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Lei H, Liu X, Zeng J, Fan Z, He Y, Li Z, Wang C. Analysis of the Clinical Characteristics of Hyponatremia Induced by Trimethoprim/Sulfamethoxazole. Pharmacology 2022; 107:351-358. [PMID: 35381593 PMCID: PMC9393806 DOI: 10.1159/000523824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/14/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Trimethoprim-sulfamethoxazole (TMP/SMX) causes hyperkalemia, and hyponatremia caused by TMP/SMX is a challenge for clinicians. We described the clinical features of hyponatremia induced by TMP/SMX after collecting cases. SUMMARY The median age of the 24 patients (10 males and 14 females) was 67 years (range: 28-90 years). Hyponatremia induced by TMP/SMX manifested as nausea (41.7%) and vomiting (29.2%) or asymptomatic hyponatremia (20.8%). The median duration of hyponatremia was 5 days (range: 3-10 days). The median serum sodium concentration was 118 mmol/L (range: 101-128.1 mmol/L). The serum sodium levels gradually returned to the normal range at 4 days (median; range: 2-14 days) after withdrawing TMP/SMX. KEY MESSAGES TMP/SMX-induced hyponatremia is a rare and serious adverse reaction. Clinicians should be aware of electrolyte disturbances caused by TMP/SMX and should always consider electrolyte monitoring.
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Affiliation(s)
- Haibo Lei
- Department of Clinical Pharmacy, Xiangtan Central Hospital, Xiangtan, China
| | - Xiang Liu
- Department of Clinical Pharmacy, Xiangtan Central Hospital, Xiangtan, China
| | - Jiang Zeng
- Department of Pharmacy, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China
| | - Zhiqiang Fan
- Department of Pharmacy, The First Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Yang He
- Department of Pharmacy, The First Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Zuojun Li
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Chunjiang Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
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Ghali MGZ, Kim MJ. Trimethoprim-sulfamethoxazole-induced hyponatremia in an elderly lady with Achromobacter xylosoxidans pneumonia: Case report and insights into mechanism. Medicine (Baltimore) 2020; 99:e20746. [PMID: 32871970 PMCID: PMC7437830 DOI: 10.1097/md.0000000000020746] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
RATIONALE Hyponatremia occurs frequently in the hospital setting and may be attributable to a host of etiologies. Drugs are frequently implicated. Trimethoprim-sulfamethoxazole (TMP/SMX) represents a well-recognized pharmacologic precipitant of drug-induced hyponatremia, with several reports extant in the retrievable literature. Nephrologists thus debate the mechanisms giving rise to TMP/SMX-induced hyponatremia and the precise mechanism by which treatment with TMP/SMX generates reductions of serum sodium concentration remain controversial. The agent has a well-known effect of antagonizing the effects of aldosterone upon the distal nephron. Renal salt wasting and the syndrome of inappropriate antidiuretic hormone secretion represent implicated mechanistic intermediaries in TMP/SMX-induced hyponatremia. PATIENT CONCERNS The patient endorsed no explicit concerns. DIAGNOSES We describe the case of an 83-year-old female clinically diagnosed with pneumonia found to have an initial serum sodium in the range of 130 to 134 mEq/L consistent with mild hyponatremia upon admission. Sputum cultures grew Achromobacter xylosoxidans susceptible to TMP/SMX. The patient's serum sodium concentration precipitously decline following institution of treatment with TMP/SMX to 112 to 114 mEq/L during the course of 5 days. INTERVENTIONS Severe hyponatremia proved recalcitrant to initial therapy with supplemental salt tabs and standard doses of the vasopressin receptor antagonist tolvaptan. OUTCOMES Escalating doses of tolvaptan increased the patient's sodium to 120 to 124 mEq/L. The patient was transferred to another hospital for further management. During her stay, the patient did not exhibit frank or obvious clinical features consistent with hyponatremia nor readily appreciable evidence of volume depletion. LESSONS TMP/SMX represents a frequent, though underreported cause of hyponatremia in the hospital setting several authors believe natriuresis may represent the most common mechanism underlying TMP/SMX-induced hyponatremia. Evidence implicating natriuresis to be mechanistic in TMP/SMX-induced hyponatremia include clinically appreciable hypovolemia and resolution of hyponatremia with oral or intravenous salt repletion. Salt repletion failed to monotherapeutically enhance our patient's hyponatremiadisfavoring renal salt wasting as originately mechanistic. Contemporaneous refractoriness of serum sodium to fluid restriction nor standard doses of tolvaptan confounded our initial attempts to mechanistically attribute the patient's hyponatremia to a specific cause. Clinical euvolemia and rapid response of hyponatremia to exceptionally high doses of tolvaptan strongly favors syndrome of inappropriate antidiuretic hormone to represent the chief mechanism by which TMP/SMX exacerbates hyponatremia.
