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Iijima Y, Nakayama M, Miwa T, Yakou F, Tomiyama H, Shikuma J, Ito R, Tanaka A, Manda N, Odawara M. Nephroprotective Effects of Dapagliflozin in Patients with Type 2 Diabetes. Intern Med 2023; 62:681-688. [PMID: 36858619 PMCID: PMC10037009 DOI: 10.2169/internalmedicine.6685-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Abstract
Objective This study analyzed changes in the estimated glomerular filtration rate calculated using cystatin C (eGFRcys) and sodium excretion in the urine after administering dapagliflozin as an add-on therapy to conventional treatment for diabetes. Methods This was a single-center, single-group, prospective interventional study. Dapagliflozin was administered to improve the plasma glucose control in 30 subjects with type 2 diabetes mellitus (age 53±8 years old; 66.6% men). Blood and urine tests were performed before and 6 and 12 months after dapagliflozin administration. The daily sodium excretion was estimated with the Kawasaki formula using second-morning urine samples. Results The eGFRcys did not markedly differ before and 6 months after the dapagliflozin administration but was significantly increased after 12 months (p<0.001), and the estimated daily sodium excretion was also significantly increased (p<0.001 at 6 months and p=0.002 at 12 months). The systolic and diastolic blood pressures tended to decrease after administration. The HbA1c level after the administration of dapagliflozin tended to be lower in the T3 group, showing the smallest increase in changes in the estimated daily sodium excretion from baseline to 6 months (28.2-107.5 mEq/day), than in the combined groups of T1 (219.5-110.1 mEq/day) and T2 (101.4-28.9 mEq/day). In contrast, the eGFRcys was significantly higher in the combined groups of T1 and T2 than that in the T3 group at both 6 and 12 months (p=0.031 and p=0.007, respectively). Conclusions Add-on therapy with dapagliflozin increased the urinary sodium excretion and decreased the blood pressure even in the early phase of this therapy. Our results suggest that dapagliflozin add-on therapy may exert nephroprotective effects in subjects with type 2 diabetes mellitus.
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Affiliation(s)
- Yasuhiro Iijima
- Department of Internal Medicine, Todachuo General Hospital, Japan
- Department of Diabetes, Endocrinology and Metabolism, Tokyo Medical University Hospital, Japan
- Department of Shirakawa Community Medicine, Tokyo Medical University, Japan
- Diabetes Center, Manda Memorial Hospital, Japan
| | - Masafumi Nakayama
- Cardiovascular Center, Todachuo General Hospital, Japan
- Cooperative Major in Advanced Biomedical Sciences, Joint Graduate School of Tokyo Women's Medical University and Waseda University, Japan
| | - Takashi Miwa
- Department of Diabetes, Endocrinology and Metabolism, Tokyo Medical University Hospital, Japan
| | - Fumiyoshi Yakou
- Department of Internal Medicine, Todachuo General Hospital, Japan
- Department of Diabetes, Endocrinology and Metabolism, Tokyo Medical University Hospital, Japan
| | | | - Junpei Shikuma
- Department of Diabetes, Endocrinology and Metabolism, Tokyo Medical University Hospital, Japan
| | - Rokuro Ito
- Department of Diabetes, Endocrinology and Metabolism, Tokyo Medical University Hospital, Japan
| | - Akihiko Tanaka
- Department of Internal Medicine, Todachuo General Hospital, Japan
| | - Naoki Manda
- Diabetes Center, Manda Memorial Hospital, Japan
| | - Masato Odawara
- Department of Diabetes, Endocrinology and Metabolism, Tokyo Medical University Hospital, Japan
- Department of Shirakawa Community Medicine, Tokyo Medical University, Japan
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Poch E, Molina A, Piñeiro G. Syndrome of inappropriate antidiuretic hormone secretion. Med Clin (Barc) 2022; 159:139-146. [PMID: 35659417 DOI: 10.1016/j.medcli.2022.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 10/18/2022]
Abstract
Hyponatremia is the most frequent electrolytic disorder in hospitalized patients, and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH), the most frequent cause of hiponatremia with clinically normal extracellular volume. It consists of a disorder of the regulation of body water that obeys to different causes, mainly cancer, pulmonary illnesses, disorders of the central nervous system and diverse drugs. As in any hiponatremia it a physiological knowledge of the regulation of body water and sodium is essential as well as the application of precise diagnostic criteria in order to manage the problem with an effective treatment. The available data until the moment show that the clinical diagnosis of SIADH made by professionals is mainly not supported on the established criteria drawn by experts and this lack of accuracy probably hits in the therapeutic result. The basis of the treatment of the SIADH is to correct its cause, water restriction, solutes (sodium chloride) and the use of vaptans in case of failure of the previous measures.
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Affiliation(s)
- Esteban Poch
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Barcelona, España; IDIBAPS; Departamento de Medicina, Universidad de Barcelona, Barcelona, España.
| | - Alicia Molina
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Barcelona, España
| | - Gastón Piñeiro
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Barcelona, España
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Bassi V, Fattoruso O. The Combined Use of Fractional Urate and Potassium Excretion in the Diagnosis of Diuretic-Induced Hyponatremia. Cureus 2021; 13:e15308. [PMID: 34221761 PMCID: PMC8238019 DOI: 10.7759/cureus.15308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction Thiazide and loop-diuretics are among the most widely used drugs in the therapy of hypertension and chronic heart failure. Furthermore, hyponatremia is the most prevalent electrolyte imbalance affecting up to 25-30% of hospitalized patients while syndrome of inappropriate antidiuresis (SIAD) is involving approximately 35% of hyponatraemic inpatients. Clinical and laboratoristic algorithms support the differential diagnosis of hypotonic hyponatremia in actual guidelines of SIAD, but a potential bias is represented by the misleading clinical assessment of the extracellular volume status in diuretic-treated patients where the necessity of withdrawal of the therapy is mandatory. We investigated the role of fractional uric acid and potassium excretion (FEUA and FEK) in the differential diagnosis of hypotonic hyponatremia in SIAD and diuretic-treated patients. Methods Thirty-six SIAD, 30 thiazide-induced hyponatremia (TIH), and 32 diuretic-induced hyponatremia (DIH) patients were investigated calculating FEUA and FEK values in receiver operating characteristic (ROC) curve analysis to improve the diagnostic approach of hypotonic hyponatremia. Results The combination of the two investigated markers showed different significative results generating patterns useful to discriminate among the three different hyponatremic groups. Conclusion The fractional uric acid and potassium excretion could be considered as new markers in the diagnostic approach of hyponatremic diuretic-treated patients where classical algorithms could fail.
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Affiliation(s)
- Vincenzo Bassi
- Unità Operativa Complessa (UOC) di Medicina Generale e Lungodegenza, San Giovanni Bosco Hospital, Azienda Sanitaria Locale (ASL) Napoli 1 Centro, Naples, ITA
| | - Olimpia Fattoruso
- Unità Operativa Complessa (UOC) di Patologia Generale, San Giovanni Bosco Hospital, Azienda Sanitaria Locale (ASL) Napoli 1 Centro, Naples, ITA
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Mareev VY, Garganeeva AA, Ageev FT, Arutunov GP, Begrambekova YL, Belenkov YN, Vasyuk YA, Galyavich AS, Gilarevsky SR, Glezer MG, Drapkina OM, Duplyakov DV, Kobalava ZD, Koziolova NA, Kuzheleva EA, Mareev YV, Ovchinnikov AG, Orlova YA, Perepech NB, Sitnikova MY, Skvortsov AA, Skibitskiy VV, Chesnikova AI. [The use of diuretics in chronic heart failure. Position paper of the Russian Heart Failure Society]. ACTA ACUST UNITED AC 2021; 60:13-47. [PMID: 33522467 DOI: 10.18087/cardio.2020.12.n1427] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 10/26/2020] [Indexed: 11/18/2022]
Abstract
The document focuses on key issues of diuretic therapy in CHF from the standpoint of current views on the pathogenesis of edema syndrome, its diagnosis, and characteristics of using diuretics in various clinical situations.
