Well tolerated spironolactone-related hyponatremia

Prevalence, Risk Factors, and Mortality of Patients Presenting with Moderate and Severe Hyponatremia in Emergency Departments

Background

Hyponatremia is among the most common electrolyte disturbances encountered in clinical practice and is associated with a high rate of morbidity and mortality. However, there are very limited data on adult cases presenting to emergency departments with hyponatremia.

Objectives

This study aimed to evaluate the frequency, clinical characteristics, and outcomes in hyponatremic patients presenting to emergency departments.

Methods

This retrospective study analyzed all patients older than 18 years who visited our institution's emergency department between October 2018 and October 2019 and has a serum sodium (Na) level <130 mmol/L.

Results

Among 24,982 patients who visited the emergency department and had a documented serum sodium level, 284 were included. Patients' median age was 67.13 ± 14.8 years. Younger patients are less likely to develop severe hyponatremia compared to older patients (adjusted odds ratio (AOR): 0.415; 95% confidence interval (CI): 0.231-0.743; p=0.003). Asymptomatic hyponatremia and gastrointestinal manifestations were the most common presenting hyponatremia symptoms (33.7% and 24.2%, respectively). Proton pump inhibitor (PPI) use, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACE/ARB) use, and spironolactone use (OR = 2.6 and 3.9, 2.3 with a p=0.02, 0.03, and 0.05, respectively) were associated with increased odds of severe hyponatremia. There is no difference in the overall mortality rate within 6 months of presentation between severe and moderate hyponatremia groups (11.1% versus 16.2%, p=0.163).

Conclusion

Moderate and severe hyponatremia are not uncommon among patients presenting to emergency departments. Moderate hyponatremia can be asymptomatic with clinical significance. Older patients, use of PPI, use of ACEi/ARBs, and spironolactone use were associated with an increased risk of severe hyponatremia compared to moderate. Further prospective analysis of a larger population is needed to confirm our findings.

Evidence-based hyponatremia management in liver disease

Hyponatremia is primarily a water balance disorder associated with high morbidity and mortality. The pathophysiological mechanisms behind hyponatremia are multifactorial, and diagnosing and treating this disorder remains challenging. In this review, the classification, pathogenesis, and step-by-step management approaches for hyponatremia in patients with liver disease are described based on recent evidence. We summarize the five sequential steps of the traditional diagnostic approach: 1) confirm true hypotonic hyponatremia, 2) assess the severity of hyponatremia symptoms, 3) measure urine osmolality, 4) classify hyponatremia based on the urine sodium concentration and extracellular fluid status, and 5) rule out any coexisting endocrine disorder and renal failure. Distinct treatment strategies for hyponatremia in liver disease should be applied according to the symptoms, duration, and etiology of disease. Symptomatic hyponatremia requires immediate correction with 3% saline. Asymptomatic chronic hyponatremia in liver disease is prevalent and treatment plans should be individualized based on diagnosis. Treatment options for correcting hyponatremia in advanced liver disease may include water restriction; hypokalemia correction; and administration of vasopressin antagonists, albumin, and 3% saline. Safety concerns for patients with liver disease include a higher risk of osmotic demyelination syndrome.

Severe hyponatremia due to trimethoprim-sulfamethoxazole-induced SIADH

Hyponatremia, a serum sodium level of <135 mEq/L, is the most common electrolyte abnormality occurring in 5%–35% of hospitalized patients. It is a predictor of increased morbidity and mortality. Diuretics, psychotropic, and antiepileptic drugs are commonly implicated in drug-induced hyponatremia. Trimethoprim-sulfamethoxazole and spironolactone are two commonly prescribed drugs; unfortunately, most providers are unfamiliar with these two drugs causing hyponatremia. Simultaneous use of trimethoprim-sulfamethoxazole and spironolactone can cause serious drug interactions that increase the risk of hyponatremia, hyperkalemia, and overall mortality. Despite recommendations to avoid using these two drugs concurrently, many healthcare providers continue to prescribe them together. We report a case of an elderly female with severe hyponatremia caused by trimethoprim-sulfamethoxazole superimposed on a chronic but stable mild hyponatremia.