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Affiliation(s)
- Michael George Zaki Ghali
- Departments of Neurological Surgery, Internal Medicine, and Neurophysiology, Karolinska Institutet, Stockholm, Sweden
- Departments of Neurological Surgery, Neurophysiology, and Internal Medicine, University of Oslo, Oslo, Norway
- Departments of Neurological Surgery and Neurophysiology, University of Finland, Helsinki, Finland
- Department of Neurological Surgery, University Hospital Zurich, Zurich, Switzerland
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ, USA
- Departments of Neurological Surgery and Internal Medicine, Johns Hopkins Medical Institute, Baltimore, MD, USA
- Department of Neurological Surgery, University of Toronto, Toronto, ON, Canada
- Department of Internal Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA
| | - Marc J. Kim
- Departments of Neurological Surgery, Internal Medicine, and Neurophysiology, Karolinska Institutet, Stockholm, Sweden
- Departments of Neurological Surgery, Neurophysiology, and Internal Medicine, University of Oslo, Oslo, Norway
- Department of Internal Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA
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Memoli E, Faré PB, Camozzi P, Simonetti GD, Bianchetti MG, Lava SA, Milani GP. Trimethoprim-associated electrolyte and acid-base abnormalities. Minerva Med 2020; 112:500-505. [PMID: 32697061 DOI: 10.23736/s0026-4806.20.06660-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The antimicrobial trimethoprim is structurally related to potassium-sparing diuretics and may consequently lead to derangements in electrolyte and acid-base balance. Since no report so far analyzed the literature documenting individual cases with electrolyte and acid-base derangements induced by trimethoprim, a systematic review was carried out. EVIDENCE ACQUISITION We retained 53 reports documenting 68 cases (42 males and 26 females 23 to 96 years of age) of electrolyte or acid-base derangements occurring on trimethoprim for about 5 days. EVIDENCE SYNTHESIS One hundred five electrolyte imbalances were detected in the 68 patients: hyperkalemia (>5.0 mmol/L) in 62 (91%), hyponatremia (<135 mmol/L) in 29 (43%) and metabolic acidosis (pH<7.38 and bicarbonate <19 mmol/L) in 14 (21%) cases. Following possible predisposing factors for electrolyte and acid-base abnormalities were found in 54 (79%) patients: high-dose trimethoprim, comedication with drugs that have been associated with electrolyte and acid-base derangements, preexisting kidney disease, age ≥80 years and diabetes mellitus. CONCLUSIONS High-dose trimethoprim, comedicated with drugs that have been associated with electrolyte and acid-base derangements, poor kidney function, age ≥80 years and diabetes mellitus predispose to trimethoprim-associated electrolyte and acid-base abnormalities. Clinicians must recognize patients at risk, possibly avoid drug combinations that may worsen the problem and monitor the laboratory values.
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Affiliation(s)
- Erica Memoli
- Pediatric Institute of Southern Switzerland, San Giovanni Hospital, Bellinzona, Switzerland.,Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Pietro B Faré
- Department of Internal Medicine, La Carità Hospital, Locarno, Switzerland.,Ente Ospedaliero Cantonale, Locarno, Switzerland
| | - Pietro Camozzi
- Ente Ospedaliero Cantonale, Bellinzona, Switzerland.,Department of Internal Medicine, San Giovanni Hospital, Bellinzona, Switzerland
| | - Giacomo D Simonetti
- Pediatric Institute of Southern Switzerland, San Giovanni Hospital, Bellinzona, Switzerland.,Ente Ospedaliero Cantonale, Bellinzona, Switzerland.,Università della Svizzera Italiana (USI), Lugano, Switzerland
| | | | - Sebastiano A Lava
- Pediatric Cardiology Unit, Department of Pediatrics, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland - .,Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Lugano, Switzerland
| | - Gregorio P Milani
- Pediatric Institute of Southern Switzerland, San Giovanni Hospital, Bellinzona, Switzerland.,Ente Ospedaliero Cantonale, Bellinzona, Switzerland.,Unit of Pediatrics, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Stephens K, Miller JL, Lewis TV, Neely S, Johnson PN. Hyponatremia With Intravenous Sulfamethoxazole/Trimethoprim in Children. Ann Pharmacother 2019; 54:351-358. [PMID: 31694388 DOI: 10.1177/1060028019887919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Intravenous (IV) sulfamethoxazole/trimethoprim (SMX/TMP) has been associated with hyponatremia in adults. Objective: The primary objective was to identify the number of patients with a serum sodium <135 mEq/L. Secondary objectives between the hyponatremic versus nonhyponatremic groups included demographic comparisons, median serum sodium concentrations, SMX/TMP