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Affiliation(s)
- V Yu Mareev
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia Faculty of Fundamental Medicine, Lomonosov Moscow State University, Russia
| | - A A Garganeeva
- "Research Institute for Cardiology", Siberian State Medical University, Tomsk National Research Medical Center, Russian Academy of Sciences
| | - F T Ageev
- Scientific Medical Research Center of Cardiology, Russia
| | - G P Arutunov
- Russian National Research Medical University named after Pirogov, Moscow
| | - Yu L Begrambekova
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia Faculty of Fundamental Medicine, Lomonosov Moscow State University, Russia
| | - Yu N Belenkov
- Sechenov Moscow State Medical University, Moscow, Russia
| | - Yu A Vasyuk
- Moscow State Medical and Dental University named after Evdokimov, Moscow, Russia
| | | | - S R Gilarevsky
- Russian Medical Academy of Postgraduate Education, Moscow, Russia
| | - M G Glezer
- Sechenov Moscow State Medical University, Moscow, Russia
| | - O M Drapkina
- National Medical Research Centre for Therapy and Preventive Medicine, Moscow, Russia
| | - D V Duplyakov
- Samara Regional Clinical Cardiological Dispensary, Russia
| | - Zh D Kobalava
- Russian State University of Peoples' Friendship, Moscow, Russia
| | - N A Koziolova
- Federal State Budgetary Institution of Healthcare of Higher Education "Perm State Medical University named after Academician E.A. Wagner ", Russia
| | - E A Kuzheleva
- "Research Institute for Cardiology", Siberian State Medical University, Tomsk National Research Medical Center, Russian Academy of Sciences, Russia
| | - Yu V Mareev
- National Medical Research Centre for Therapy and Preventive Medicine, Moscow, Russia Robertson Centre for Biostatistics, Glasgow, Great Britain
| | | | - Ya A Orlova
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia Faculty of Fundamental Medicine, Lomonosov Moscow State University, Russia
| | | | - M Yu Sitnikova
- Almazov National Medical Research Center, St. Petersburg, Russia
| | - A A Skvortsov
- Scientific Medical Research Center of Cardiology, Russia
| | - V V Skibitskiy
- Kuban State Medical University" of the Ministry of Health of the Russian Federation, Russia
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Grattagliano I, Mastronuzzi T, D'Ambrosio G. Hyponatremia associated with long-term medication use in the elderly: an analysis in general practice. J Prim Health Care 2019; 10:167-173. [PMID: 30068472 DOI: 10.1071/hc17084] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION The aim of this study is to determine the prevalence of hyponatremia, its association with long-term medication use and underlying chronic conditions, the rate of hospitalisation and death within 3 months from its discovery and its management in community-dwelling older people. METHODS One year of data for ~5635 patients aged >65 years was extracted from the databases of 19 general practitioners (GPs); 2569 (45.6%) were checked for hyponatremia. RESULTS Hyponatremia occurred in 205 (8.0%) of 2569 checked individuals: 78.5% (161/205) had hypertension, 31.2% (64/205) diabetes, 23.9% (49/205) chronic renal failure; 38.0% (78/205) received diuretics, 36.6% (75/205) renin-angiotensin system antagonists (ACE-I/ARB) and 9.8% (20/205) serotonin reuptake inhibitors. Drug consumption was higher in hyponatremic patients, although only diuretics, ACE-I/ARB, anti-arrhythmics and opioids were significantly associated with hyponatremia. The likelihood of hyponatremia trebled when four drugs were taken, and it was seven-fold higher with the use of six drugs. Hyponatremia was associated with a higher prevalence of chronic illnesses and higher rate of hospitalisation (13.7% vs 7.7%, P = 0.005) and death (3.9% vs 1.8%, P < 0.035). The use of at least one long-term medication was associated with hospitalisation or death in hyponatremic patients (10% vs 6.3%, P = 0.010). Less than 20% of hyponatremic patients had their sodium level checked again after 1 month. DISCUSSION Hyponatremia is not uncommon among community-living older patients, especially in patients taking medications potentially causing hyponatremia. Hyponatremic patients are likely to encounter more serious events, including hospitalisation and death. Targeted training of GPs is desirable to improve their practice.
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Affiliation(s)
| | - Tecla Mastronuzzi
- Italian College of General Practitioners and Primary Care, Bari, Italy
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Mukartihal R, Puranik HG, Patil SS, Dhanasekaran SR, Menon VK. Electrolyte imbalance after total joint arthroplasty: risk factors and impact on length of hospital stay. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 29:1467-1472. [DOI: 10.1007/s00590-019-02471-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 06/12/2019] [Indexed: 10/26/2022]
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Channavajjhala SK, Bramley R, Peltz T, Oosthuyzen W, Jia W, Kinnear S, Sampson B, Martin N, Hall IP, Bailey MA, Dear JW, Glover M. Urinary Extracellular Vesicle Protein Profiling and Endogenous Lithium Clearance Support Excessive Renal Sodium Wasting and Water Reabsorption in Thiazide-Induced Hyponatremia. Kidney Int Rep 2018; 4:139-147. [PMID: 30596177 PMCID: PMC6308385 DOI: 10.1016/j.ekir.2018.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 08/22/2018] [Accepted: 09/17/2018] [Indexed: 12/11/2022] Open
Abstract
Introduction Thiazide diuretics are among the most widely used antihypertensive medications worldwide. Thiazide-induced hyponatremia (TIH) is 1 of their most clinically significant adverse effects. A priori TIH must result from excessive saliuresis and/or water reabsorption. We hypothesized that pathways regulating the thiazide-sensitive sodium-chloride cotransporter NCC and the water channel aquaporin-2 (AQP2) may be involved. Our aim was to assess whether patients with TIH would show evidence of altered NCC and AQP2 expression in urinary extracellular vesicles (UEVs), and also whether abnormalities of renal sodium reabsorption would be evident using endogenous lithium clearance (ELC). Methods Blood and urine samples were donated by patients admitted to hospital with acute symptomatic TIH, after recovery to normonatremia, and also from normonatremic controls on and off thiazides. Urinary extracellular vesicles were isolated and target proteins evaluated by western blotting and by nanoparticle tracking analysis. Endogenous lithium clearance was assessed by inductively coupled plasma mass spectrometry. Results Analysis of UEVs by western blotting showed that patients with acute TIH displayed reduced total NCC and increased phospho-NCC and AQP2 relative to appropriate control groups; smaller differences in NCC and AQP2 expression persisted after recovery from TIH. These findings were confirmed by nanoparticle tracking analysis. Renal ELC was lower in acute TIH compared to that in controls and convalescent case patients. Conclusion Reduced NCC expression and increased AQP2 expression would be expected to result in saliuresis and water reabsorption in TIH patients. This study raises the possibility that UEV analysis may be of diagnostic utility in less clear-cut cases of thiazide-associated hyponatremia, and may help to identify patients at risk for TIH before thiazide initiation.
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Affiliation(s)
- Sarath K Channavajjhala
- Division of Therapeutics and Molecular Medicine, University of Nottingham, Nottingham, UK.,NIHR-Nottingham Biomedical Research Centre, Nottinghamshire, UK
| | - Roger Bramley
- Trace Element Laboratory, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Theresa Peltz
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Wilna Oosthuyzen
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Wenjing Jia
- Division of Therapeutics and Molecular Medicine, University of Nottingham, Nottingham, UK.,NIHR-Nottingham Biomedical Research Centre, Nottinghamshire, UK
| | - Sue Kinnear
- Division of Therapeutics and Molecular Medicine, University of Nottingham, Nottingham, UK.,NIHR-Nottingham Biomedical Research Centre, Nottinghamshire, UK
| | - Barry Sampson
- Trace Element Laboratory, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Nick Martin
- Trace Element Laboratory, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Ian P Hall
- Division of Therapeutics and Molecular Medicine, University of Nottingham, Nottingham, UK.,NIHR-Nottingham Biomedical Research Centre, Nottinghamshire, UK
| | - Matthew A Bailey
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - James W Dear
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Mark Glover
- Division of Therapeutics and Molecular Medicine, University of Nottingham, Nottingham, UK.,NIHR-Nottingham Biomedical Research Centre, Nottinghamshire, UK
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Abdul Naseer JF, Chen LL, Gui HS, Ong KY, Cheen MHH, Mamun K. A retrospective case-control study evaluating thiazide-induced hyponatraemia-related hospitalisation among older Singaporeans. PROCEEDINGS OF SINGAPORE HEALTHCARE 2017. [DOI: 10.1177/2010105816669367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction:Thiazide diuretics are recommended as first-line therapy for hypertension in older adults. However, thiazides are also associated with hyponatraemia-related hospitalisations in older patients. This study aims to determine the predictors of hospitalisation due to thiazides usage in older adults.Methods:This is a retrospective matched case-control study. Patients aged ⩾65 admitted due to adverse drug reactions based on International Classification of Diseases, Ninth Revision (ICD9) codes from the period of 1 June to 31 December 2011 in Singapore General Hospital were extracted. Patients with the ICD9 code E944.3 Saluretics causing adverse effects in therapeutic use and who experienced thiazide-induced hyponatraemia were identified. Controls were identified from a pool of patients from outpatient clinics who were prescribed thiazide during the study period. Each case was matched to four controls based on gender and race. Patients’ demographics, length of stay, and cost of hospital admission were obtained.Results:In total, 19 cases with thiazide-induced hyponatraemia were matched with 76 controls. Cases were older than control (78.8±6.1 vs. 75.6±7.0, p=0.052), with the majority being females (84.2%) and Chinese (94.7%). The mean length of stay was 4 (±3) days; the mean cost of stay was SGD 1118 (±898). Serum potassium levels and concurrent use of beta-blockers were identified as unadjusted possible predictors for hospitalisation due to thiazide-induced hyponatraemia.Conclusion:Potential predictors of hospitalisation due to thiazide-induced hyponatraemia include low potassium levels and concurrent use of beta-blockers. Identification of predictors is crucial to guide safe and effective prescribing of thiazides in older patients.