Hyponatremia in Cirrhosis

Hyponatremia is the most common electrolyte disorder encountered in clinical practice, and it is a common complication of cirrhosis reflecting an increase in nonosmotic secretion of arginine vasopressin as a result of of the circulatory dysfunction that is characteristic of advanced liver disease. Hyponatremia in cirrhosis has been associated with poor clinical outcomes including increased risk of morbidity and mortality, poor quality of life, and heightened health care utilization. Despite this, the treatment of hyponatremia in cirrhosis remains challenging as conventional therapies such as fluid restriction are frequently ineffective. In this review, we discuss the epidemiology, clinical outcomes, pathogenesis, etiology, evaluation, and management of hyponatremia in cirrhosis.

Non-thiazide diuretics and hospitalization due to hyponatraemia: A population-based case-control study

OBJECTIVE

Diuretics are often implicated in hyponatraemia. While thiazides constitute one of the most common causes of hyponatraemia, data on loop diuretics and potassium-sparing agents are limited and partly conflicting. The objective of this investigation was to study the association between use of different types of non-thiazide diuretics and hospitalization due to hyponatraemia.

DESIGN, PATIENTS AND MEASUREMENTS

This was a register-based case-control study on the adult Swedish population. By linking national registers, patients hospitalized with a principal diagnosis of hyponatraemia (n = 11,213) from 1 October 2005 through 31 December 2014 were compared with matched controls (n = 44,801). Multivariable logistic regression, adjusted for multiple confounders, was used to analyse the association between use of diuretics and hyponatraemia. In addition, newly initiated use (≤90 days) and ongoing use were examined separately.

RESULTS

Adjusted odds ratios (aORs) (95% CI) were 0.61 (0.57-0.66) for the use of furosemide, 1.69 (1.54-1.86) for the use of amiloride and 1.96 (1.78-2.18) for the use of spironolactone and hospitalization due to hyponatraemia. For newly initiated therapy, aORs ranged from 1.23 (1.04-1.47) for furosemide to 3.55 (2.75-4.61) for spironolactone. The aORs for ongoing use were 0.52 (0.47-0.57) for furosemide, 1.62 (1.47-1.79) for amiloride and 1.75 (1.56-1.98) for spironolactone.

CONCLUSIONS

Ongoing use of furosemide was inversely correlated with hospitalization due to hyponatraemia, suggesting a protective effect. Consequently, if treatment with furosemide precedes the development of hyponatraemia by some time, other causes of hyponatraemia should be sought. Spironolactone and amiloride may both contribute to hyponatraemia; this effect is most prominent early in treatment.

Chronic hyponatremia in patients with proximal femoral fractures after low energy trauma: A retrospective study in a level-1 trauma center

Introduction

We evaluated the prevalence and influence of chronic hyponatremia in patients with low energy trauma. We also investigated the influence of medication and diseases on hyponatremia.

Material and methods

This retrospective study included 314 cases of proximal femoral fracture due to low energy trauma. Patients were treated in the University Medical Center Goettingen within 3 years. Hyponatremia was defined as serum sodium <135 mmol/L at admission.

Results

Overall, 15.6% of patients in the low energy trauma group had hyponatremia. Among patients older than 80 years, women showed distinctly higher rates of hyponatremia (female: 16.4%; male: 5.9%). In contrast only 4.7% of patients who underwent elective hip arthroplasty showed hyponatremia. Patients on sartanes and aldosterone antagonists showed significantly higher rates of hyponatremia. Alcoholism was significantly associated with hyponatremia.

Conclusions

We confirmed a high prevalence of chronic hyponatremia in patients with fractures due to low energy trauma. Our data underscore chronic hyponatremia as a contributing factor to hip fractures. Women older than 80 have a higher risk of developing hyponatremia. Sartanes, aldosterone antagonists, and alcohol disease are associated with hyponatremia. Treating hyponatremia may decrease the risk of fracture after low energy trauma. Therefore, physicians of different specialties should focus on treatment of chronic hyponatremia to reduce the fracture rate associated with low energy trauma.

