The physician may ask to reduce their liquid intake, adjust salt intake and stay under strict monitoring. Mild chronic hyponatremia, as defined by a persistent (>72 hours) plasma sodium concentration between 125 and 135 mEq/L without apparent symptoms, is common in ambulatory patients and generally perceived as being inconsequential. Hyponatremia causes neurologic symptoms ranging from confusion to seizures to coma. We report the case of an elderly patient who developed hyponatremia most likely related to SIADH induced by duloxetine, an SNRI. There is little if any experience with the use of vaptans in patients with serum sodium < 115 mEq/L. In the elderly hypertensive patient (assuming body weight of 70 kg) with mild to moderate hyponatremia free water excess is around 2.5 L. One bottle of Nepro/day will generate about 120 mosm to be excreted via urine. Once the patient is discharged, I check the serum sodium concentration 4 days later, then weekly for 2 weeks and then monthly. A subsequent study also found this association of hyponatremia with large bone fractures in the elderly (14). In view of the limitations of other available therapies described above, the development of antagonists to the hydro-osmotic effect of vasopressin via its V2 receptor has received significant attention. The numbers in the parentheses (1, 2, 3) are clickable links to peer-reviewed scientific papers. This article does not provide medical advice. As long as the thirst response is intact, significant hypernatremia should not develop. These agents reliably increase free water excretion and, in contrast to loop diuretics, do not significantly increase urinary sodium or potassium excretion. The risk of fatality increases for patients with blood sodium level of 110mEq/L, especially if these individuals are also suffering from other underlying related comorbidity. Hyponatremia widely affects the geriatric age group, especially hospitalized elderly patients. This may be concerning in elderly patients with limited mobility. Although the high cost of the drug is a frequent impediment to its long-time use, her insurance company was willing to cover the cost. The treatment of hyponatremia depends on the type of hyponatremia. In those that are hypervolemic (high body volume load), diuresis should be induced. If your doctor thinks you drink too much water, you may need to cut back. A decrease in the expression of the Na-K-2Cl co-transporter in the ascending limb of the loop of Henle and the Na-Cl co-transporter in the distal tubule has been reported in aging rodents (7). Hyponatremia is therefore of special significance in frail older people. Advice to remain well hydrated and on use of electrolyte replacement solutions may help prevent hyponatraemia occurring in the setting of acute diarrhoea and/or being sick (vomiting), especially in the elderly and young. Approximately 10% of the patients given a vaptan report polyuria. With a serum sodium concentration < 136 mEq/L used as a cutoff and a ≤30-year-old cohort as a reference group, patients >60 years had a significantly higher prevalence of hyponatremia both at presentation and as a hospital-acquired disorder (Figure 1). Although changes in the renal concentrating mechanism brought about by aging have been extensively studied, the effect of aging on the renal diluting process has received much less attention. Once you have decided to start a patient on a vaptan, how often do you monitor serum sodium levels, and what instructions do you give your patients taking vaptans about water intake? The syndrome of inappropriate antidiuretic hormone secretion in the elderly. A subsequent case-control study of >530 patients with a mean age of 81 years also found that the presence of hyponatremia (mean serum sodium concentration, 131 mEq/L) was associated with a four-fold greater risk of presenting with a fracture compared with age-matched normonatremic controls (13). Vasopressin receptor antagonists for the treatment of hyponatremia: Systematic review and meta-analysis. Patients should be warned of this potential side-effect and the symptoms that may occur. Thyroid-stimulating hormone was normal at 3.29 mIU/L. and her devoted husband for allowing the use of her case for this discussion. Because the secretion of vasopressin is sometimes transient, it would be reasonable to periodically stop the drug to determine whether it is still required. Although a recent study by Soupart and colleagues in 13 patients with SIADH found that urea was as effective in raising serum sodium levels and was as well tolerated as the vasopressin antagonist tolvaptan (23), in my experience and in informal surveys of practicing nephrologists in North America, urea is not widely used in North America, primarily because of limited availability. Hyponatremia Treatments Since so many different things can cause hyponatremia, your treatment depends on the cause. She has had four pulmonary bacterial infections during the last 7 years and was found to have radiologic evidence of bronchiectasis. Hyponatremia as observed in a chronic disease facility. Long-term effect of tolvaptan on serum sodium in the SALTWATER trial. In many cases, blood sodium levels fall gradually, producing only mild symptoms as the body has time to make adjustments. When given a water load, healthy elderly persons can readily dilute their urine to <100 mOsm/Kg, but the rate of free water excretion is slower than in younger controls (6). The increasing prevalence of hyponatremia with age is best illustrated in an analysis of >300,000 samples obtained from >120,000 patients of various ages (5). Therapy may be short-term or long-term. This decision is based on the presence of symptoms, the degree of hyponatremia, whether the condition is acute (arbitrarily defined as a duration of less than 48 hours) or chronic, and the presence of any degree of hypotension. The doctor may even enquire about the patient’s medical history for the purpose of diagnosis. Does the collecting duct become “hypersensitive” to arginine vasopressin or does resistance to vasopressin