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Affiliation(s)
| | - Li Li Chen
- Department of Pharmacy, Singapore General Hospital, Singapore
| | - Huey Sywu Gui
- Department of Pharmacy, Singapore General Hospital, Singapore
| | - Kheng Yong Ong
- Department of Pharmacy, Singapore General Hospital, Singapore
| | | | - Kaysar Mamun
- Department of Geriatric Medicine, Singapore General Hospital, Singapore
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Yang HJ, Cheng WJ. Antipsychotic use is a risk factor for hyponatremia in patients with schizophrenia: a 15-year follow-up study. Psychopharmacology (Berl) 2017; 234:869-876. [PMID: 28078393 DOI: 10.1007/s00213-017-4525-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 01/02/2017] [Indexed: 01/05/2023]
Abstract
RATIONALE Hyponatremia affects 10% of patients with chronic schizophrenia and can lead to severe consequences. However, the role of antipsychotics and other risk factors in hyponatremia occurrence has remained inconsistent. OBJECTIVE This study examined the association between antipsychotic use and hyponatremia occurrence in patients with schizophrenia. METHODS We utilized the National Health Insurance Research Database to follow 2051 patients with schizophrenia from 1998 to 2013. Among them, 137 (6.7%) developed hyponatremia. Sociodemographic characteristics, physical comorbidities, and psychiatric treatment experiences were compared between those who had hyponatremia and those who did not. A Cox proportional hazards model was used to examine the hazard ratios (HRs) of these characteristics. RESULTS In patients with hyponatremia, the mean age at first hyponatremia occurrence was 54.7 ± 13.9 years, an average of 9.5 ± 4.0 years after schizophrenia diagnosis, and 32.9% of them were off antipsychotics before hyponatremia occurrences. Age at schizophrenia diagnosis (HR = 1.1), low-income household (HR = 2.4), comorbidities (HR = 1.2), and psychiatric admissions (HR = 1.04) were associated with the risks of hyponatremia. Compared with no antipsychotic use, atypical (HR = 2.1) and typical antipsychotics (HR = 3.1) were associated with an elevated risk of hyponatremia, after adjustment for age, sex, and physical comorbidities. Carbamazepine use (HR = 2.9) was also a significant risk factor for hyponatremia (p < 0.05). CONCLUSIONS Antipsychotic use in patients with schizophrenia with polypharmacy should be monitored for hyponatremia occurrences. Clinicians should pay attention to the impact of poor living conditions on hyponatremia occurrence.
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Affiliation(s)
- Hang-Ju Yang
- Department of Emergency Medicine, Jen-Ai Hospital, 483 Dong Rong Road, Taichung, 41265, Taiwan
| | - Wan-Ju Cheng
- Department of Psychiatry, China Medical University Hospital, 2 Yude Road, Taichung, 40447, Taiwan. .,Department of Public Health, China Medical University, 91 Hsueh-Shih Road, Taichung, 40402, Taiwan.
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Turck D, Bresson JL, Burlingame B, Dean T, Fairweather-Tait S, Heinonen M, Hirsch-Ernst KI, Mangelsdorf I, McArdle H, Neuhäuser-Berthold M, Nowicka G, Pentieva K, Sanz Y, Siani A, Sjödin A, Stern M, Tomé D, Van Loveren H, Vinceti M, Willatts P, Aggett P, Martin A, Przyrembel H, Brönstrup A, Ciok J, Gómez Ruiz JÁ, de Sesmaisons-Lecarré A, Naska A. Dietary reference values for potassium. EFSA J 2016. [DOI: 10.2903/j.efsa.2016.4592] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Abstract
Loop diuretics are not recommended in current hypertension guidelines largely due to the lack of outcome data. Nevertheless, they have been shown to lower blood pressure and to offer potential advantages over thiazide-type diuretics. Torsemide offers advantages of longer duration of action and once daily dosing (vs. furosemide and bumetanide) and more reliable bioavailability (vs. furosemide). Studies show that the previously employed high doses of thiazide-type diuretics lower BP more than furosemide. Loop diuretics appear to have a preferable side effect profile (less hyponatremia, hypokalemia, and possibly less glucose intolerance). Studies comparing efficacy and side effect profiles of loop diuretics with the lower, currently widely prescribed, thiazide doses are needed. Research is needed to fill gaps in knowledge and common misconceptions about loop diuretic use in hypertension and to determine their rightful place in the antihypertensive arsenal.
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Affiliation(s)
- Line Malha
- Department of Nephrology and Hypertension, Hypertension Center, NY Presbyterian Hospital-Weill Cornell Medicine, 424 E. 70th Street, New York, NY, 10021, USA
| | - Samuel J Mann
- Department of Nephrology and Hypertension, Hypertension Center, NY Presbyterian Hospital-Weill Cornell Medicine, 424 E. 70th Street, New York, NY, 10021, USA.
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Grammatiki M, Rapti E, Mousiolis AC, Yavropoulou M, Karras S, Tsona A, Daniilidis M, Yovos J, Kotsa K. Patient With Severe Hyponatremia Caused by Adrenal Insufficiency Due to Ectopic Posterior Pituitary Lobe and Miscommunication Between Hypothalamus and Pituitary: A Case Report. Medicine (Baltimore) 2016; 95:e2872. [PMID: 26962783 PMCID: PMC4998864 DOI: 10.1097/md.0000000000002872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Hyponatremia may be one of the clinical manifestations of adrenal insufficiency (AI) and during the diagnostic workup of hyponatremic patients investigation of AI should be included.We report the case of an 82-year-old patient who was admitted to our hospital with clinical symptoms and laboratory findings of hyponatremia. Following the diagnostic algorithm of hyponatremia we reached the diagnosis of AI. Clinician's attention must focus on the underlying cause of AI which in this case was hidden in a miscommunication between hypothalamus and pituitary due to an ectopic posterior pituitary lobe and became apparent by a pituitary magnetic resonance imaging (MRI) scan. Treatment with oral hydrocortisone resulted in full clinical recovery and electrolyte balance, which was maintained after 7 months of follow-up.Secondary AI is related with hyponatremia through increased ADH secretion. Although a hyponatremic episode may be the first presentation of AI, clinical suspicion is of high importance in order to place the right diagnosis. Disruption of communication between hypothalamus and pituitary is a rare but considerable cause of AI.
