Use of Metolazone in the Treatment of Ascites due to Liver Disease

In 8 out of 20 patients with chronic liver disease ascites was controlled with metolazone, 10 required additional amiloride or spironolactone to achieve control, and 2 were resistant to all diuretic therapy. An initial dose of 5 mg daily is suggested, though much higher doses may be required ultimately. When metolazone is used alone the high incidence of hypokalaemia (80%), hypochloraemia (35%), and encephalopathy (35%) compared with the results of other series is a major disadvantage and indicates that this drug should be used with caution in patients with liver disease. Hypokalaemia can usually be prevented by the simultaneous administration of amiloride or spironolactone. The low incidence of azotaemia (5%) suggests that this diuretic may be useful if renal function is particularly impaired.