Syndrome of inappropriate antidiuretic hormone medical therapy

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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 ofsyndrome of inappropriate antidiuretic hormone depends on the etiology. The mainstay of therapy is fluid]] restriction. Depending on thesodium levels and symptoms, 3% hypertonic saline and loop diuretics with normal saline may be used. In emergency settings,vasopressin-2 receptor antagonists such as (conivaptan or tolvaptan) are used. The most definitive way to treat SIADH is to deal with the underlying problem itself.

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.

• 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.The role is limited in emergency care due to the slow onset of action.

• Urea: Urea, at a dose of 30 g/day, increases urinary solute excretion and enhances water excretion.

• 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 hyponatremia	Chronic hyponatremia
3% hypertonic saline	Fluid restriction
Loop diuretics with saline	Vasopressin-2 receptor anatgonists
Vasopressin-2 receptor antagonists(conivaptan and tolvaptan)	Loop diuretics with increased salt intake
Water restriction	Urea
	Demeclocycline

• Raise serum sodium by 0.5-1 mEq/hr, and not more than 10-12 mEq in the first 24 hours,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-venous hemofiltration (CVVH)
• Slow, low-efficiency daily dialysis (SLEDD have been used to improve hyponatremia. These methods are invasive so their use is very limited.