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Affiliation(s)
- Maria Grammatiki
- From the Department of Endocrinology and Metabolism - Diabetes Center, 1st Clinic of Internal Medicine (MG, ER, ACM, MY, SK, JY, KK); and 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece (AT, MD)
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Huang CC, Chung CM, Hung SI, Pan WH, Leu HB, Huang PH, Chiu CC, Lin LY, Lin CC, Yang CY, Li SY, Chen YC, Wu TC, Lin SJ, Chen JW. Clinical and Genetic Factors Associated With Thiazide-Induced Hyponatremia. Medicine (Baltimore) 2015; 94:e1422. [PMID: 26313793 PMCID: PMC4602917 DOI: 10.1097/md.0000000000001422] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Thiazide diuretics are associated with an increased risk of hyponatremia. The aim of this study was to investigate possible predictors of thiazide-induced hyponatremia.A total of 48 patients admitted to the ward or to the emergency department due to severe thiazide-induced hyponatremia (Na < 125 mmol/L) were enrolled in our study as the case group. Another 211 hypertensive patients with normal sodium levels after treatment with thiazide diuretics were selected as the control group. Twelve tag single nucleotide polymorphism markers were selected from the Potassium Channel, Inwardly Rectifying Subfamily J, Member 1 (KCNJ1) gene: rs1231254, rs2238009, rs1148058, rs675482, rs673614, rs12795437, rs2855800, rs2509585, rs3016774, rs881333, rs4529890, and rs7116606. Clinical and genetic parameters between patients with thiazide-induced hyponatremia and the control group were compared. Logistic regression was used to analyze data.The patients with thiazide-induced hyponatremia were older (P < 0.001), predominantly female (P = 0.008), had a lower mean body mass index (BMI) (P < 0.001), and more commonly used angiotensin II receptor antagonist (P < 0.001) and spironolactone (P = 0.007) compared with the control groups. Analysis with multivariate logistic regression revealed that age (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.08-1.19, P < 0.001), female gender (OR, 4.49; 95% CI, 1.54-13.11, P = 0.006), BMI (OR, 0.80; 95% CI, 0.69-0.93, P = 0.003), and KCNJ1 rs2509585 C/T or T/T polymorphisms (OR, 5.75; 95% CI, 1.25-26.45, P = 0.03) were independent predictors for thiazide-induced hyponatremia.Older female patients with lower BMIs and KCNJ1 rs2509585 C/T or T/T polymorphisms were more likely to develop thiazide-induced hyponatremia.
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Affiliation(s)
- Chin-Chou Huang
- From the Department of Medical Education (C-CH); Department of Medical Research (S-JL, J-WC); Division of Cardiology, Department of Medicine (C-CH, H-BL, P-HH, C-CC, T-CW, S-JL, J-WC); Healthcare and Management Center (H-BL); Division of Endocrinology and Metabolism, Department of Medicine (L-YL); Division of Nephrology, Department of Medicine (C-CL, C-YY, S-yL); Department of Emergency Medicine, Taipei Veterans General Hospital (Y-CC); Cardiovascular Research Center (C-CH, H-BL, P-HH, C-CC, T-CW, S-JL, J-WC); Institute of Pharmacology (C-CH, S-IH, L-YL, J-WC); Institute of Clinical Medicine, National Yang-Ming University (H-BL, P-HH, T-CW, S-JL); Institute of Biomedical Sciences, Academia Sinica (W-HP); Institute of Epidemiology, School of Public Health, National Taiwan University, Taipei (W-HP); Environment-Omics-Disease Research Centre, China Medical University Hospital (C-MC); Graduate Institute of Clinical Medical Science, China Medical University, Taichung (C-MC); and Institute of Population Health Science, National Health Research Institutes, Miaoli, Taiwan, R.O.C. (W-HP)
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14
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Braconnier A, Vrigneaud L, Bertocchio JP. [Hyponatremias: From pathophysiology to treatments. Review for clinicians]. Nephrol Ther 2015; 11:201-12. [PMID: 26095871 DOI: 10.1016/j.nephro.2015.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 04/22/2015] [Accepted: 04/22/2015] [Indexed: 10/23/2022]
Abstract
Hyponatremia could be defined as a public health topic: too many patients are concerned in both hospitalized and general populations; hyponatremia induces lots of clinical outcomes and a great economic burden. Its pathophysiology involves thirst regulation (hypotonic water intakes) and losses regulation (through the kidney under vasopressin control). Diagnostic approach should insure that hyponatremia reflects hypo-osmolality and hypotonicity: first, a false hyponatremia should be ruled out, then a non-hypotonic one. Next step is clinic: extracellular status should be evaluated. When increased, any edematous status should be evoked: heart failure, liver cirrhosis or nephrotic syndrome. When decreased, any cause of extracellular dehydration should be evoked: natriuresis could help distinguishing between renal (adrenal insufficiency, diuretics use or salt-losing nephropathy) or extrarenal (digestive mostly) etiologies. When clinically normal, a secretion of inappropriate antidiuretic hormone (SIADH) should be evoked, once hypothyroidism or hypoadrenocorticism have been ruled out. Therapy depends on the severity of the clinical impact. From extracellular rehydration, through fluid restriction, the paraneoplastic and heart failure-induced SIADH benefit from a new class of drug, available among the therapeutic strategies: aquaretics act through antidiuretic hormone receptor antagonism (vaptans). Their long-term benefits still have to be proven but it is a significant step forward in the treatment of hyponatremias.
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Affiliation(s)
- Antoine Braconnier
- Service de néphrologie, hémodialyse, transplantation, hôpital Maison-Blanche, CHU de Reims, avenue Cognacq-Jay, 51092 Reims cedex, France; Faculté de médecine, université Reims Champagne Ardenne, 51000 Reims, France; Club des jeunes néphrologues, 11, rue Auguste-Mourcou, 59000 Lille, France
| | - Laurence Vrigneaud
- Club des jeunes néphrologues, 11, rue Auguste-Mourcou, 59000 Lille, France; Service de néphrologie, médecine interne, centre hospitalier de Valenciennes, avenue Désandrouin, CS 50479, 59322 Valenciennes cedex, France
| | - Jean-Philippe Bertocchio
- Club des jeunes néphrologues, 11, rue Auguste-Mourcou, 59000 Lille, France; Service d'explorations fonctionnelles rénales et métaboliques, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75908 Paris cedex, France; Université Paris Descartes, 75006 Paris, France.
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Glover M, O'Shaughnessy KM. Molecular insights from dysregulation of the thiazide-sensitive WNK/SPAK/NCC pathway in the kidney: Gordon syndrome and thiazide-induced hyponatraemia. Clin Exp Pharmacol Physiol 2014; 40:876-84. [PMID: 23683032 DOI: 10.1111/1440-1681.12115] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 05/10/2013] [Accepted: 05/14/2013] [Indexed: 12/11/2022]
Abstract
Human blood pressure is dependent on balancing dietary salt intake with its excretion by the kidney. Mendelian syndromes of altered blood pressure demonstrate the importance of the distal nephron in this process and of the thiazide-sensitive pathway in particular. Gordon syndrome (GS), the phenotypic inverse of the salt-wasting Gitelman syndrome, is a condition of hyperkalaemic hypertension that is reversed by low-dose thiazide diuretics or a low-salt diet. Variants within at least four genes [i.e. with-no-lysine(K) kinase 1 (WNK1), WNK4, kelch-like family member 3 (KLHL3) and cullin 3 (CUL3)] can cause the phenotype of GS. Details are still emerging for some of these genes, but it is likely that they all cause a gain-of-function in the thiazide-sensitive Na(+) -Cl(-) cotransporter (NCC) and hence salt retention. Herein, we discuss the key role of STE20/sporulation-specific protein 1 (SPS1)-related proline/alanine-rich kinase (SPAK), which functions as an intermediary between the WNKs and NCC and for which a loss-of-function mutation produces a Gitelman-type phenotype in a mouse model. In addition to Mendelian blood pressure syndromes, the study of patients who develop thiazide-induced-hyponatraemia (TIH) may give further molecular insights into the role of the thiazide-sensitive pathway for salt reabsorption. In the present paper we discuss the key features of TIH, including its high degree of reproducibility on rechallenge, possible genetic predisposition and mechanisms involving excessive saliuresis and water retention. Together, studies of Gordon syndrome and TIH may increase our understanding of the molecular regulation of sodium trafficking via the thiazide-sensitive pathway and have important implications for hypertensive patients, both in the identification of new antihypertensive drug targets and avoidance of hyponatraemic side-effects.
