Diuretics, sometimes referred to as “water pills,” are not effective for treating lipedema or uncomplicated lymphedema.
Lipedema and lymphedema may be similar at times in appearance, but these conditions differ in their root cause. Lipedema is a chronic fat disorder causing painful, symmetrical adipose tissue buildup in the limbs, while lymphedema is the buildup of protein-rich fluid trapped in the tissue due to damaged or blocked lymph vessels.
How do diuretics work?
There are two compartments of fluid in the body, intracellular fluid (ICF) and extracellular fluid (ECF). ICF makes up about 40% of total body weight, and ECF makes up about 20% of total body weight. ECF is subdivided into three distinct regions:
— Interstitial fluid fills the spaces between tissue cells and makes up about 12% of body weight.
— Blood plasma makes up the liquid portion of blood and makes up about 5% of body weight.
— Transcellular fluids are specialized fluids and isolated by cellular barriers, such as cerebrospinal fluid, synovial joint fluid, and ocular fluid, and make up about 1–2% of body weight.
Diuretic drugs primarily remove fluid from the ECF compartment. Most conventional diuretics (such as loop diuretics) work by blocking the reabsorption of sodium and chloride in the kidneys. Because water naturally follows sodium, this triggers the excretion of salt and water into the urine, increasing urine output.
This fluid is pulled directly from the blood plasma and interstitial fluid (which comprise the ECF) and lowers blood and plasma volume, which reduces pressure inside the blood vessels. As fluid leaves the blood vessels and moves into the kidneys, the drop in pressure creates a shift that draws excess fluid out of the tissues and into the bloodstream.
Why are diuretics counterproductive?
Diuretics do not cause the body to manufacture or deposit more protein into tissues, but they do cause a relative increase in protein concentrations. This occurs through a mechanism known as hemoconcentration.
Diuretics prompt the kidneys to excrete excess water and sodium from the bloodstream. As the fluid volume in the blood vessels drops, water is pulled out of the interstitial tissue spaces to compensate. Protein molecules are large and are too bulky to move easily across these fluid barriers. While the water is rapidly evacuated, the proteins are left behind. Because there is less water to dilute them, the concentration (or ratio) of protein rises.
The protein-rich fluid remaining in the interstitial tissues makes the local environment thicker and more gel-like. The trapped proteins naturally attract water and cause increased swelling, producing firmer, denser tissue. The higher concentration of proteins also encourages the hardening of tissue (fibrosis). Long-term use of diuretics can cause dehydration, electrolyte imbalances, and rebound swelling.
Why won’t diuretics work for lipedema?
According to Amato & Benitti (2021), diuretics are not indicated, as there is no accumulation of liquid.
Lipedema is primarily an abnormal accumulation of subcutaneous fat and connective tissue and not a systemic fluid-overload problem which water pills can flush. Besides worsening tissue fibrosis over time, the use of diuretics for lipedema can cause dehydration and electrolyte imbalances without shrinking the underlying lipedema fat.
“An example, a few years ago, one of the heart failure doctors kept coming to me and saying, these patients have swollen legs, and they’re not responding to diuretics. Well, one of the treatments of lipedema is to not use diuretics. I think the point here is that not all doctors recognize lipedema and lymphedema as well. I think, again, you can make the diagnosis with a good history and physical examination. In that case of the heart failure patient, I said, well, she had lipedema. We don’t like to give them diuretics, and we had moved on to a different form of treatment.”
John Bartholomew MD, Cleveland Clinic
Marcia Byrd MD relates that, “While diuretics don’t address the underlying fat accumulation, they may provide temporary relief from fluid retention that often accompanies lipedema. These medications should only be used under medical supervision, as improper use can lead to dehydration and electrolyte imbalances.”
Why won’t diuretics work for lymphedema?
According to the Lymphoedema Support Network, diuretics or water tablets are generally not recommended for lymphoedema as they do not help reduce the swelling. However, they may be used when swelling is severe or complicated or in circumstances where there may be more than one cause for the swelling (as in heart or renal problems).
“Diuretics promote the excretion of whole-body water as urine. Therefore, in the initial phase, these agents are effective in some patients. However, lymphedema treatment is limited, and these agents may induce body-fluid/electrolyte imbalance. Long-term administration should be avoided.”
Ogawa (2012). Recent advances in medical treatment for lymphedema.
“Use of diuretics for patients with lymphedema will merely increase concentration of proteins and macromolecules in the interstitial space and speed the inflammatory process that leads to irreversible skin and soft tissue changes and increased risk of cellulitis. Therefore, use of diuretics solely for reduction of swelling in patients with lymphedema is contraindicated.”
Farrow (2010). Phlebolymphedema — A common underdiagnosed and undertreated problem in the wound care clinic.
Diuretics are appropriate for heart failure, some kidney and liver conditions, and blood pressure management. If you have been prescribed one for a reason like that, keep taking it and talk to the prescriber about hydration rather than stopping.
Research
Amato, A., & Benitti, D. (2021). Lipedema can be treated non-surgically: A report of 5 cases. American Journal of Case Reports.
Farrow, W. (2010). Phlebolymphedema — A common underdiagnosed and undertreated problem in the wound care clinic. Journal of the American College of Certified Wound Specialists.
Mead, C., & Wheeler, V. (2010). Are diuretics safe and effective for lymphedema? Evidence-Based Practice.
Ogawa, Y. (2012). Recent advances in medical treatment for lymphedema. Annals of Vascular Diseases.
Additional Information
Does drinking water help lipedema? | Lipedema Institute
Get the facts about lymphedema | Sigvaris Group
Lymphedema and lipedema: Notes on diagnosis | Cleveland Clinic
Lymphedema in the legs | Franciscan Health
Managing lipedema: Medications, supplements, and surgery options | Byrd Lipedema Surgery Center
Myth: There is edema in lipedema | International Lipoedema Association
Your questions answered | Lymphoedema Support Network