Syndrome of inappropriate antidiuretic hormone medical therapy: Difference between revisions
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==Medical treatment of SIADH== | ==Medical treatment of SIADH== | ||
The mainstay of therapy for SIADH is | |||
3% | *Fluid restriction | ||
Oral salt tablets with loop diuretics | * 3% hypertonic saline( if sodium level falls below 125meq/l ). | ||
Vasopressin-2 receptor antagonists such as conivaptan or tolvaptan used in severe hyponatremia in emergency setting. | *Oral salt tablets with loop diuretics. | ||
*Vasopressin-2 receptor antagonists such as conivaptan or tolvaptan used in severe hyponatremia in emergency setting. The use of V2 receptor antagonists is limited due to increased thirst, rapid correction of sodium and high cost.<ref name="pmid17105757">{{cite journal |vauthors=Schrier RW, Gross P, Gheorghiade M, Berl T, Verbalis JG, Czerwiec FS, Orlandi C |title=Tolvaptan, a selective oral vasopressin V2-receptor antagonist, for hyponatremia |journal=N. Engl. J. Med. |volume=355 |issue=20 |pages=2099–112 |year=2006 |pmid=17105757 |doi=10.1056/NEJMoa065181 |url=}}</ref><ref name="pmid22029026">{{cite journal |vauthors=Pillai BP, Unnikrishnan AG, Pavithran PV |title=Syndrome of inappropriate antidiuretic hormone secretion: Revisiting a classical endocrine disorder |journal=Indian J Endocrinol Metab |volume=15 Suppl 3 |issue= |pages=S208–15 |year=2011 |pmid=22029026 |pmc=3183532 |doi=10.4103/2230-8210.84870 |url=}}</ref> | |||
Demeclocycline:It is a tetracycline derivative which induces drug-induced diabetes insipidus by acting on the collecting tubule cell to diminish its responsiveness to ADH.[36] The role is limited in emergency care due to the slow onset of action.<ref name="pmid402098">{{cite journal |vauthors=Cox M, Guzzo J, Morrison G, Singer I |title=Demeclocycline and therapy of hyponatremia |journal=Ann. Intern. Med. |volume=86 |issue=1 |pages=113–4 |year=1977 |pmid=402098 |doi= |url=}}</ref> | *Demeclocycline:It is a tetracycline derivative which induces drug-induced diabetes insipidus by acting on the collecting tubule cell to diminish its responsiveness to ADH.[36] The role is limited in emergency care due to the slow onset of action.<ref name="pmid402098">{{cite journal |vauthors=Cox M, Guzzo J, Morrison G, Singer I |title=Demeclocycline and therapy of hyponatremia |journal=Ann. Intern. Med. |volume=86 |issue=1 |pages=113–4 |year=1977 |pmid=402098 |doi= |url=}}</ref> | ||
Urea: Urea, at a dose of 30 g/day, increases urinary solute excretion and enhances water excretion.<ref name="pmid7386514">{{cite journal |vauthors=Decaux G, Brimioulle S, Genette F, Mockel J |title=Treatment of the syndrome of inappropriate secretion of antidiuretic hormone by urea |journal=Am. J. Med. |volume=69 |issue=1 |pages=99–106 |year=1980 |pmid=7386514 |doi= |url=}}</ref><ref name="pmid6794768">{{cite journal |vauthors=Decaux G, Genette F |title=Urea for long-term treatment of syndrome of inappropriate secretion of antidiuretic hormone |journal=Br Med J (Clin Res Ed) |volume=283 |issue=6299 |pages=1081–3 |year=1981 |pmid=6794768 |pmc=1507492 |doi= |url=}}</ref> | *Urea: Urea, at a dose of 30 g/day, increases urinary solute excretion and enhances water excretion.<ref name="pmid7386514">{{cite journal |vauthors=Decaux G, Brimioulle S, Genette F, Mockel J |title=Treatment of the syndrome of inappropriate secretion of antidiuretic hormone by urea |journal=Am. J. Med. |volume=69 |issue=1 |pages=99–106 |year=1980 |pmid=7386514 |doi= |url=}}</ref><ref name="pmid6794768">{{cite journal |vauthors=Decaux G, Genette F |title=Urea for long-term treatment of syndrome of inappropriate secretion of antidiuretic hormone |journal=Br Med J (Clin Res Ed) |volume=283 |issue=6299 |pages=1081–3 |year=1981 |pmid=6794768 |pmc=1507492 |doi= |url=}}</ref> | ||