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Affiliation(s)
- Mark Glover
- Division of Therapeutics and Molecular Medicine, University of Nottingham, Nottingham, UK
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16
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Nakayama M, Tomiyama H, Kuwajima I, Saito T, Hokama Y, Fujii Y, Shimizu T, Nakayama T, Yamashina A, Aizawa Y. Low Salt Intake and Changes in Serum Sodium Levels in the Combination Therapy of Low-Dose Hydrochlorothiazide and Angiotensin II Receptor Blocker. Circ J 2013; 77:2567-72. [DOI: 10.1253/circj.cj-13-0287] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Masafumi Nakayama
- Oshima Medical Center
- Department of Cardiology, Tokyo Medical University
| | | | | | - Tetsushi Saito
- Oshima Medical Center
- Department of Cardiology, Niizashiki Central General Hospital
| | - Yohei Hokama
- Oshima Medical Center
- Department of Cardiology, Tokyo Medical University
| | | | | | - Tohru Nakayama
- Department of Health and Nutrition, Kanto Gakuin University College of Human and Environmental Studies
| | | | - Yoshifusa Aizawa
- Department of Research and Development, Tachikawa Medical Center
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17
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Mannesse CK, Vondeling AM, van Marum RJ, van Solinge WW, Egberts TCG, Jansen PAF. Prevalence of hyponatremia on geriatric wards compared to other settings over four decades: a systematic review. Ageing Res Rev 2013; 12:165-73. [PMID: 22588025 DOI: 10.1016/j.arr.2012.04.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 04/23/2012] [Accepted: 04/30/2012] [Indexed: 12/11/2022]
Abstract
Aim of the study was to analyze temporal trends in prevalence of hyponatremia over four decades in different settings. A systematic review of the literature from 1966 to 2009 yielded prevalences of hyponatremia, with standard errors (SE) and pooled estimated means (PEM), calculated by year and setting (geriatric, ICU, other hospital wards, psychiatric hospitals, nursing homes, outpatients). 53 studies were included. Prevalence of hyponatremia was stable from 1976 to 2006, and higher on geriatric wards accept for ICU: e.g. PEM prevalence of mild hyponatremia (serum sodium <135 mM) was 22.2% (95%CI 20.2-24.3) on geriatric wards, 6.0% (95%CI 5.9-6.1) on other hospital wards and 17.2% (SE 7.0) in one ICU-study; for severe hyponatremia (serum sodium<125 mM) these figures were 4.5% (95%CI 3.0-6.1), 0.8% (95%CI 0.7-0.8) and 10.3% (SE 5.6). In nursing homes PEM prevalence of mild hyponatremia was 18.8% (95%CI 15.6-22.2). The higher prevalence on geriatric wards could partly be explained by age-related changes in the regulation of serum sodium. Other underlying factors can be the presence of multiple diagnoses and the use of polypharmacy.
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Affiliation(s)
- Cyndie K Mannesse
- Department of Geriatric Medicine, Vlietland Hospital, JH Schiedam, The Netherlands.
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18
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Yam FK, Eraly SA. Syndrome of inappropriate antidiuretic hormone associated with moxifloxacin. Am J Health Syst Pharm 2012; 69:217-20. [DOI: 10.2146/ajhp110201] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Felix K. Yam
- Skaggs School of Pharmacy and Pharmaceutical Sciences
| | - Satish A. Eraly
- School of Medicine, University of California San Diego, San Diego
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19
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Rastogi D, Pelter MA, Deamer RL. Evaluations of hospitalizations associated with thiazide-associated hyponatremia. J Clin Hypertens (Greenwich) 2012; 14:158-64. [PMID: 22372775 DOI: 10.1111/j.1751-7176.2011.00575.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The prevalence of hypertension in the United States has grown dramatically in recent years. Thiazide diuretics have played a major role in the rising rate of blood pressure (BP) control. Accompanying this has been the appearance of adverse drug events, including hospitalizations associated with thiazide-associated hyponatremia (HTAH). Hyponatremia is a common yet often overlooked side effect of this drug class. Identification of HTAH risk factors may aid in creating strategies to prevent hospitalizations. This is a retrospective, case-controlled study of 10,805 patients (1802 cases, 9003 controls) examining HTAH risk factors within a group-model integrated-care organization. Multivariate analysis revealed that age (odds ratio [OR], 1.75; 95% confidence interval [CI], 1.58-1.93), angiotensin-converting enzyme (ACE) inhibitor use (OR, 1.53; 95% CI, 1.16-2.00), and hypokalemia (OR, 40.94; 95% CI, 26.46-66.33) were most associated with HTAH. Urinary tract infection (UTI), type 2 diabetes, hyperlipidemia, and gastroesophageal reflux disease (GERD) were also found to be HTAH risk factors. Potassium supplements (OR, 0.60; 95% CI, 0.44-0.83) and weight (OR, 0.91; 95% CI, 0.88-0.93) had protective effects. A predictive model was developed to determine overall HTAH risk given the presence of individual risk factors. Age, weight, hypokalemia, GERD, type 2 diabetes, UTI, and ACE inhibitor use independently correlated with an increased risk of HTAH. This model may be applied in clinical practice to guide thiazide prescribing.
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Affiliation(s)
- Divaker Rastogi
- Kaiser Permanente Woodland Hills Medical Center, 5601 De Soto Ave., Woodland Hills, CA, USA.
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20
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21
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Leung AA, Wright A, Pazo V, Karson A, Bates DW. Risk of thiazide-induced hyponatremia in patients with hypertension. Am J Med 2011; 124:1064-72. [PMID: 22017784 DOI: 10.1016/j.amjmed.2011.06.031] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Revised: 06/24/2011] [Accepted: 06/24/2011] [Indexed: 01/06/2023]
Abstract
BACKGROUND Although hyponatremia is a well-recognized complication of treatment with thiazide diuretics, the risk of thiazide-induced hyponatremia remains uncertain in routine care. METHODS We conducted a retrospective cohort study using a multicenter clinical research registry to identify 2613 adult outpatients that were newly treated for hypertension between January 1, 2000 and December 31, 2005 at 2 teaching hospitals in Boston, Massachusetts, and followed them for up to 10 years. RESULTS Two hundred twenty patients exposed to ongoing thiazide therapy were compared with 2393 patients who were not exposed. In the exposed group, 66 (30%) developed hyponatremia (sodium ≤130 mmol/L). The adjusted incidence rate of hyponatremia was 140 cases per 1000 person-years for patients treated with thiazides, compared with 87 cases per 1000 person-years in those without thiazides. Patients exposed to thiazides were more likely to develop hyponatremia (adjusted incidence rate ratio, 1.61; 95% confidence interval [CI], 1.15-2.25). There was no significant difference in the risk of hospitalizations associated with hyponatremia (adjusted rate ratio, 1.04; 95% CI, 0.46-2.32) or mortality (adjusted rate ratio, 0.41; 95% CI, 0.12-1.42). The number needed to harm (to result in one excess case of incident hyponatremia in 5 years) was 15.02 (95% CI, 7.88-160.30). CONCLUSIONS Approximately 3 in 10 patients exposed to thiazides who continue to take them develop hyponatremia.
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Affiliation(s)
- Alexander A Leung
- Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Boston, MA, USA
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22
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Abstract
Thiazide diuretics are one of the most widely used and cost-effective classes of antihypertensive agents worldwide. Thiazides however have a significant side effect profile and are frequently insufficient to normalize blood pressure alone. Thiazide-induced hyponatraemia (TIH) is a major adverse effect, affecting up to one in seven patients receiving these drugs. TIH is more common in females, the elderly and those of low body weight and may cause symptoms such as confusion, falls and seizures. It is a common cause of hospital admission in the elderly. Although TIH occurs at least as frequently as hypokalaemia, much less is understood about the mechanism by which this occurs. Thiazides lower blood pressure by reducing the reabsorption of sodium from the distal nephron by inhibition of the NaCl cotransporter. The molecular mechanism by which this occurs together with the little known role of thiazides in regulating water reabsorbtion from the collecting ducts is discussed and the relevance to TIH evaluated. TIH is highly reproducible by thiazide rechallenge suggesting there may be a genetic predisposition. Both targeted resequencing of candidate genes and genome wide association techniques offer promising strategies by which such genetic contributions may be investigated. The rewards for uncovering the molecular mechanisms underlying TIH and the regulation of distal nephron sodium and water absorption are significant; not only could it inform the design of better tolerated, more efficacious thiazide-like antihypertensive agents but it may also facilitate the pharmacogenomic profiling of hypertensive patients to avoid thiazides in those likely to suffer adverse effects.
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Affiliation(s)
- Mark Glover
- Division of Therapeutics and Molecular Medicine, University of Nottingham, Nottingham, United Kingdom.
