Hypotonic Hyponatremia CASSIE JORDAN PHARM D CANDIDATE 2017

Hypotonic Hyponatremia CASSIE JORDAN PHARM D CANDIDATE 2017 HAMPTON UNIVERSITY SCHOOL OF PHARMACY PRECEPTOR: LEAH GONZALEZ PHARM D, BCPS

OBJECTIVES Patient CJ Hyponatremia Overview Hyponatremia Treatment Options CJ Treatment Assessment

ADMISSION PMH CJ 63 y/o Female Presented to SLH on 4/11/17 for bilateral total knee replacement due to longstanding arthritis causing pain and disability. Asthma Current Therapy Albuterol PRN* Mild Intermittent Osteopenia Oscal-D (1, 500 mg Ca/Vit D 200 u) QD (600 mg elemental Ca) Hepatitis C Interferon + ribavirin x 12 weeks (2011 @ VCU) (treated) Seasonal Allergies Claritin PRN Cough Guaifenesin 600 mg Q 12 Pulmonary Hypertension n/a GERD Dexlansoprazole 60 mg QD Hyperlipidemia Atorvastatin 10 mg HS

ADMISSION Social History Ø No tobacco use Ø Family History Ø Cataract removal ‘ 16 No illicit drug use Ø Partial hysterectomy ‘ 00 Ø Alcohol use: 1 glass/day Ø Oophorectomy ‘ 00 Ø Married Ø Right breast lumpectomy ‘ 96 Ø Retired pediatric nurse practitioner Ø Tonsil & adenoidectomy (child) Ø Not contributory Surgical History

ADMISSION Lab Values Vitals 139 99 27 4. 4 26 0. 7 9. 7 8. 5 246 28 98 T: 98. 8ºF (37. 1ºC) HR: 86 RR: 18 O 2 RA: 98 BMI: 21. 3 BP: 104/56 Wt: 58 kg

POST OPERATION-Labs NA K Glu BUN OSM 4/12/17 128 4 125 16 268* 4/13/17 121 3. 2 142 6 263 252* 4/14/17 131 - - 4/15/17 133 3. 3 119 14 277* *

Hyponatremia [Na+] serum < 135 m. Eq/L Thiazides

HYPONATREMIA Clinical Presentation 1 SIGNS SYMPTOMS Dry mucous membranes* Nausea & malaise- first findings Decreased skin turgor* Headache Tachycardia* Restlessness Decreased JVP* Disorientation Postural hypotension* Seizures Pulmonary edema Depressed reflexes Coma Lab values of [Na] <135 Permanent brain damage Death *seen in hypovolemic patients Coyle, J. D. , & Joy, M. S. (2008). Chapter 52 Disorders of Sodium and Water Homeostasis. In Pharmacotherapy A Pathophysiological Approach (7 th ed. , pp. 845 -860). Mc. Graw Hill Medical

HYPONATREMIA ECF- Interstitial & Intravenous fluids ICF- Inside the cell

HYPONATREMIA-Diagnostic Algorithm 1 Coyle, J. D. , & Joy, M. S. (2008). Chapter 52 Disorders of Sodium and Water Homeostasis. In Pharmacotherapy A Pathophysiological Approach (7 th ed. , pp. 845 -860). Mc. Graw Hill Medical

HYPONATREMIA and ADH (vasopressin)

HYPONATREMIA-SIADH Causes Ø Ø Tumors: Oat cell lung cancer CNS disorders: head trauma, stroke, meningitis, pituitary surgery Pulmonary disease Drug Induced q Desmopressin q Oxytocin q Carbamazepine q Cyclophosphamide q NSAIDs q SSRI q TCA q Opiates q Phenothiazines (promethazine) q Ecstasy Ø Blood volume depletion 1. 2

HYPONATREMIA- Hypotonic Treatment Discontinue any medications known to cause SIADH Severe symptoms 100 m. L of 3% Na. Cl infused IV over 10 min x 3 prn Mild to moderate symptoms 3% Na. Cl infused at 0. 5 -2 m. L/kg/h 3 3 Diagnosis, Evaluation, and Treatment of Hyponatremia: Expert Panel Recommendations Verbalis, Joseph G. et al. The American Journal of Medicine , Volume 126 , Issue 10 , S 1 - S 42