cumulative dose, number of diuretics, and other medications causing hyponatremia. Methods: This was a retrospective study of children <18 years receiving IV SMP/TMX. Comparisons were conducted via Mann-Whitney-Wilcoxon and Mantel-Haenszel χ2 tests with an a priori P value <0.05. Results: Sixty-one patients received 66 total courses; 20 courses (30.3%) were associated with hyponatremia with a decrease in the median nadir serum sodium concentration of 133 and 138 mEq/L in the hyponatremic and nonhyponatremic groups, respectively (P<0.001). The median age (interquartile range) was lower in the hyponatremic versus nonhyponatremic group, but this was not statistically significant: 0.6 (0.1-5.5) versus 3.9 (0.3-11.0) years; P=0.077. There was no significant difference in the median cumulative dose (mg/kg) between groups; P=0.104. In addition, there was a significant difference in the number of children in the hyponatremic versus nonhyponatremic groups receiving diuretics (16 [80.0%] vs 23 [50.0%], P=0.023) and other medications that cause hyponatremia (7 [35.0%] vs 5 [10.9%], P=0.034), respectively. Furosemide was noted to be the medication most associated with hyponatremia. Conclusion and Relevance: Approximately one-third administered IV SMX/TMP developed hyponatremia. Concomitant furosemide administration was one of the most common risk factors. Clinicians should be aware of this potential adverse event when initiating IV SMX/TMP in children.
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Affiliation(s)
- Katy Stephens
- University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Jamie L Miller
- The University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Teresa V Lewis
- The University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Stephen Neely
- The University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Peter N Johnson
- The University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
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Zhou N, Yang C. A case of extreme hyponatremia without neurologic symptoms. Clin Case Rep 2019; 7:1874-1879. [PMID: 31624600 PMCID: PMC6787862 DOI: 10.1002/ccr3.2383] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/02/2019] [Accepted: 07/28/2019] [Indexed: 12/25/2022] Open
Abstract
Our case report highlights that profound hyponatremia with sodium level 101 mmol/L could have no CNS symptoms, and drugs and endocrine disorders are relatively common causes and should be considered in the differential diagnosis of hyponatremia. Standard dose trimethoprim-sulfamethoxazole-induced hyponatremia is rare but still worth close attention in clinical practice.
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Affiliation(s)
- Na Zhou
- Kidney Research ClinicUniversity of Utah School of MedicineSalt Lake CityUtah
| | - Chang Yang
- Apogee Hospital MedicinePassavant Area HospitalJacksonvilleIllinois
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Herzog AL, Wanner C, Lopau K. Successful Short-Term Intravenous Treatment of Disseminated Nocardia farcinica Infection with Severe Hyponatremia After Kidney Transplantation: A Case Report. Transplant Proc 2017; 48:3115-3119. [PMID: 27932160 DOI: 10.1016/j.transproceed.2016.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 04/25/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Nocardia is a genus of gram-positive Actinomycetes that are ubiquitous in decaying organic material, soil, and water. Some Nocardia species can infect humans, mainly by airborne transmission. Several reports describe disseminated infections, which are rare and mostly affect strongly immunocompromised patients because intact T-cell-mediated immunity is the major protective mechanism. CASE REPORT We report a case of disseminated pulmonary, cerebral, and cutaneous infection with Nocardia farcinica in a 66-year-old kidney transplant recipient treated with low-dose triple immunosuppression. The patient was initially admitted because of severe hyponatremia and pneumonia with radiologic signs of pleural effusion. The infectious agent was isolated when cutaneous lesions developed. Oral trimethoprim/sulfamethoxazole treatment led to severe hyponatremia; therefore, long-term treatment with parenteral amikacin and minocycline was initiated. After 7 months of consistent intravenous treatment, the lesions completely resolved and treatment was stopped, against some expert suggestions. The patient had remained free of relapse at the time of writing. CONCLUSIONS Disseminated Nocardia infection in immunocompromised patients is a rare but life-threatening disease. Owing to its infrequency, the variety of clinical patterns, antimicrobial resistance, and often fatal complications of standardized therapy, the diagnosis and treatment of this infection remain challenging and protracted.