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Sarafidis PA, Georgianos PI, Lasaridis AN. Diuretics in clinical practice. Part II: electrolyte and acid-base disorders complicating diuretic therapy. Expert Opin Drug Saf 2010; 9:259-73. [PMID: 20095916 DOI: 10.1517/14740330903499257] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD As with all potent therapeutic agents, the use of diuretic compounds has been linked with several adverse effects that may reduce quality of life and patient compliance and, in some cases, may be associated with considerable morbidity and mortality. Among the various types of adverse effects, disturbances of electrolyte and acid-base balance are perhaps the most common, and some of them are the aetiological factors of other side effects (i.e., hypokalaemia causing ventricular arrhythmias or glucose intolerance). The mechanism and site of action and, therefore, the pharmacological effects of each diuretic class largely determine the specific electrolyte or acid-base abnormalities that will accompany the use of each diuretic agent. AREAS COVERED IN THE REVIEW This article reviews the major electrolyte disturbances (hypokalaemia, hyperkalaemia, hyponatraemia, disorders of magnesium and calcium balance), as well as the acid-base abnormalities complicating the use of the various diuretic agents. WHAT THE READER WILL GAIN The reader will gain insights into the pathogenesis of the diuretic-induced electrolyte and acid-base disorders together with considerations for their prevention and treatment. TAKE HOME MESSAGE Knowledge of the pharmacologic properties of each diuretic class and appropriate monitoring of patients under diuretic treatment represent the most important strategies to prevent the development of diuretic-related adverse events and their consequences.
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Affiliation(s)
- Pantelis A Sarafidis
- Section of Nephrology and Hypertension, 1st Department of Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, St Kiriakidi 1, 54636, Thessaloniki, Greece.
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Hwang KS, Kim GH. Thiazide-induced hyponatremia. Electrolyte Blood Press 2010; 8:51-7. [PMID: 21468197 PMCID: PMC3041494 DOI: 10.5049/ebp.2010.8.1.51] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 05/24/2010] [Indexed: 11/13/2022] Open
Abstract
The importance of thiazide-induced hyponatremia (TIH) is reemerging because thiazide diuretic prescription seems to be increasing after the guidelines recommending thiazides as first-line treatment of essential hypertension have been introduced. Thiazide diuretics act by inhibiting reabsorption of Na+ and Cl- from the distal convoluted tubule by blocking the thiazide-sensitive Na+/Cl- cotransporter. Thus, they inhibit electrolyte transport in the diluting segment and may impair urinary dilution in some vulnerable groups. Risk factors predisposing to TIH are old age, women, reduced body masses, and concurrent use of other medications that impair water excretion. While taking thiazides, the elderly may have a greater defect in water excretion after a water load compared with young subjects. Hyponatremia is usually induced within 2 weeks of starting the thiazide diuretic, but it can occur any time during thiazide therapy when subsequent contributory factors are complicated, such as reduction of renal function with aging, ingestion of other drugs that affect free water clearance, or changes in water or sodium intake. While some patients are volume depleted on presentation, most appear euvolemic. Notably serum levels of uric acid, creatinine and urea nitrogen are usually normal or low, suggestive of syndrome of inappropriate secretion of antidiuretic hormone. Despite numerous studies, the pathophysiological mechanisms underlying TIH are unclear. Although the traditional view is that diuretic-induced sodium or volume loss results in vasopressin-induced water retention, the following 3 main factors are implicated in TIH: stimulation of vasopressin secretion, reduced free-water clearance, and increased water intake. These factors will be discussed in this review.
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Affiliation(s)
- Kyu Sig Hwang
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
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Berl T, Rastegar A. A patient with severe hyponatremia and hypokalemia: osmotic demyelination following potassium repletion. Am J Kidney Dis 2010; 55:742-8. [PMID: 20338465 DOI: 10.1053/j.ajkd.2009.12.024] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Accepted: 12/23/2009] [Indexed: 12/12/2022]
Affiliation(s)
- Tomas Berl
- University of Colorado Denver, Division of Renal Diseases and Hypertension, Aurora, CO 80045, USA.
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26
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Crosland L, Longcroft-Wheaton G, Fraser J, Stone A. Antidepressants, thiazide diuretics and alcoholism: central pontine myelinolysis waiting to happen? Br J Hosp Med (Lond) 2009; 70:296-7. [DOI: 10.12968/hmed.2009.70.5.42237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A 50-year-old man, with a known weekly alcohol intake of almost 100 units, presented to his GP feeling drowsy. Routine blood tests revealed a profound hyponatraemia of 100 mmol/litre, and he was referred to hospital for investigations. On admission he was drowsy, but had a Glasgow Coma Scale score of 15, an abbreviated mental test score of 10/10 and an entirely normal neurological examination. Liver function tests were consistent with excessive alcohol consumption. He had been prescribed bendroflumethazide and clomipramine (a tricyclic antidepressant) by his GP. In view of their potential tocause hyponatraemia these were subsequently withheld and he was fluid restricted to 1.5 litres per day. His sodium level rose gradually and on day 5 of admission it had increased to 122 mmol/litre. He was discharged on day 8 having been advised to stop drinking. Less than a week after discharge he represented to his GP with symptoms of excessive sweating, shaking, constipation, disorientation and dysarthria. He was febrile at 38.6°C , and had a blood pressure of 180/90 mmHg. Electrolytes were normal (Na+ 135 mmol/litre). Although he denied consuming any alcohol since his initial admission, his symptoms were consistent with acute alcohol withdrawal and he was treated accordingly. He failed to improve on two attempts at reducing doses of chlordiazepoxide. His dysarthria progressed until his speech was difficult to understand and his swallow became unsafe. He continued to spike temperatures throughout the admission and although a catheter specimen of urine was positive for enterococcus, treatment with a prolonged course of antibiotics had not resolved his fever. A computed tomography scan of his head and a lumbar puncture were performed. Other than cortical atrophy in keeping with alcohol abuse, neither investigation provided any answers. It was considered that his symptoms could be explained by autonomic dysfunction. In view of his corrected hyponatraemia, central pontine myelinolysis was suggested and a magnetic resonance imaging head scan was performed (Figure 1). This confirmed the presence of central hyperintensity on the water sensitive sequences within the central pons, in keeping with an osmotic demyelination syndrome. Additionally these changes were identified within the caudate nuclei, possibly accounting for the patient's inability to fully control voluntary movement. The ongoing temperatures without sepsis suggested hypothalamic involvement. Following diagnosis this patient failed to improve. Treatment became supportive, and he died 7 weeks later.
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Affiliation(s)
| | | | | | - Adam Stone
- St. Richard's Hospital, Chichester PO19 6SE
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27
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Liamis G, Milionis H, Elisaf M. A review of drug-induced hyponatremia. Am J Kidney Dis 2008; 52:144-53. [PMID: 18468754 DOI: 10.1053/j.ajkd.2008.03.004] [Citation(s) in RCA: 274] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2007] [Accepted: 03/03/2008] [Indexed: 12/19/2022]
Abstract
Hyponatremia (defined as a serum sodium level < 134 mmol/L) is the most common electrolyte abnormality in hospitalized patients. Certain drugs (eg, diuretics, antidepressants, and antiepileptics) have been implicated as established causes of either asymptomatic or symptomatic hyponatremia. However, hyponatremia occasionally may develop in the course of treatment with drugs used in everyday clinical practice (eg, newer antihypertensive agents, antibiotics, and proton pump inhibitors). Physicians may not always give proper attention in time to undesirable drug-induced hyponatremia. Effective clinical management can be handled through awareness of the adverse effect of certain pharmaceutical compounds on serum sodium levels. Here, we review clinical information about the incidence of hyponatremia associated with specific drug treatment and discuss the underlying pathophysiologic mechanisms.
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Affiliation(s)
- George Liamis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
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28
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Palmer BF, Naderi ASA. Metabolic complications associated with use of thiazide diuretics. ACTA ACUST UNITED AC 2007; 1:381-92. [DOI: 10.1016/j.jash.2007.07.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2007] [Revised: 07/21/2007] [Accepted: 07/24/2007] [Indexed: 10/22/2022]
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29
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Auyeung TW, Lee JSW. Prognostic significance of admission electrolyte disturbances in older people: A retrospective cohort study. Geriatr Gerontol Int 2007. [DOI: 10.1111/j.1447-0594.2007.00380.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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30
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Abstract
An 18-year-old girl with nephrotic syndrome presented with a life-threatening respiratory failure and a severe encephalopathy, shortly after being started on furosemide. The evaluation confirmed furosemide as the sole culprit for the clinical manifestations. This case highlights an unpredictable dose-response relationship of furosemide. The pathophysiological basis, differential diagnosis and clinical implications of the observed findings are discussed.
