Hyponatremia Management Resource Guide

March 21, 2011

Up-to-date collection of hyponatremia diagnostic and management guidelines, case reviews, and other resources.

We’ve compiled this up-to-date collection of hyponatremia diagnostic and management guidelines, case reviews, and other resources.

Hyponatremia Treatment Guidelines 2007: Expert Panel Recommendations

By Verbalis et al., published in a November 2007 supplement to the American Journal of Medicine. Presents the findings of an expert panel that “assessed the potential contributions of aquaretic nonpeptide small-molecule arginine vasopressin receptor (AVPR) antagonists to hyponatremia therapies.” Among its conclusions, the panel identified “appropriate treatment populations and possible future indications for aquaretic AVPR antagonists.”

Commentary on “Hyponatremia Treatment Guidelines 2007”

Published in the February 2009 issue of The Clinical Biochemist Reviews, this article by Paul Chubb notes that although severe hyponatraemia “is important because of its associated mortality and morbidity risks, and because its treatment also carries the risk of severe morbidity,” our understanding of its pathophysiology is incomplete. Indeed, although many authors have published on this topic, there is “little in the way of evidence-based guidelines.” Chubb goes on to provide extensive commentary on the Verbalis et al. paper linked to above, noting that although the paper “is not a systematic review carried out according to the principles of evidence based medicine,” it “explains the pathophysiology of the hyponatraemias, updates the knowledge of more recently discovered clinical conditions and highlights areas of uncertainty that remain to be explained.”

Management of Symptomatic Hyponatremia

This algorithm from the UK provides guidance on managing “Hypotonic Hyponatraemia with Seizures CNS Symptoms Respiratory Depression” and “Hypotonic Hyponatraemia with Mild Symptoms / Asymptomatic Acute Hyponatraemia,” defined as plasma sodium less than 125 mmol/L.

Management Strategies for Hyponatremia in Neurosurgical Patients

The November 2009 issue of Neurosurgery featured this review of hyponatremia literature scientific studies published from 1950 through 2008, which formed the basis of “an evaluation and treatment protocol for hyponatremia in neurosurgical patients at the University of Florida.” Although this objective was accomplished, the authors noted that “the practice management recommendations relied heavily on expert opinion because of a paucity of class I evidence literature on hyponatremia.”

Treatment Overview: Hyponatremia

This UpToDate topic reminds clinicians that initial treatment of patients with chronic/gradual onset hyponatremia “typically consists of slow correction of the hyponatremia via fluid restriction or, if volume depletion is present, the administration of isotonic saline (or oral salt tablets),” although isotonic saline may worsen hyponatremia in patients with SIADH. Vasopressin receptor antagonists “also may be helpful.” Initial recommended therapy for patients with severe hyponatremia includes “hypertonic saline with or without vasopressin receptor antagonists.”

Management of Hyponatremia in a Variety of Settings

The authors “review the treatment of hyponatremia in order to provide clinicians with a sound approach in a variety of settings in which severity, symptoms, and underlying disease states influence therapy” and discuss “the current role of vasopressin antagonists in treatment.” Originally published in the October 2010 issue of the Cleveland Clinic Journal of Medicine.

Emergency Medicine Hyponatremia Case Review

From the American College of Emergency Physicians, this resource notes that hyponatremia is “one of the more common electrolyte abnormalities in clinical medicine,” the clinical manifestations of which “depend on multiple factors including the chronicity of the symptoms, the absolute level of sodium, and the patient's overall health.” As part of a general discussion of management strategies for hyponatremia, the authors present the case of a patient who presented to the emergency department with severe hyponatremia, outline the statements made by a plaintiff expert witness regarding the clinical characteristics of hyponatremia and the “proper” management of this condition, and summarize the findings of the Standard of Care Panel, which acknowledged that “multiple literature sources state that there is significant controversy in the management of hyponatremia,” despite the certainty expressed by the plaintiff’s expert witness.

Management of Hyponatremia

This useful resource from the maker of Samsca notes that “the risk of hyponatremia-associated complications must be balanced against the risk of serum sodium correction. Factors that should be considered before treating include the rapidity of onset of hyponatremia; degree, duration, and symptomatology of hyponatremia; and the presence or absence of risk factors for neurologic complications.”

SIADH and Hyponatremia

Because “hyponatraemia is such a heterogeneous and complex disorder, and because tolvaptan has been approved only for the treatment of hyponatraemia secondary to SIADH,” this article, published in a 2009 supplement to NDT Plus (“a bi-monthly journal which enhances, complements and adds value to the leading nephrology journal Nephrology Dialysis Transplantation”), suggests that “a rational use of vasopressin-receptor antagonists first requires a proper diagnosis of SIADH.” To assist in this task, this article reviews hyponatraemia and SIADH and discusses the potential role of vasopressin-receptor antagonists.

HCPLive wants to know:

What are the most important factors to consider when evaluating a patient for a possible diagnosis of hyponatremia?

What prophylactic measures can be taken to help prevent hyponatremia in at-risk patients?

What is your preferred treatment for patients with gradual onset hyponatremia? What factors do you consider when selecting this treatment? What is your preferred treatment for patients with severe hyponatremia?

Leave a comment below!