Ankle edema

Therapy of congestive heart failure. By lowering peripheral resistance, diuretics aid the heart in ejecting blood (reduction in afterload, pp. 132, 306) cardiac output and exercise tolerance are increased. Due to the increased excretion of fluid, EEV and venous return decrease (reduction in preload, p. 306). Symptoms of venous congestion, such as ankle edema and hepatic enlargement, subside. The drugs principally used are thiazides (possibly combined with K+-sparing diuretics) and loop diuretics. 

A 50-year-old woman is seen in the emergency department complaining of a severe headache, shortness of breath, and ankle edema. Her vision is blurry and her blood pressure is 200/140 mm Hg. A blood test reveals azotemia and proteinuria. A chest radiograph reveals an enlarged cardiac silhouette. Is this a hypertensive emergency, and if so what pharmacological treatment might be considered ... 

Amantadine was originally introduced as an antiviral compound (see Chapter 50), but it is modestly effective in treating symptoms of parkinsonism. It is useful in the early stages of parkinsonism or as an adjunct to levodopa therapy. Its mechanism of action in parkinsonism is not clear, but amantadine may affect dopamine release and reuptake. Additional sites of action may include antagonism at muscarinic and A-methyl-D-aspartate (NMDA) receptors. Adverse effects include nausea, dizziness, insomnia, confusion, hallucinations, ankle edema, and livedo reticularis. Amantadine and the anticholinergics may exert additive effects on mental functioning. 

Julie Singer is a 55-year-old white woman who was admitted to the emergency department in acute distress. A previous physical examination showed hypertension and diabetes mellitus type 2. The patient s present medications include enalapril 40 mg, nifedipine 60 mg, and 100 U insulin. A physical examination revealed prominent ankle edema, a palpable spleen, and hepatomegaly. Chest radiography revealed diffuse cardiac enlargement and left ventricular hypertrophy. Based upon the history and clinical hndings, what is your diagnosis and what treatment do you recommend ... 

Adverse effects include headache ankle edema, hypotension, dizziness, flushing, weight gain, nausea, GI disturbances including anorexia, nausea, vomiting, constipation diarrhoea and taste disturbances. Occasionally there is gingival hyperplasia, skin rash and transient elevation in liver enzyme values. 

Side effects such as ankle edema seem less pronounced for lipophilic compounds (lacidipine, lercanidipine), most likely due to their slow onset of action. 

Hypokalemia, occurring either in isolation or with hypertension, has been reported regularly in a small fraction of patients (23). Marked ankle edema with weight gain was seen in a patient taking itraconazole 400 mg/day, in whom there was no explanation other than the use of the drug after withdrawal of the itraconazole the symptoms disappeared. Hypokalemia and edema have also been... 

Manidipine is a dihydropyridine calcium channel blocker that can be given once a day for hypertension. In a comparison of manidipine 10 mg/day and amlodipine 5 mg/day in a multicenter, randomized, double-blind study in 530 patients with mild-to-moderate hypertension, the two drugs had comparable antihypertensive effects, but manidipine was associated with a significantly lower incidence of ankle edema (1). Nevertheless, adverse events caused withdrawal from treatment in a similar number of patients, 23 with manidipine and 26 with amlodipine. 

Calcium channel blockers Group toxicity dihydropyridines can cause headache, ankle edema, gingival hyperplasia and flushing nondihydropyridine can cause bradycardia, constipation, gingival hyperplasia, and AV block ... 

Analbuminemia. Only 20 or so famflies with inherited analbuminemia have been reported, attesting to the protein s physiological importance. Although affected individuals have plasma albumin levels less than 0.5 g/L (about 1% of normal), they were originally reported to be clinically normal except for mild edema (usually none before the second to fourth decades of Life) and altered lipid metabolism. In 1996, the presence of lipodystrophy in women and osteoporosis, hypotension, arcus lipoides corneae, and xanthomatosis in some patients was first reported. In one patient, ankle edema disappeared rapidly with intravenous albumin infusion however, she developed signs of hypocalcemia during infusions. The infusions did not affect her lipodystrophy. In spite of the lipid abnormalities in affected individuals, there is no increased risk for atherosclerosis. The plasma half-life of infused albumin in affected individuals is 50 to 60 days or approximately three times normal. 

CALCIUM CHANNEL BLOCKERS Dihydropyridine headache, ankle edema. 

Hydrochlorthiazide (12.5-mg tablets one tablet daily for ankle edema)... 

Ankle edema occurred in about 5% of patients treated with both rosiglitazone and pioglitazone in some cases, pulmonary edema can develop. Edema was more frequent in insulin combination therapy with either drug (about 15% compared with 5.4-7% with insulin alone). The reasons for fluid retention and peripheral edema with TZDs are multifactorial. The increase in plasma volume may result from a reduction in renal excretion of sodium and an increase in sodium and free water retention. TZDs may also interact synergistically with insulin to cause arterial vasodilatation, leading to sodium reabsorption and an increase in extracellular volume [61,62], In case reports, the edema has not been responsive to diuretics [63,64]. 

A 74-year-old man with chronic myeloid leukemia took imatinib mesylate 400 mg bd. His other medications were perindopril and ator-vastatin. After 2 months he developed angio-edema, probably related to perindopril, which was withdrawn and replaced by amlodipine 10 mg/day. After 2 weeks he developed typical symptoms of imatinib toxicity nausea, marked periorbital, and ankle edema. Diuretics improved the edema, but after 10 days he complained of numbness of the chin and bilateral pain and numbness in the soles of the feet. Light touch and vibration sense were reduced, but power and reflexes were intact. Imatinib was reduced to 400 mg/day and amlodipine was withdrawn. The edema, numbness and neuropathic pain resolved. Despite residual plantar numbness he was able to increase the dose of imatinib to 600 mg/day without worsening symptoms. About 1 month later he took two doses of amlodipine in error and developed nausea and palpitation, which resolved when the amlodipine was withdrawn. Nerve conduction testing 1 month later showed a mild sensorimotor axonal neuropathy. After 9 months the neuropathy had resolved despite continuing imatinib therapy. 

Belcaro GV, Rulo A, Grimaldi R (1990) Capillary filtration and ankle edema in patients with venous hypertension treated with TTFCA. Angiology 41 12-18... 

Edema of the extremities is one of the most frequent symptoms of ACD and has been reported in about 50 per cent of cases. In some patients there is simultaneous swelling of the eyelids, or periorbital edema only (Curry and Fleisher 1961). Rarely, the edema becomes quite severe as in the case of Hofmann and Hauser (1962) and VoRSTER (1964). Here elephantiasis of the left lower leg developed in addition to bilateral ankle edema... 

On physical examination she was normoten-sive. The heart rate was eighty-six and the rhythm at the time was regular. No murmur was evident. The point of maximum impulse was shifted to the left. There was jugular venous distension and mild ankle edema. She had scars of the neck, anterior chest —midline and left pectoral area, relative to previous surgeries. The protrusion of a mechanical device was evident in her abdominal wall. 

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