Special consideration: Hyponatremia is the most common electrolyte abnormality in SIADH. So, the rate at which sodium is corrected is very important in clinical settings. It depends on the degree of hyponatremia, duration (acute or chronic),and symptomatology. | *Special consideration: Hyponatremia is the most common electrolyte abnormality in SIADH. So, the rate at which sodium is corrected is very important in clinical settings. It depends on the degree of hyponatremia, duration (acute or chronic),and symptomatology. | ||
*Acute setting (<48 hours since onset) where moderate symptoms are noted, treatment options for hyponatremia include the following: | |||
3% hypertonic saline (513 mEq/L) | *3% hypertonic saline (513 mEq/L) | ||
Loop diuretics with saline | *Loop diuretics with saline | ||
Vasopressin-2 receptor antagonists (aquaretics, such as conivaptan or tolvaptan) | *Vasopressin-2 receptor antagonists (aquaretics, such as conivaptan or tolvaptan) | ||
Water restriction | * Water restriction | ||
chronic asymptomatic setting, the treatment is as follows: | * In chronic asymptomatic setting, the treatment is as follows: | ||
Fluid restriction | *Fluid restriction | ||
Vassopressin-2 receptor antagonists | *Vassopressin-2 receptor antagonists | ||
*Other agents to be considered include loop diuretics with increased salt intake, urea, and demeclocycline | |||
Raise serum sodium by 0.5-1 mEq/hr, and not more than 10-12 mEq in the first 24 hours. This is to avoid complications like Osmotic demyelination syndrome. | *Raise serum sodium by 0.5-1 mEq/hr, and not more than 10-12 mEq in the first 24 hours. This is to avoid complications like Osmotic demyelination syndrome. | ||
In rare medical emergencies more commonly seen in cardiology in the context of hypervolemic severe hyponatremia rather than in SIADH | *In rare medical emergencies more commonly seen in cardiology in the context of hypervolemic severe hyponatremia rather than in SIADH | ||
* Continuous veno-venoushemofiltration (CVVH) a | |||
*Slow, low-efficiency daily dialysis (SLEDD have been used to improve hyponatremia. These methods are invasive so their use is very limited.<ref name="pmid19628685">{{cite journal |vauthors=Salahudeen AK, Kumar V, Madan N, Xiao L, Lahoti A, Samuels J, Nates J, Price K |title=Sustained low efficiency dialysis in the continuous mode (C-SLED): dialysis efficacy, clinical outcomes, and survival predictors in critically ill cancer patients |journal=Clin J Am Soc Nephrol |volume=4 |issue=8 |pages=1338–46 |year=2009 |pmid=19628685 |pmc=2723965 |doi=10.2215/CJN.02130309 |url=}}</ref> | |||
==References== | ==References== | ||
Revision as of 13:57, 9 August 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vindhya BellamKonda, M.B.B.S [2]
Overview
Treatment of syndrome of inappropriate antidiuretic hormone depends on the etiology. For immediate improvement, all patients with SIADH require sharp restriction of their daily water intake and depending on the sodium levels, 3%hypertonic saline,loop diuretics with normal saline may be used. In emergency settings,Vasopressin-2 receptor antagonists (aquaretics, such as conivaptan or tolvaptan) are used. The most definitive way to treat SIADH is to deal with the underlying problem itself. If SIADH produced by drugs, then the patient must stop taking the medicine. If some infection may be the cause, the patient needs to controlling them by some antibiotics or other anti-microbiological drugs.