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Affiliation(s)
- Ajay P Sharma
- Department of Pediatrics, University of Western Ontario, London, Ontario, Canada.
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Gill G, Huda B, Boyd A, Skagen K, Wile D, Watson I, van Heyningen C. Characteristics and mortality of severe hyponatraemia--a hospital-based study. Clin Endocrinol (Oxf) 2006; 65:246-9. [PMID: 16886968 DOI: 10.1111/j.1365-2265.2006.02583.x] [Citation(s) in RCA: 156] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine the characteristics, causes and outcome of severe hyponatraemia (< 125 mmol/l) in hospitalized patients, and to identify mortality predictors. DESIGN Prospective case controlled study of sequentially presenting patients with a serum sodium (Na) < 125 mmol/l. PATIENTS AND METHODS One hundred and four hyponatraemic and 104 randomly chosen normonatraemic (Na > 135 mmol/l) adult patients were studied. We measured hospital mortality and days in hospital, diagnoses, drug history and cause of hyponatraemia. Na was recorded at admission, as well as the closest level measured before death or discharge. In addition, the lowest Na was recorded (if this was not at admission). RESULTS Hyponatraemic patients were older (mean age +/- 1 SD 69 +/- 14 years) than controls (61 +/- 16 years, P < 0.001), but of similar sex ratio. On admission, Na in the hyponatraemic group was 125 +/- 7 mmol/l compared with 139 +/- 3 mmol/l in controls (P < 0.0001), but fell to 120 +/- 4 mmol/l before rising at discharge to 131 +/- 7 mmol/l (all changes P < 0.001). Overall mortality was 27% in hyponatraemic patients compared with 9% in controls (P = 0.009), and length of admission was also greater (16 +/- 12 vs. 13 +/- 11 days, P < 0.005). Mortality was greater in patients whose Na levels fell during admission (34%vs. 16%, P < 0.05), and these patients appeared to have an excess of diuretic-induced and possibly iatrogenic hyponatraemia. CONCLUSIONS Severe hyponatraemia in hospital patients is associated with prolonged admissions and significantly increased mortality compared with normonatraemic patients. A particular group at high risk of death are those whose Na levels fall after admission. They may represent a 'sicker' group, and deserve increased monitoring and surveillance.
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Affiliation(s)
- Geoffrey Gill
- Department of Diabetes and Endocrinology, University HospitalAintree, Liverpool, UK.
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Clayton JA, Rodgers S, Blakey J, Avery A, Hall IP. Thiazide diuretic prescription and electrolyte abnormalities in primary care. Br J Clin Pharmacol 2006; 61:87-95. [PMID: 16390355 PMCID: PMC1884982 DOI: 10.1111/j.1365-2125.2005.02531.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
AIMS Thiazide diuretics have a number of well-documented metabolic adverse effects. The aim of this study was to estimate the frequency of hyponatraemia and hypokalaemia amongst patients taking a thiazide diuretic in primary care. METHODS A computerized search of the electronic prescribing and laboratory records of six UK general practices was performed. Of the 32 218 adult patients identified, 3773 had received at least one prescription for a thiazide between the years 1990 and 2002. RESULTS Detailed prescribing data were available for 2942 patients of whom 951 (32.3%) had a recorded check of their electrolytes. One hundred and ninety-six (20.6%) had a sodium and/or potassium concentration below the normal range. The sodium distribution had a negative skew (-1.8) and in 130 (13.7%) patients was within the hyponatraemic range. Hypokalaemia was less common, occurring in 79 (8.5%) patients. Hyponatraemia was significantly associated with increased age; the odds ratio for developing hyponatraemia in patients over 70 years was 3.87 compared with those of < or = 70 years. Hypokalaemia was significantly associated with increased thiazide dose. CONCLUSIONS Prescription of a thiazide diuretic in primary care is associated with a high frequency of hyponatraemia and hypokalaemia. Thiazides should be prescribed at low dose and the risk of hyponatraemia, especially in the elderly, should be considered and monitored for when prescribing these agents.
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Affiliation(s)
- J A Clayton
- Division of Therapeutics and Molecular Medicine, University Hospital, Queen's Medical Centre, Nottingham, UK.
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Abstract
BACKGROUND Thiazide-induced hyponatraemia is common and potentially life threatening. In the absence of well-defined risk factors for this complication, guidelines for prescribing cannot be established. AIM To examine whether a subgroup of patients is particularly susceptible to this complication. DESIGN Retrospective case-control study. METHODS We defined and recruited cases of symptomatic hyponatraemia that necessitated hospitalization from January 1996 to April 2002. Controls were selected from 8420 patients being prescribed thiazides and seen at the same institution during that period of time. RESULTS There were 223 cases and 216 controls, with a median 115 days thiazide use. Cases were older than controls (76 +/- 9 vs. 66 +/- 13 years, p < 0.001) and lighter (52.3 +/- 10.3 vs. 63.4 +/- 3 kg, p < 0.001). By univariate analysis, serum potassium level, use of indapamide, elderly home institutionalization and physical immobility were risk factors for thiazide-induced hyponatraemia, but gender, duration of thiazide use, concomitant therapy with loop diuretics, angiotensin-converting enzyme inhibitors or non-steroidal anti-inflammatory drugs, and renal function were not. By stepwise logistic regression analysis, patient age, body weight and serum potassium were the only independent predictive factors. Each 10-year increment of age was associated with a two-fold increase in risk (hazards ratio 2.14, 95%CI 1.59-2.88). For a 5 kg increment in mass, there was a 27% decrease in odds ratio (odds ratio 0.77, 95%CI 0.68-0.87). One SD increase in serum potassium (0.84 mmol/l) was associated with a 63% decrease in risk (odds ratio 0.37, 95%CI 0.27-0.50; p < 0.0001). DISCUSSION Hyponatraemia is a common problem after thiazide therapy. Extra caution and close monitoring are warranted when prescribing thiazides for elderly patients with low body mass.
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Affiliation(s)
- K M Chow
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong, China
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Zuccalà G, Pedone C, Cocchi A, Pahor M, Carosella L, Carbonin P, Bernabei R. Older age and in-hospital development of hypokalemia from loop diuretics: results from a multicenter survey. GIFA Investigators. Multicenter Italian Pharmacoepidemiologic Study Group. J Gerontol A Biol Sci Med Sci 2000; 55:M232-8. [PMID: 10811153 DOI: 10.1093/gerona/55.4.m232] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Hypokalemia is a common finding among older patients taking diuretic medications. However, it is not known whether older age per se carries an increased risk of hypokalemia, particularly during a patient's treatment with loop diuretics. METHODS The association between age and incident hypokalemia was examined in 18,872 patients with normal baseline serum potassium enrolled during three yearly multicenter surveys; 4,035 patients started receiving loop diuretics during their hospital stay. Demographic variables, comorbid conditions, medications, and objective tests that were associated with incident hypokalemia in separate age- and sex-adjusted logistic regression models were examined as potential confounders. RESULTS Among patients with normal baseline serum potassium, the factors of age, presence of coronary disease or diabetes, comorbidity, the use of ACE inhibitors, loop diuretics, digitalis, corticosteroids, or insulin, and baseline serum potassium were associated with incident hypokalemia in initial models. After these variables were adjusted for, age (for each decade, odds ratio = 1.30; 95% confidence interval = 1.17-1.46; p < .0001) was associated with incident hypokalemia. The use of parenteral (2.30; 1.53-3.46; p < .0001) but not oral (1.16; 0.79-1.69; p = .44) loop diuretics was associated with hypokalemia. Eventually, age was associated with hypokalemia when the summary regression model was analyzed in patients taking loop diuretics (1.33; 1.03-1.71; p = .027), as well as in those taking intravenous loop diuretics only (1.84; 1.25-2.70; p = .002). CONCLUSIONS Older age is independently associated with the in-hospital development of hypokalemia, particularly among patients taking loop diuretics. Monitoring of serum potassium levels is therefore advisable when older patients are treated with these agents.
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Affiliation(s)
- G Zuccalà
- Department of Gerontology, Catholic University of Rome, Italy.
