ArcaMax

DEAR DR. ROACH: Your recent column regarding edema from venous insufficiency caught my interest since I was diagnosed with venous insufficiency over 25 years ago. Your recommendation was to raise your legs several times a day for 20 minutes a day, if I recall. Also, you mentioned that sometimes furosemide (Lasix) is prescribed but that you prefer not to recommend this method. My question is why?

I have been using 20 mg of furosemide almost daily for several years, and it seemed to help. I was told that it robs the body from vitamin B, so I do take supplemental vitamin B. Why not use furosemide to treat edema from venous insufficiency? -- M.B.

ANSWER: Venous insufficiency is a condition where the pressure inside the veins is high enough that fluid comes out of the blood vessels and goes into the tissues. Fluid in the tissues is called edema. In most cases, the valves in the veins that prevent the backup of blood fail, leading to high pressure in the veins and dilated, swollen ("varicose") veins. But chronic venous insufficiency may also happen after damage to the blood vessels, such as a blood clot.

Fluid can also come out of structurally normal veins when the oncotic pressure (the tendency for fluid to stay in the veins due to proteins in the blood) is low. This happens because of the loss of proteins from kidney or liver disease or severe malnutrition.

Diuretics are often used to treat excess fluid from heart failure, but even if your blood pressure goes way down, diuretics do not appreciably reduce the pressure in the small vessels in your legs, which is what is driving fluid out. Diuretics like furosemide have no role in the treatment of chronic venous insufficiency, but unfortunately, I still see them used frequently. However, a person can have both heart failure and venous insufficiency and may require a diuretic like furosemide.

The main conservative treatment for venous insufficiency without other underlying conditions, in addition to periodic leg elevation, is support stockings, which increase the pressure in surrounding tissues so that the fluid does not leak out of the veins. Many of my patients don't like them; the stockings are very tight when people first put them on, but as they work and the legs get less swollen, they aren't as tight and become more comfortable.

They can also be hard to put on, especially by yourself, but there are devices like "stocking donners" that make it much easier. Stockings should be removed at night. There are also many companies now that make stockings that aren't as hideously ugly as they were in the past.

Exercise is also helpful for chronic venous insufficiency. The muscles of the leg act to force the blood in the veins to go back to the heart, reducing pressure in the veins and reducing edema.

It's not vitamin B that is removed by furosemide but potassium and magnesium. Some people need to supplement these or use a second drug that helps keep these minerals in the body. Still, it's better to avoid furosemide completely unless it's necessary.

More severe cases of venous insufficiency (for example, when ulcers develop, or if compression therapy isn't working) may require surgical treatments. There are many different kinds of surgical procedures that are effective at treating venous insufficiency, which are far more effective and less damaging than the old vein stripping procedures. A vascular surgeon is an essential consultant for a person with venous insufficiency that isn't getting better with conservative management.

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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu.

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