remain even after the drug is stopped? The symptoms of hyponatremia in elderly depend on its severity and the underlying cause. Hyponatremia is a medical condition characterized by low concentration of sodium in the blood. How Common Is Chronic Hyponatremia in the Elderly? Heart failure is also a common comorbid condition in this age group. The urinary sodium level (>20 mEq/L), urinary osmolality (>100 mOsm/kg), and low serum uric acid levels are findings that supported the diagnosis of the syndrome of inappropriate antidiuresis (also known as the syndrome of inappropriate antidiuretic hormone, or SIADH). In this study as well, patients with SIADH and heart failure had a more robust response than those with cirrhosis. Thus, although urea is inexpensive and potentially effective, its unavailability and patient intolerance regarding its taste make it a limited treatment option. Given the absence of liver or heart disease and the patient's apparently normal volume status, she was considered to have euvolemic hyponatremia. Let us look at the common causes of hyponatremia in elderly, it symptoms and treatment. The symptoms of hyponatremia in elderly too vary depending on the severity of the illness. This occurs because of confusion and disorientation that commonly is a symptom in hyponatremia. Treatment of isovolemia hypotonic hyponatremia associated with SSRI use includes water restriction and mild diuresis with a loop diuretic. During this period, her serum sodium concentration ranged between 125 and 132 mEq/L. In the last year she has had increased gait instability and sustained a fall that resulted in a pelvic fracture. In fact, thirst was one of the more frequent complaints in the SALT trials, even when serum sodium was nowhere near the normal range. Nonetheless, the goal of increasing the serum sodium concentration by 6–8 mEq/L in the first 24 hours should be attended to, and patients should be allowed free access to water in order to mitigate excessive correction rates. Also, the presence of some type of illness further increases their risk of developing hyponatremia. Of note is that when multiple serum sodium measurements were made during a 12-month period, approximately half of the nursing home population had at least one serum sodium measurement < 135 mEq/L. The treatment of hyponatremia can be divided into two steps. No studies have compared this therapeutic approach with other therapies for chronic hyponatremia in the elderly. The reasons for the increased incidence and prevalence of hyponatremia in the elderly are discussed, with emphasis on the effects of aging on urinary dilution, the frequently multifactorial nature of hyponatremia in this population, and the absence of a definite cause for inappropriate and persistent vasopressin release in many such patients. Effect of posture on blood pressure in the elderly. This is a normal part of aging. Whether such downregulation occurs in humans is not known, but if present it could impair both maximal concentrating and diluting abilities. We follow a strict editorial policy and we have a zero-tolerance policy regarding any level of plagiarism. Since then she has continued to receive this dose of tolvaptan, and her serum sodium levels over 20 months, without any water restriction, have fluctuated between 135 and 140 mEq/L (Figure 3). Rapid correction of hyponatremia occurs more frequently with vaptans than with placebo (28). Our articles are resourced from reputable online pages. In my experience, this symptom occurs early in the administration of the drug and in no case was it a cause for discontinuation. Plasma demeclocycline levels and nephrotoxicity. The association between increased mortality and hyponatremia in hospitalized patients in various settings and etiologies is widely recognized. Commensurate with the above discussion, our patient had disturbed gait and had sustained a fall and fracture. The change in medication has to be done very carefully under the supervision of a medical … 29, with permission. The various available treatment approaches, including water restriction, demeclocycline, loop diuretics with NaCl supplementation, urea, and vasopressin antagonists are summarized, with emphasis on the efficacy and limitations of each of these therapies. Despite the absence of any scientific support, limitation of water intake is often strongly encouraged. Hyponatremia in a nursing home population. Changing the medicine which affects the sodium level, managing the underlying illness, regulating the intake of water and salt in diet are some simple ways through which hyponatremia can be managed successfully. Dr. Berl was formerly on Otsuka's speaker's bureau. More severe cases may be treated with higher doses of loop diuretics and hypertonic saline. What is Hereditary Papillary Renal Cancer & How is it Treated? For treatment of moderate and chronic hyponatremia in elderly, caused by excessive intake water and fluids, improper diet or consumption of diuretics, appropriate changes are advised. Its poor palatability also leads to poor adherence. This health issue can range from being mild, to moderate, to severe. However, experience has revealed that adherence with significant water restriction is problematic and that such restriction is poorly tolerated over time. is a 73-year-old woman referred for management of chronic hyponatremia. noted that approximately 7% of patients >65 years of age had serum sodium concentrations ≤ 137 mEq/L (1). Question 3. It is critical to establish the underlying cause and type of the hyponatremia in order to address the problem and prevent future occurrences. Chronic hyponatremia is frequently multifactorial in the elderly (4,8). However, there is limited information about specific risk factors associated with developing hyponatremia in elderly. For treatment of moderate and chronic hyponatremia in elderly, caused by excessive intake water and fluids, improper diet or consumption of diuretics, appropriate changes are advised. With the aging of the population and the greater propensity of the elderly to