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Crook MA, Velauthar U, Moran L, Griffiths W. Review of investigation and management of severe hyponatraemia in a hospital population. Ann Clin Biochem 1999; 36 ( Pt 2):158-62. [PMID: 10370730 DOI: 10.1177/000456329903600204] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this study was to assess retrospectively the prevalence of severe hyponatraemia in a hospital population and its laboratory investigation, treatment and clinical outcome. Over a 6-month period 47 patients (27 women and 20 men) were found to have a plasma sodium concentration of < or = 120 mmol/L (this number made up less than 0.17% of all plasma sodium requests over that time period). The mean patient age was 75 +/- 16 years and the average hospital stay was 37 +/- 45 days (1-179 days). Patient mortality was 51% (women 57% and men 43%). The mean initial plasma sodium concentration was 116 +/- 4.5 mmol/L, rising after therapeutic intervention to a mean of 130 +/- 4.2 mmol/L. The mean plasma sodium correction rate was 4.7 +/- 4.3 mmol/L/24 h (0.9-17.5 range). Twelve per cent of the patients had their plasma sodium raised at a rate of greater than 10 mmol/L/24 h after their initial presentation. Two patients may have had symptoms and signs suggestive of cerebral oedema/cortical dysfunction: in one patient the sodium concentration was raised at a rate of 9.5 mmol/L/24 h and in the other at 12.0 mmol/L/24 h. Sixty-one per cent of the patients had a chest infection, 44% were on diuretics, 28% had congestive cardiac failure, 28% were post-operative (9% orthopaedic procedures), 19% had carcinoma and 9% were on a selective serotonin re-uptake inhibitor. Regarding laboratory investigations, 56% had liver function tests, 41% had thyroid function tests, 36% had plasma osmolality determination, 36% had urinary electrolytes including urinary osmolality and < 2% had tests to exclude hypoadrenalism.
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Affiliation(s)
- M A Crook
- Department of Chemical Pathology, University Hospital Lewisham, London, UK
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Abstract
Despite the relative paucity of drug trials in the old and especially the very old (> 85 years), some general principles of pharmacology in the aging patient can be taken from available data and clinical experience. The pharmacokinetic changes most consistently seen with aging occur in the volume of distribution, clearance, and half-life of a drug. Renal drug clearance is consistently diminished with aging. Hepatic metabolism is more variably affected, and in contrast to renal clearance, no reliable formula exists to estimate hepatic drug clearance. Pharmacodynamic changes, although present, are less well studied or described in the elderly. Drug interactions and adverse drug reactions increase with increasing numbers of medications prescribed and represent a complex interplay of age, underlying disease, and number and types of medications. The clinical caveats that apply to drug prescription in the very old include reduced starting doses with slow incremental increases; elimination of unnecessary medications; and anticipating and monitoring for drug interactions and ADRs, especially when prescribing warfarin, digoxin, and amiodarone. Future studies that look at the aging patient in the presence of effects of age, physiology, gender, comorbid illness, and multiple drug therapies may help evolve a new set of paradigms for geriatric drug prescribing.
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Affiliation(s)
- P M Podrazik
- Department of Medicine, Northwestern University Medical School, Chicago, Illinois, USA
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Miekley TF. A Patient-Focused Approach to Managing Diuretic Therapy. Crit Care Nurs Clin North Am 1998. [DOI: 10.1016/s0899-5885(18)30188-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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van Kraaij DJ, Jansen RW, Bruijns E, Gribnau FW, Hoefnagels WH. Diuretic usage and withdrawal patterns in a Dutch geriatric patient population. J Am Geriatr Soc 1997; 45:918-22. [PMID: 9256841 DOI: 10.1111/j.1532-5415.1997.tb02959.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To describe diuretic usage and withdrawal patterns in a population of very old geriatric patients and to evaluate the long-term probability of remaining free from diuretic therapy after withdrawal. DESIGN Retrospective analysis of medical records and 1-year follow-up study. SETTING University Hospital Nijmegen and Rijnstate Hospital Arnhem, a non-academic teaching hospital, The Netherlands. PARTICIPANTS All 1547 patients, aged 75 years or older, visiting geriatric medicine departments in the two hospitals for the first time in the years 1990 through 1993. MEASUREMENTS Data on medical history, physical examinations, and medication use were obtained from medical records. Diuretic withdrawal and motivation was recorded as reported. Record review indicating diuretic withdrawal prompted a 1-year follow-up investigation and collection of additional updated information from family care and/or nursing-home physicians. RESULTS A total of 593 three patients (38.3%) were using diuretics. Use of diuretics increased with age from 33.6% in patients aged 75 to 79 years to 47.4% in patients aged 90 years or older (P < .05). Diuretics were withdrawn in 218 patients (36.8%), in 101 patients because of doubts about the initial or persistent indication for diuretic use and in 91 patients because of adverse effects. No reasons for withdrawal were reported in 26 patients. Withdrawal of diuretics was attempted more often in cases of diuretic prescriptions for unknown reasons (51.2%) or ankle edema without heart failure (45.0%) than when prescriptions were for heart failure (28.5%) or hypertension (35.4%). The overall probability of remaining free of diuretic therapy for 1 year was 0.41. Success of diuretic withdrawal was significantly less when congestive heart failure was the initial indication for prescription (probability 0.24). We did not find other clinical parameters related to the success of withdrawal. CONCLUSIONS Our study demonstrates that diuretic therapy can be withdrawn for at least a 1-year period in a substantial number of very old geriatric patients receiving these medications, regardless of the initial indications for prescription. However, withdrawal is performed without application of uniform criteria. Future prospective studies should be directed at developing clear guidelines for diuretic withdrawal in order to facilitate identification of eligible patients and to further improve the success of withdrawal attempts.
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Affiliation(s)
- D J van Kraaij
- Department of Geriatric Medicine, University Hospital Nijmegen, The Netherlands
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Fidler HM, Goldman J, Bielawska CA, Rai GS, Hoffbrand BI. A study of plasma sodium levels in elderly people taking amiloride or triamterene in combination with hydrochlorothiazide. Postgrad Med J 1993; 69:797-9. [PMID: 8290411 PMCID: PMC2399955 DOI: 10.1136/pgmj.69.816.797] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This study was performed to compare the effect of one month's treatment with hydrochlorothiazide (25 mg) in combination with either amiloride (2.5 mg) or triamterene (50 mg) on plasma sodium levels in elderly people in institutional care. Fifty residents of NHS nursing or social service residential care established on diuretics for congestive cardiac failure and aged 64 years or over were recruited. Forty-one patients were included in the final data analysis. Patients on hydrochlorothiazide/amiloride had a significantly lower plasma sodium (137 vs 139 mmol/l, 95% confidence interval for difference between medians 0-2 mmol/l) than those on hydrochlorthiazide/triamterene (P = 0.01). In equivalent potassium-retaining doses, amiloride is associated with significantly lower plasma sodium levels than triamterene, when given in combination with hydrochlorothiazide in elderly patients with congestive cardiac failure. This finding adds weight to uncontrolled observations implicating thiazide/amiloride diuretic combinations in causing serious hyponatraemia. This danger, although uncommon, should perhaps influence prescribing habits in an at-risk population.
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Affiliation(s)
- H M Fidler
- Department of Care of the Elderly, Whittington Hospital, London, UK
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Chan TYK, Law CB, Yeung VTF, Ting SM, Tse LKK. Letter: Adelphane-Esidrex causing severe postural hypotension. Pharmacoepidemiol Drug Saf 1993. [DOI: 10.1002/pds.2630020211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Rhodes KE. Prescription of diuretic drugs and monitoring of long-term use in one general practice. Br J Gen Pract 1992; 42:68-70. [PMID: 1493009 PMCID: PMC1371927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
A cross-sectional survey of the prescription and monitoring of diuretic drugs for long-term use was performed in a Nottinghamshire training practice, which has 7619 patients. It was found that 330 patients were long-term users of diuretic drugs, with 79% of these patients aged 60 years or over. Twenty three different diuretic drugs were prescribed with a total cost of 13,643 pounds per year. A few drugs accounted for a disproportionate amount of the total cost, with combination diuretic drugs being particularly expensive. The most common indications for the prescription of diuretic drugs were hypertension and congestive cardiac failure. General practitioners initiated the prescribing of diuretic drugs in 87% of cases, with only a small proportion being prescribed by hospital doctors. One third of the patients had no record of urea and electrolyte levels in their notes after commencing treatment with a diuretic drug. On the basis of these findings recommendations are made for the initiation and monitoring of the long-term use of diuretic drugs.
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