Dropsy

I’ve heard the term dropsy for many years, but like so many things you hear, unless you have a reason for figuring out what it means, you tend to ignore it. So I ignored dropsy, figuring it was something akin to the vapors or vertigo and it certainly didn’t affect me. Well, now I have learned that dropsy is an old medical term for what we now call edema – the abnormal accumulation of fluid in body tissues that causes swelling. The word comes from the Greek “hydrops,” meaning water. Historically, dropsy was used to describe the visible symptom of fluid retention, particularly when it caused swelling in the legs, ankles, abdomen, or other parts of the body. Physicians would observe patients with swollen limbs or distended bellies and diagnose them with “dropsy” without necessarily understanding the underlying cause. Today we understand that edema can result from various conditions including heart failure, kidney disease, liver problems, venous insufficiency, or certain medications. Edema is most prevalent in people who are overweight…and that now includes me. I have had mild edema in my ankles for over five years, but lately it has increased and is bothering me enough to cause me to try to deal with it. Up until now my doctors have said that since I don’t have diabetes and they have no evidence of heart disease, there is little to be done other than use compression socks and keep my legs elevated (tough to comply if you want to be less sedentary). I am choosing to go beyond those observations to do a full-court press on the thing.

Edema occurs when fluid leaks out of blood vessels (how does THAT happen?) and accumulates in surrounding tissues. Several mechanisms can cause this fluid imbalance. Heart failure is a major cause – when the heart can’t pump effectively, blood backs up in vessels, increasing pressure and forcing fluid into tissues. This often causes swelling in the legs, ankles, and feet. Now, when you are my size and have been your entire life, you realize that congestive heart failure is a possibility and needs to always be in mind. It occurs when the heart muscle becomes weakened or stiffened and cannot pump blood effectively throughout the body. The most common cause is coronary heart disease (which I have been told I do not have). I don’t seem to get much, if any, plaque in my arteries (heart, neck, ankles or anywhere) nor on my teeth for that matter. I’ve been told I process cholesterol well, so maybe that’s why. Another cause of congestive heart failure is high blood pressure, which is something I’ve been medicated for for many years (even though I still question the measurement techniques). Hypertension forces the heart to work harder to pump blood against increased resistance. Over years, this extra workload can weaken and enlarge the heart muscle…so who knows. Then there are various cardiomyopathies and heart valve problems, which I have no evidence of having. There is also arrhythmia…who among us does not occasionally have an irregular heart beat? Maybe its sleep apnea, but then I’ve successfully used a CPAP for thirty years, so I doubt that. But congestive heart failure typically develops gradually as the heart tries to compensate for underlying problems, so its possible that it has become less able to meet the body’s demands for blood flow. My doctor now wants a new echo-cardiogram to look into any heart enlargement going on. I will book that test soon.

Another cause of edema stems from venous problems: blood clots, varicose veins, or other circulation issues can cause fluid to pool in affected areas, commonly the legs, but I don’t seem to have that going on. To be sure, my doctor has ordered a venous insufficiency extremity scan and what is called a duplex low extremity arterial bilateral scan. These will supposedly tell us how the blood and lymphatic flow in my lower legs is going, since that seems to be where the problem is focused.

There is also a chance that the edema is being caused by medications. God knows, side effects are probably as big a cause of medical problems as the underlying things that give rise to the prescribing of those medications. For my high blood pressure treatment, I take a daily cocktail of Carvidilol (beta-blocker), Clonidine (relaxes blood vessels and decreases heart rate), Ramipril (ACE inhibitor), and Hydralizine (vasodialator), which my doctor has fidgeted with repeatedly over the past five years. One of the big effects has been on my pulse rate, which is now extraordinarily low and hovers in the high 40s when I am at rest. Let’s think about this for a moment…these meds are all doing the job of reducing my blood pressure (I tend to run about 140/71 or a little high on the systolic and low on the diastolic), but they have also lowered my pulse rate to an artificially low level. Logic tells me that a lower pulse rate might well mean that my lower extremities are not getting enough hyrdrolic action to clear out all that lymphatic fluid accumulating in my ankles. Also, certain drugs can cause fluid retention, including some blood pressure medications, steroids, NSAIDs, and diabetes medications, but I also take a diuretic (currently moving from furosemide to bumetanide) so we’ll see if that helps.

Furosemide and bumetanide are both what are called loop diuretics – medications that help remove excess fluid from the body by blocking sodium reabsorption in the kidneys. They’re often used to treat edema and heart failure, but have some key differences. Bumetanide is much more potent than furosemide. About 1 mg of bumetanide equals roughly 40 mg of furosemide in diuretic effect. My recent change will take me from 20mg to 80mg, so expect me to be running for the can pretty regularly. This means smaller doses of bumetanide are needed to achieve the same fluid removal. Bumetanide has more consistent and predictable absorption from the digestive tract (about 80-100% bioavailability) compared to furosemide (10-90% bioavailability). Furosemide typically works for 6-8 hours, while bumetanide’s effects last about 4-6 hours. Both start working within an hour when taken orally. Furosemide is often the first-choice loop diuretic due to familiarity and cost considerations, but we are now ratcheting this up to bumetanide to see if that helps. Some studies suggest bumetanide may cause less hearing damage (ototoxicity) at equivalent doses…wait a minute…another potential side effect of all this?

So, while edema is hard to manage, we are going to give it a try. Edema can be challenging to treat for several interconnected reasons. Edema is usually a symptom of another condition rather than a disease itself. Successfully treating it often requires addressing the root cause. Also, the body’s fluid regulation involves complex interactions between the heart, kidneys, blood vessels, and various hormones. Removing too much fluid too quickly with diuretics can cause dehydration, kidney problems, or dangerous electrolyte imbalances. Finding the right balance requires careful monitoring and adjustment. And then there is the natural aging and progressive nature of whatever underlying problem is causing the edema. This all requires a very personalized approach that takes time to optimize through trial and adjustment. So, I am beginning the process rather than just ignoring the problem.

I remember my step-father, Irving, having these problems and wrestling with them for twenty years until he died at age 95. I’m really not sure I should be doing all this since, like over-medication, I could well end up with lots of added side-effects with or without any benefit to my puffy ankles. We’ll see, but at least I have documented it for posterity now and if I get hit by a dropsy bus, at least everyone will be able to understand what happened…or not.