Medical treatment of SIADH
The mainstay of therapy for SIADH is
*Fluid restriction
- 3% hypertonic saline( if sodium level falls below 125meq/l ).
- Oral salt tablets with loop diuretics.
- Vasopressin-2 receptor antagonists such as conivaptan or tolvaptan used in severe hyponatremia in emergency setting. The use of V2 receptor antagonists is limited due to increased thirst, rapid correction of sodium and high cost.[1][2]
- Demeclocycline:It is a tetracycline derivative which induces drug-induced diabetes insipidus by acting on the collecting tubule cell to diminish its responsiveness to ADH.[36] The role is limited in emergency care due to the slow onset of action.[3]
- Urea: Urea, at a dose of 30 g/day, increases urinary solute excretion and enhances water excretion.[4][5]
- Special consideration: Hyponatremia is the most common electrolyte abnormality in SIADH. So, the rate at which sodium is corrected is very important in clinical settings. It depends on the degree of hyponatremia, duration (acute or chronic),and symptomatology.
- Acute setting (<48 hours since onset) where moderate symptoms are noted, treatment options for hyponatremia include the following:
- 3% hypertonic saline (513 mEq/L)
- Loop diuretics with saline
*Vasopressin-2 receptor antagonists (aquaretics, such as conivaptan or tolvaptan) * Water restriction
- In chronic asymptomatic setting, the treatment is as follows:
- Fluid restriction
- Vassopressin-2 receptor antagonists
- Other agents to be considered include loop diuretics with increased salt intake, urea, and demeclocycline
- Raise serum sodium by 0.5-1 mEq/hr, and not more than 10-12 mEq in the first 24 hours. This is to avoid complications like Osmotic demyelination syndrome.
- In rare medical emergencies more commonly seen in cardiology in the context of hypervolemic severe hyponatremia rather than in SIADH
- Continuous veno-venoushemofiltration (CVVH) a
- Slow, low-efficiency daily dialysis (SLEDD have been used to improve hyponatremia. These methods are invasive so their use is very limited.[6]
References
- ↑ Schrier RW, Gross P, Gheorghiade M, Berl T, Verbalis JG, Czerwiec FS, Orlandi C (2006). "Tolvaptan, a selective oral vasopressin V2-receptor antagonist, for hyponatremia". N. Engl. J. Med. 355 (20): 2099–112. doi:10.1056/NEJMoa065181. PMID 17105757.
- ↑ Pillai BP, Unnikrishnan AG, Pavithran PV (2011). "Syndrome of inappropriate antidiuretic hormone secretion: Revisiting a classical endocrine disorder". Indian J Endocrinol Metab. 15 Suppl 3: S208–15. doi:10.4103/2230-8210.84870. PMC 3183532. PMID 22029026.
- ↑ Cox M, Guzzo J, Morrison G, Singer I (1977). "Demeclocycline and therapy of hyponatremia". Ann. Intern. Med. 86 (1): 113–4. PMID 402098.
- ↑ Decaux G, Brimioulle S, Genette F, Mockel J (1980). "Treatment of the syndrome of inappropriate secretion of antidiuretic hormone by urea". Am. J. Med. 69 (1): 99–106. PMID 7386514.
- ↑ Decaux G, Genette F (1981). "Urea for long-term treatment of syndrome of inappropriate secretion of antidiuretic hormone". Br Med J (Clin Res Ed). 283 (6299): 1081–3. PMC 1507492. PMID 6794768.
- ↑ Salahudeen AK, Kumar V, Madan N, Xiao L, Lahoti A, Samuels J, Nates J, Price K (2009). "Sustained low efficiency dialysis in the continuous mode (C-SLED): dialysis efficacy, clinical outcomes, and survival predictors in critically ill cancer patients". Clin J Am Soc Nephrol. 4 (8): 1338–46. doi:10.2215/CJN.02130309. PMC 2723965. PMID 19628685.