Why does my mother have swelling in the legs?

Q: My 62 years old mother weighs 85 kg and her height is 5.2 feet. She has hypertension and is taking Olmesartan, Metoprolol, Succinate and Rosuvastatin. Recently she showed signs of water retention and hence she had undergone all tests for the same. The results suggested high uric acid - 7.40 mg/dl, proteins in the blood - 8.70 g/dl and traces of proteins in the urine - 10 mg/dl. Except this all liver function test (LFT), kidney function test (KFT) and thyroid were within the normal limits. Now she is having swelling in the legs, which seems to be due to water retention. She complains of pain in the legs too with irritation and burning sensation in the feet. She also complains of weakness all the time, as there is no strength in her legs with joint pains. I have put her on Allopurinol 100 mg twice daily, and it’s almost 3 days now. The only improvement she has shown over this time is a bit reduction in the swelling but the burning and irritation sensation is still the same. She had mild fever in the morning with a temperature of 97.5 degrees whereas in the evening it goes to 99 degrees or 99.5 degrees. Does she need to be started with some diuretic such as Torsemide to reduce water retention? Or should she continue with Allopurinol only? Will this serve the purpose? For weakness she is also taking Methylcobalamin with other multivitamins. Please suggest if she can take some calcium supplement too (such as Cholecalciferol) for the ongoing problem. She takes Calcitonin nasal spray on alternate days for slip disc problem. Can she continue with this? What are the precautions or dos and don’ts for the raised uric acid levels?

A:Your mother is on hypertension and cholesterol medication, which do not cause water retention as a side effect. Although you have mentioned normal liver, kidney and thyroid functions but the level of proteins and uric acid in the blood tests are high. She also needs evaluation for her mild rise in temperature in the evening (although it remains < 100 degree F). I would suggest the following investigations to be done for her-

• Haemogram with ESR and peripheral smear.
• Ratio of albumin to globulin.
• CPK levels which is a muscle enzyme since she is on a statin.
• Echocardiography to check cardiac status in view of her water retention tendency and to determine need for diuretics.
• USG abdomen including kidney size and echogenicity.
• Chest X-ray PA.
• Serum calcium, phosphorus and vitamin B12 levels, blood sugar.

She can continue the current medication. She can be tried on a low dose of diuretic under medical supervision. Also start her on adequate calcium and vitamin D supplementation, as she is in the postmenopausal group prone to osteoporosis. A bone densitometry is useful in identifying the extent of the problem. Calcitonin does not have a role in management of slip disc and is a very mild agent for osteoporosis treatment.

Encourage your mother to keep her legs elevated on pillows during the night and avoid keeping them hanging down unsupported while sitting. Avoid excessive salt intake. Foods rich in uric acid like red meat, tomatoes, rajma may be restricted in quantity. She has a high body mass index (BMI) indicating obesity and needs to be on a weight reducing diet.