Hyponatremia diuretics

The major limitation to the use of spironolactone is its liability to cause (sometimes lethal) hyperkalemia, particularly in the elderly, in patients with reduced renal function, and in patients who simultaneously take potassium supplements or ACE inhibitors. As with other diuretics, hyponatremia and dehydration can occur. Other less frequent adverse effects are gastrointestinal intolerance, neurological symptoms, and skin rashes. Hypersensitivity rashes and a lupus-Uke syndrome have been reported rarely. A few cases of mammary carcinoma have been reported and potential human metabolic products of spironolactone are carcinogenic in rodents. Second-generation effects have not been reported. 

The use of V2 antagonists is promising in the treatment of the hyponatremia that usually accompanies congestive heart failure and cirrhosis, two edematous conditions in which the use of diuretics is indicated. In addition, V2 antagonists may be beneficial in the treatment of polycystic kidney disease. 

Electrolyte imbalances that may be seen during therapy with a diuretic include hyponatremia (low blood sodium) and hypokalemia (low blood potassium), although other imbalances may also be seen. See Chapter 58 and Display 58-2 for the signs and symptoms of electrolyte imbalances. The primary care provider is notified if any signs or symptoms of an electrolyte imbalance occur. 

Ms. Palmer, age 88 years, is a resident in a nursing home. Her primary health care provider prescribes a thiazide diuretic for CHF. The nurse in charge advises you to evaluate Ms. Palmer for signs and symptoms of dehydration and hyponatremia. Discuss the assessment you would make. Identify which of these signs and symptoms might be difficult to evaluate considering the patient s age... 

Hypotonic hyponatremia with an increase in ECF is also known as dilutional hyponatremia. In this scenario, patients have an excess of total body sodium and TBW however, the excess in TBW is greater than the excess in total body sodium. Common causes include CHF, hepatic cirrhosis, and nephrotic syndrome. Treatment includes sodium and fluid restriction in conjunction with treatment of the underlying disorder—for example, salt and water restrictions are used in the setting of CHF along with loop diuretics, angiotensin-converting enzyme inhibitors, and spironolactone.15... 

In hypotonic hyponatremia with a decreased ECF volume, patients usually have a deficit of both total body sodium and TBW, but the sodium deficit exceeds the TBW deficit. Common causes include diuretic use, profuse sweating,... 

Oxcarbazepine Hyponatremia (serum sodium concentrations less than 125 mEq/L) has been reported and occurs more frequently during the first 3 months of therapy serum sodium concentrations should be monitored in patients receiving drugs that lower serum sodium concentrations (e.g., diuretics or drugs that cause inappropriate antidiuretic hormone secretion) or in patients with symptoms of hyponatremia (e.g., confusion, headache, lethargy, and malaise). Hypersensitivity reactions have occurred in approximately 25-30% of patients with a history of carbamazepine hypersensitivity and requires immediate discontinuation. 

Rosner MH. Severe hyponatremia associated with the combined use of thiazide diuretics and selective serotonin reuptake inhibitors. Am J Med Sci 2004 327 109-111. 

Patients who experience encephalopathy, severe hyponatremia despite fluid restriction, or renal insufficiency should have diuretic therapy discontinued. 

Patients with hypervolemic hypotonic hyponatremia should be treated with 3% saline and prompt initiation of fluid restriction. Loop diuretic therapy will also likely be required to facilitate urinary excretion of free water. 

The activity of the renin-angiotensin system is reduced with age (Muhlberg and Platt 1999). The ability of the kidney to concentrate urine maximally after water deprivation decreases with age, as does the ability to excrete a water and salt load, particularly during the night. Nocturnal polyuria is common in the elderly (Lubran 1995). Diuretics are commonly used in the elderly. There is an increased risk for hypokalemia and hyponatremia from diuretics in the elderly (Passare et al. 2004). Electrolyte disturbances may also be caused by several types of drugs in the elderly and it is important to monitor serum electrolyte levels in the elderly. Treatment with... 

High-risk patients Hypertensive patients at risk of excessive hypotension include those with the following concurrent conditions or characteristics Heart failure, hyponatremia, high-dose diuretic therapy, recent intensive diureses or increase in diuretic dose, renal dialysis, or severe volume or salt depletion of any etiology. Single doses of enalaprilat as low as 0.2 mg have produced excessive hypotension in normotensive patients with these diagnoses. Because of the potential for an extreme hypotensive response in these patients, initiate therapy under very close medical supervision. The... 

Initial dose 5 mg once daily with diuretics and digitalis. Usual effective dosage range is 5 to 20 mg/day as a single dose. In patients with hyponatremia (serum sodium less than 130 mEq/L), initiate dose at 2.5 mg once daily. If used with diuretics, initial dose is 5 mg/day. 