develop hyponatremia, this electrolyte disorder is of increasing importance to the practicing nephrologist. This article on Epainassist.com has been reviewed by a medical professional, as well as checked for facts, to assure the readers the best possible accuracy. Therefore, at present tolvaptan is the only agent in this class available for long-term oral use. In one observational study, more than half of the patients with hyponatremia had more than one cause for the condition. Only when the diluting defect is mild and this ratio is <0.5 will a tolerable restriction of approximately 1 L/d be of any therapeutic benefit. The feedback link “Was this Article Helpful” on this page can be used to report content that is not accurate, up-to-date or questionable in any manner. The presence of these conditions usually increases the risk of hyponatremia in elderly. How significant is the burden of polyuria on patients who are receiving long-term vaptan therapy? Because of interactions with drugs metabolized by the CYP3A4 hepatic isoenzyme, conivaptan is approved only for short term (4 days) intravenous administration. Also, use of certain medicines like anti-inflammatory drugs or diuretics, are believed to be some of the common causes of hyponatremia in elderly. Advertisement PDF Version $34.95 $8.99 Buy Now Kindle Version $34.95 $8.99 Buy Now Paperback $74.95 $24.95 Buy Now, Advertisement Kindle Version $0.99 Buy Now. Such a trial has not yet been undertaken in the patient under discussion. Most cases of prolonged hyponatremia in the elderly are related to medication. It is important that the elderly or caregivers do NOT stop medication. Special attention is also needed to correct serum sodium levels at the appropriate rate, especially in chronic hyponatremia, in order to avoid the osmotic demyelination syndrome. Finally, in a case-control study of 122 hyponatremic patients (mean serum sodium, 126 mEq/L; mean age, 72 years), these investigators found that the gait disturbance associated with hyponatremia culminated in an increase in risk for falls by an odds ratio of 67.4 (95% confidence interval [CI], 7.48–607.4; P<0.001). The rationale for treating the hyponatremia, even when apparently asymptomatic, is discussed, with attention to cognitive function, gait, and bone structure disturbances that increase the risk for fractures. It must be recognized that there is a serious paucity of data demonstrating that vaptans clearly improve patient outcomes. Thus, the rationale for initiating a therapeutic intervention to increase her serum sodium concentration appeared compelling. BP was 148/78 mmHg, pulse rate was 98 beats/min, and she weighed 65 kg. Symptoms of hyponatremia emerged after treatment initiation and resolved with conservative care following discontinuation of duloxetine. Intravenous fluids. She had no history of cardiac or liver disease. The drug is not Food and Drug Administration (FDA) approved for treatment of hyponatremia. There were deformities of the proximal interphalangeal joints. What Therapeutic Options Are Available to Treat Chronic Hyponatremia in the Elderly? Presence of neurological symptoms and the severity of hyponatremia also play an important role in determining the right course of treatment of hyponatremia in elderly. The patient had difficulty adhering to this because of mouth dryness. Because hyponatremia is usually only mildly symptomatic or asymptomatic, treatment should be tailored to the clinical situation. Why Are Elderly Patients More Prone to Hyponatremia, and What Are the Causes of Hyponatremia in This Population? A third agent, lixivaptan, is under review by the FDA. As was elegantly analyzed by Furst and colleagues (18), when the sum of the concentration of urinary sodium plus potassium is greater than the serum sodium concentration, no electrolyte-free water is excreted and therefore almost no amount of water restriction will result in an increase in the serum sodium concentration. An open-label trial demonstrated continued efficacy of tolvaptan to maintain serum sodium level >135 mEq/L in most treated patients for up to 4 years (Figure 2) (29). The aim of this review is to practically present the current evidence regarding the thiazide-induced hyponatremia in elderly patients. The physician may ask to reduce their liquid intake, adjust salt intake and stay under strict monitoring. In conclusion, both the evaluation and the treatment of hyponatremia constitute many challenges in the elderly population. Hyponatremia is a complex condition that demands a systematic approach to diagnosis and management.23 In older adults, hyponatremia is one of the most common electrolyte imbalances and is associated with increased mortality.11 Careful attention to common causes, clinical presentation, laboratory diagnosis, and appropriate treatment will help practitioners safely reverse this potentially life-threatening condition. Hyponatremia in a euvolemic patient can be managed with fluid restriction and discontinuation of any medications that affect free-water excretion, along with initiation of treatment of the underlying cause. The rationale for use of loop diuretics and NaCl supplementation revolves around the ability of loop diuretics to increase electrolyte-free water excretion. Age and gender as risk factors for hyponatremia and hypernatremia. This approach has the virtue of addressing the underlying responsible mechanism and is very attractive for its lack of any associated cost. Finally, an age-related decrement in the percentage of body water content makes the elderly more prone to dysnatremias because smaller disturbances in water balance will cause greater changes in the serum sodium concentration. Elderly patients who cannot access water should not be given these drugs. This increase in solute delivery from NaCl intake and excretion may also increase electrolyte free water clearance (or reduce negative electrolyte free water clearance). Urinary sodium concentration was 75 mEq/L with a urine osmolality of 382 mOsm/kg. 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