HYPONATREMIA-Hypotonic Treatment SIADH 3 Observe limits of correction- not to exceed 12 m. Eq/day Goal of Na+ correction Minimum correction by 4 -8 m. Eq/L per day Lower goal of 4 -6 m. Eq/L per day if high risk for ODS Do Not Exceed High risk of ODS: 8 m. Eq/L in any 24 -h period Normal risk of ODS: 10 -12 m. Eq/L in any 24 -h period; 18 m. Eq/L in any 48 -h period 3 Diagnosis, Evaluation, and Treatment of Hyponatremia: Expert Panel Recommendations Verbalis, Joseph G. et al. The American Journal of Medicine , Volume 126 , Issue 10 , S 1 - S 42

HYPONATREMIA-Hypotonic Treatment SIADH 3 Fluid restriction is considered first line 500 -800 m. L/day total intake Several days of restriction are generally needed to see an increase in osmolality Do not limit Na+ or protein intake Discontinue any drugs known to be associated with SIADH Consider pharmacologic therapy if urinary parameters indicate hyperosmolar urine or if the serum Na+ has not corrected after 24 -48 hours of fluid restriction Urea Demeclocycline Vasopressin receptor antagonists (Vaptans)

POST ADMISSION-Problems/Treatment Active Medical Problems S/P bilateral TKR DVT prophylaxis: SCDS, Heparin bridge w/warfarin Pain management: Toradol Q 6 H (d/c 4/12/17) Dilaudid 6 mg Q 6 H- Started 4/13/17 @ 0810 - D/C 4/15/17 06: 46 Nausea: Scopolamine patch Q 72 H Anemia (d/t acute blood loss) Tranexamic acid 1 g/100 m. L (400 m. L/hr over 15 mins given) Monitor and possible discharge rx for Iron GERD Omeprazole 40 mg QD HLD Atrovastatin 10 mg QHS Asthma Albuterol PRN Osteopenia Oscal held until discharge Seasonal allergies Claritin 10 mg QD

HYPONATREMIA-Problems/Treatment Active Medical Problem cont… Hypotonic Hyponatremia • • 3% saline 15 m. L/hr 4/13 19: 00 -19: 17 3% saline 25 m. L/hr X 6 hrs 4/13 20: 00 -22: 27 Saline tablets 1 g PO-4/13 11: 06, 16: 56; 4/14 08: 30, 22: 54 Saline tablets 2 g PO 4/14 16: 06 10 g Urea powder dissolved in 50 m. L water 20 g Urea powder 4/14 16: 40 Fluid restriction BMP ordered Q 6 H

POST ADMISSION-Discharge Medications Dilaudid 2 mg 1 -2 T PO Q 46 PRNP Ultram 50 mg 1 T PO Q 46 PRN BTP Zofran 4 mg 1 T PO Q 6 PRN Nausea Warfarin per protocol Resume pre-op medications Home Health SLH Pharmacy Warfarin 5 mg

Review of Therapy Proper DVT prophylaxis was used Medications known to cause SIADH were stopped upon notice of hyponatremia. Toradol Hypertonic saline was used instead of isotonic Oral saline tablets given Urea given Medications were ordered for OIC if needed Dulcolax Miralax Fleet’s Enema

REFERENCES 1. Coyle, J. D. , & Joy, M. S. (2008). Chapter 52 Disorders of Sodium and Water Homeostasis. In Pharmacotherapy A Pathophysiological Approach (7 th ed. , pp. 845 -860). Mc. Graw Hill Medical 2. (n. d. ). Retrieved April 17, 2017, from https: //www. uptodate. com/contents/causesof-hyponatremia-in-adults? source=machine. Learning&search=hypoosmolar hyponatremia&selected. Title=1~150§ion. Rank=1&anchor=H 5#H 22 3. Diagnosis, Evaluation, and Treatment of Hyponatremia: Expert Panel Recommendations Verbalis, Joseph G. et al. The American Journal of Medicine , Volume 126 , Issue 10 , S 1 - S 42