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Affiliation(s)
- A L Herzog
- Division of Nephrology, Medizinische Klinik I, University of Würzburg, Würzburg, Germany.
| | - C Wanner
- Division of Nephrology, Medizinische Klinik I, University of Würzburg, Würzburg, Germany
| | - K Lopau
- Division of Nephrology, Medizinische Klinik I, University of Würzburg, Würzburg, Germany
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Tsapepas D, Chiles M, Babayev R, Rao MK, Jaitly M, Salerno D, Mohan S. Incidence of Hyponatremia with High-Dose Trimethoprim-Sulfamethoxazole Exposure. Am J Med 2016; 129:1322-1328. [PMID: 27542610 DOI: 10.1016/j.amjmed.2016.07.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 07/22/2016] [Accepted: 07/24/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trimethoprim-sulfamethoxazole (TMP-SMX) is a commonly prescribed antibiotic used at high doses for treatment of pneumocystis pneumonia and other infections. Trimethoprim is structurally related to the potassium-sparing diuretic amiloride and has been associated with hyperkalemia and hyponatremia through blocking of epithelial sodium channels in the distal nephron. The incidence of hyponatremia in hospitalized patients treated with high-dose TMP-SMX is unknown. METHODS We performed a single-center retrospective chart review of all hospitalized patients who received high-dose TMP-SMX (n = 235) from January 2012 to July 2014. Patients with congestive heart failure, cirrhosis, estimated glomerular filtration rate <30 mL/min/1.73 m2, baseline hyponatremia, and those on other medications associated with hyponatremia were excluded. Hyponatremia was defined as a serum sodium level <136 mEq/L. RESULTS Analysis was restricted to 76 unique patients who received more than 8 mg/kg/d of TMP for ≥3 days. Mean starting serum sodium at time of TMP-SMX initiation was 138.4 ± 2.1 mEq/L. Fifty-five patients (72.3%) developed hyponatremia while on therapy, of which 43.6% (n = 24) were cases of serum sodium <130 mEq/L. Mean sodium at the time of nadir was 131.6 ± 5.1 mEq/L. Hyponatremia was noted, on average, 5.5 days after initiation of therapy, with more severe hyponatremia development among African American patients. Urine sodium concentrations were available for 40.0% (22/55) of incident hyponatremia cases, with mean urinary sodium of 104.8 ± 55.9 mEq/L. Hyponatremia often resolved within 3 weeks of drug discontinuation. CONCLUSIONS There is a high incidence (72.3%) of hyponatremia associated with the use of high-dose TMP-SMX among hospitalized patients. This is an overlooked and potentially reversible cause of hyponatremia.
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Affiliation(s)
- Demetra Tsapepas
- Department of Pharmacy, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY; Division of Abdominal Transplantation, Department of Surgery, Columbia University, New York, NY
| | - Mariana Chiles
- Division of Nephrology, Department of Medicine, Columbia University, New York, NY
| | - Revekka Babayev
- Division of Nephrology, Department of Medicine, Columbia University, New York, NY
| | - Maya K Rao
- Division of Nephrology, Department of Medicine, Columbia University, New York, NY
| | - Manasvi Jaitly
- Department of Medicine, Claxton Hepburn Medical Center, Ogdensburg, NY
| | - David Salerno
- Department of Pharmacy, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY.
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Huntsberry AM, Linnebur SA, Vejar M. Hyponatremia after initiation and rechallenge with trimethoprim-sulfamethoxazole in an older adult. Clin Interv Aging 2015; 10:1091-6. [PMID: 26170649 PMCID: PMC4494188 DOI: 10.2147/cia.s82823] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Purpose The purpose of this study is to describe a case report of a patient experiencing hyponatremia from trimethoprim–sulfamethoxazole (TMP–SMX) upon initial use and subsequent rechallenge. Summary An 82-year-old woman presented to the emergency department with altered mental status thought to be due to complicated cystitis and was treated with TMP–SMX 160 mg/800 mg orally twice daily for 7 days. Her basic metabolic panel prior to initiation of TMP–SMX was within normal limits, with the exception of her serum sodium of 132 mmol/L (range 133–145 mmol/L). The day after completing her 7-day course of TMP–SMX therapy the patient was evaluated by her primary care provider and another basic metabolic panel revealed a reduction in the serum sodium to 121 mmol/L. The patient’s serum sodium concentrations increased to baseline 7 days after completion of the TMP–SMX therapy, and remained normal until she was treated in the emergency department several months later for another presumed urinary tract infection. She was again started on TMP–SMX therapy empirically, and within several days her serum sodium concentrations decreased from 138 mmol/L to a low of 129 mmol/L. The TMP–SMX therapy was discontinued upon negative urine culture results and her serum sodium increased to 134 mmol/L upon discharge. Based upon the Naranjo probability scale score of 9, TMP–SMX was the probable cause of the patient’s hyponatremia. Conclusion Our patient developed hyponatremia from TMP–SMX therapy upon initial use and rechallenge. Although hyponatremia appears to be rare with TMP–SMX therapy, providers should be aware of this potentially life-threatening adverse event.
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Affiliation(s)
- Ashley M Huntsberry
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Sunny A Linnebur
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Maria Vejar
- Division of Geriatrics, Department of Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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