Electrolyte imbalance and BUN increases Hyponatremia and hypochloremia may occur when amiloride is used with other diuretics. Increases in BUN levels usually accompany vigorous fluid elimination, especially when diuretic therapy is used in seriously ill patients, such as those who have hepatic cirrhosis with ascites and metabolic alkalosis, or those with resistant edema. 

Hyponatremia Hyponatremia may be caused or aggravated by spironolactone, especially in combination with other diuretics. Symptoms include dry mouth, thirst, lethargy, drowsiness. 

Cardiovascular effects May cause fluid retention and peripheral edema. Use caution in compromised cardiac function, hypertension, in patients on chronic diuretic therapy, or other conditions predisposing to fluid retention. Agents may be associated with significant deterioration of circulatory hemodynamics in severe heart failure and hyponatremia. 

Frequent serum electrolyte analysis is essential during therapy with the high-ceiling diuretics. Overdose may result in a rapid reduction of blood volume, dizziness, headache, orthostatic hypotension, hyponatremia, and hypokalemia. Nausea, vomiting, diarrhea, and loss of appetite are especially common with ethacrynic acid. 

Use with caution in oider patients with Renal impairment. Hypothyroidism, Dehydration, Hyponatremia, Patients taking diuretics, NSAIDs or ACE inhibitors... 

Oxcarbazepine is typically started at a dosage of 150 mg twice a day and titrated by 300 mg/day at weekly intervals. Therapeutic dosages are in the range of 450 mg twice a day to 1,200 mg twice a day. The conversion from carbamazepine to oxcarbazepine is approximately 1 to 1.5. Oxcarbazepine has a higher risk of hyponatremia than does carbamazepine. Serum sodium should be monitored in patients at risk for hyponatremia, such as the elderly or patients who are also taking diuretics. Stevens-Johnson syndrome and toxic epidermal necrolysis may occur between 3 and 10 times more frequently in oxcarbazepine-treated patients than in the general population. Median time from starting treatment to the development of these serious reactions is 19 days. 

Because CBZ can cause hyponatremia, it should be used cautiously in patients on a salt-restricted diet ( 373). Hyponatremia is rarely clinically significant when sodium values are above 125 mmol/L. Low sodium levels, as well as concomitant diuretic and lithium users, may predispose to the development of the syndrome of inappropriate ADH. Since CBZ enhances the effects of ADH, it can lead to impairment of free water clearance from the body. Older patients are at higher risk and should be closely monitored for this adverse effect which can be managed by dose reduction of CBZ. More severe cases, however, usually require switching to... 

Because Henle s loop is indirectly responsible for water reabsorption by the downstream collecting duct, loop diuretics can cause severe dehydration. Hyponatremia is less common than with the thiazides (see below), but patients who increase water intake in response to hypovolemia-induced thirst can become severely hyponatremic with loop agents. Loop agents are sometimes used for their calciuric effect, but hypercalcemia can occur in volume-depleted patients who have another—previously occult—cause for... 

Hyponatremia is an important adverse effect of thiazide diuretics. It is due to a combination of hypovolemia-induced elevation of ADH, reduction in the diluting capacity of the kidney, and increased thirst. It can be prevented by reducing the dose of the drug or limiting water intake. 

Mannitol is rapidly distributed in the extracellular compartment and extracts water from cells. Prior to the diuresis, this leads to expansion of the extracellular volume and hyponatremia. This effect can complicate heart failure and may produce florid pulmonary edema. Headache, nausea, and vomiting are commonly observed in patients treated with osmotic diuretics. 

Delisle F. Hyponatremia and syndrome of inappropriate anti-diuretic hormone reported with the use of vincristine an over-representation of Asians ... 

The most serious side effects of diuretics are fluid depletion and electrolyte imbalance.13,88 By the very nature of their action, diuretics decrease extracellular fluid volume as well as produce sodium depletion (hyponatremia) and potassium depletion (hypokalemia). Hypokalemia is a particular problem with the thiazide and loop diuretics, but occurs less frequently when the potassium-sparing agents are used. Hypokalemia and other disturbances in fluid and electrolyte balance can produce serious metabolic and cardiac problems and may even prove fatal in some individuals. Consequently, patients must be monitored closely, and the drug dosage should be maintained at the lowest effective dose. Also, potassium supplements are used in some patients to prevent hypokalemia. 

By the very nature of their action, diuretics are often associated with disturbances in fluid and electrolyte balance. Volume depletion, hyponatremia, hypokalemia, and altered pH balance are among the most fre-... 

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