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15.6% of patients with prox. femur fracture after low energy trauma had hyponatremia.

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Hyponatremia rate in group of patients before hip arthroplasty was only 4.7%.

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Sartanes, aldosterone antagonists, and alcohol disease are associated with hyponatremia.

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Women older than 80 have a higher risk of developing hyponatremia.

A systematic review and meta-analysis of thiazide-induced hyponatraemia: time to reconsider electrolyte monitoring regimens after thiazide initiation?

AIMS

Hyponatraemia is one of the major adverse effects of thiazide and thiazide-like diuretics and the leading cause of drug-induced hyponatraemia requiring hospital admission. We sought to review and analyze all published cases of this important condition.

METHODS

Ovid Medline, Embase, Web of Science and PubMed electronic databases were searched to identify all relevant articles published before October 2013. A proportions meta-analysis was undertaken.

RESULTS

One hundred and two articles were identified of which 49 were single patient case reports. Meta-analysis showed that mean age was 75 (95% CI 73, 77) years, 79% were women (95% CI 74, 82) and mean body mass index was 25 (95% CI 20, 30) kg m(-2) . Presentation with thiazide-induced hyponatraemia occurred a mean of 19 (95% CI 8, 30) days after starting treatment, with mean trough serum sodium concentration of 116 (95% CI 113, 120) mm and serum potassium of 3.3 (95% CI 3.0, 3.5) mm. Mean urinary sodium concentration was 64 mm (95% CI 47, 81). The most frequently reported drugs were hydrochlorothiazide, indapamide and bendroflumethiazide.

CONCLUSIONS

Patients with thiazide-induced hyponatraemia were characterized by advanced age, female gender, inappropriate saliuresis and mild hypokalaemia. Low BMI was not found to be a significant risk factor, despite previous suggestions. The time from thiazide initiation to presentation with hyponatraemia suggests that the recommended practice of performing a single investigation of serum biochemistry 7-14 days after thiazide initiation may be insufficient or suboptimal. Further larger and more systematic studies of thiazide-induced hyponatraemia are required.

Electrolyte disorders in community subjects: prevalence and risk factors

BACKGROUND

Electrolyte disorders have been studied mainly in hospitalized patients, whereas data in the general population are limited. The aim of this study was to determine the prevalence and risk factors of common electrolyte disorders in older subjects recruited from the general population.

METHODS

A total of 5179 subjects aged 55 years or more were included from the population-based Rotterdam Study. We focused on hyponatremia, hypernatremia, hypokalemia, hyperkalemia, and hypomagnesemia. Multivariable logistic regression was used to study potential associations with renal function, comorbidity, and medication. The adjusted mortality also was determined for each electrolyte disorder.

RESULTS

A total of 776 subjects (15.0%) had at least 1 electrolyte disorder, with hyponatremia (7.7%) and hypernatremia (3.4%) being most common. Diabetes mellitus was identified as an independent risk factor for hyponatremia and hypomagnesemia, whereas hypertension was associated with hypokalemia. Diuretics were independently associated with several electrolyte disorders: thiazide diuretics (hyponatremia, hypokalemia, hypomagnesemia), loop diuretics (hypernatremia, hypokalemia), and potassium-sparing diuretics (hyponatremia). The use of benzodiazepines also was associated with hyponatremia. Hyponatremic subjects who used both thiazides and benzodiazepines had a 3 mmol/L lower serum sodium concentration than subjects using 1 or none of these drugs (P < .001). Hyponatremia and hypomagnesemia were independently associated with an increased mortality risk.

CONCLUSIONS

Electrolyte disorders are common among older community subjects and mainly associated with diabetes mellitus and diuretics. Subjects who used both thiazides and benzodiazepines had a more severe degree of hyponatremia. Because even mild electrolyte disorders were associated with mortality, monitoring of electrolytes and discontinuation of offending drugs may improve outcomes.