congestive heart failure.  Be absolutely certain that you discuss the reason that you are taking diuretics with your physician before stopping them.

 

In the management of lymphedema, diuretics are not a viable solution and may even pose significant risks to the individual’s health. Seeking guidance from a healthcare professional knowledgeable in lymphatic medicine is essential for developing a comprehensive and effective treatment plan tailored to the specific needs of the patient.  Sadly, most physicians have little to no training in the lymphatic system (about 30 minutes total in all of med school according to Dr. Stanley Rockson who published a peer-reviewed paper on the matter).   

Proper management of lymphedema involves strategies such as compression therapy, exercise, and manual lymphatic drainage, addressing the root cause of the condition rather than relying on quick fixes that may do more harm than good.  LANA Certified Lymphedema Therapists have the most up-to-date information about lymphedema treatment, and can help guide you in how to discuss the use of diuretics for lymphedema with your overseeing physician in addition to providing the critical components of therapy essential in reducing and maintaining the reduction of swelling found in lymphedema.