Why do manic patients have lower limb Oedema more often? Prog Neuropsy Biol Psych.Dec.2013

17.10.2013

Lower limb oedema occasionally become a problem for patients with severe mental disorders. Many medications have been linked to the appearance of this. Can lower limb oedema (LLO)  linked to diagnosis more than medications? Hochman E, Krivoy A, Shoval G, Valevski A, Weizman A, Fischel T addressed this question using hospital data for 10 years.

Study: Retrospective cross-sectional study conducted using medical charts of 2529 patients admitted between 2002 and 2012.   Presence of LLO was retrieved from the records of physical examination.  Data on medications before admission was collected along with other clinical and demographic variables.

Results: LLO was identified in 3.8% of patients. 10% of manic patients, 2.6% of those with non affective psychosis  and 2.7% of those with depression had LLO.This difference remained significant after controlling for all likely confounding factors. (age at admission, sex, education, no. of previous admissions, cardiovascular co-morbidity, total protein,  substance abuse and psychotropic drugs, including lithium, prescribed at admission) . Acute manic episode leading to hospitalisation, was associated with an increased risk of LLO compared with depressive episode (OR 8.72,95% CI: 3.53–21.52, p b 0.001), and NAP episode (OR 3.96,95% CI: 2.16–7.26, p b 0.001).

Various mechanisms have been suggested to explain this. Ateration in circulatory serotonin and noradrenaline levels can mediate psychotropic drug-related edema by induction of vascular smooth muscle relaxation leading eventually to peripheral vasodilatation and to local edema. Peripheral dopamine can stimulate cardiac contractility, vasodilatation and induce diuresis and natriuresis .Dopamine might also antagonise vasopressin and renal renin angiotensin system.Alterations in albumin ( secondary to immune system activation /  reflectve of inflammatory process) which is important colloid -oncotic pressure generation is also suggested as a possible mechanism.

Increased physical activity is another explanation. Excitement scores or CK levels (which  increase with  excessive activity) were not different in manic group in this study.

 Limitations:  Retrospective chart review analysis , clinical assessment  was unstructured. No follow up.

Conclusion:  Patients admitted with a manic episode are at higher risk for LLO and its possible complications . Clinicians need to give particular attention to this.

 Summary of the article:

Acute manic episode is associated with an increased risk of lower limb edema. Hochman E, Krivoy A, Shoval G, Valevski A, Weizman A, Fischel T. Prog Neuropsychopharmacol Biol Psychiatry. 2013 Aug 29;47C:99-103

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