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Mannheimer B, Lindh JD, Fahlén CB, Issa I, Falhammar H, Skov J. Drug-induced hyponatremia in clinical care. Eur J Intern Med 2025:S0953-6205(25)00175-X. [PMID: 40328519 DOI: 10.1016/j.ejim.2025.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2025] [Revised: 04/22/2025] [Accepted: 04/23/2025] [Indexed: 05/08/2025]
Abstract
PURPOSE Over the last decades, advances in understanding of previously described associations have important implications for diagnosis and workup of hyponatremia. In addition, new drug groups potentially affecting sodium balance and water homeostasis have evolved. The aim of this review is to summarize current evidence on drug-induced hyponatremia in clinical care. METHODS We searched PubMed using the string "Inappropriate ADH Syndrome/chemically induced"[Mesh] OR "Inappropriate ADH Syndrome/diagnosis"[Mesh]) OR ("Hyponatremia/chemically induced"[Mesh] OR "Hyponatremia/diagnosis"[Mesh]), January 1st, 2008, to September 2nd 2024. In total 2003 articles were found and reviewed. Relevant articles referenced herein were subsequently traced backwards and also reviewed. RESULTS Drugs associated with hyponatremia, including selective serotonin reuptake inhibitors, antipsychotics, antiepileptic drugs and proton pump inhibitors, typically cause hyponatremia shortly after initiation of treatment. For thiazide diuretics, the number one culprit in drug-induced hyponatremia, the risk for hyponatremia is highest the first weeks after initiation and then gradually decreases to a stable but still increased level after around 3 months. Several drugs that promote a negative water balance such as loop diuretics, lithium and of sodium-glucose cotransporter-2 inhibitors appear to decrease the risk for hyponatremia. Treatment with immune checkpoint inhibitors is associated with an increased risk of hypophysitis and adrenalitis resulting in hyponatremia due to secondary and primary cortisol deficiency. CONCLUSION For most drugs associated with hyponatremia, including thiazides, the cause-effect relationship is tightly linked to newly initiated treatment. Further research is warranted to characterize the association between hyponatremia and newly developed drugs such as sodium-glucose cotransporter-2 inhibitors and immune checkpoint inhibitors.
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Affiliation(s)
- Buster Mannheimer
- Department of Clinical Science and Education at Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Department of Medicine, Södersjukhuset, Stockholm, Sweden.
| | - Jonatan D Lindh
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden; Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Bergh Fahlén
- Department of Clinical Science and Education at Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Department of Medicine, Södersjukhuset, Stockholm, Sweden
| | - Issa Issa
- Department of Clinical Science and Education at Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Department of Medicine, Södersjukhuset, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Jakob Skov
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Medicine, Karlstad Central Hospital, Region Värmland, Sweden
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Bembenick KN, Mathew J, Heisler M, Siddaiah H, Moore P, Robinson CL, Kaye AM, Shekoohi S, Kaye AD, Varrassi G. Hyponatremia With Anticonvulsant Medications: A Narrative Review. Cureus 2024; 16:e57535. [PMID: 38707045 PMCID: PMC11066697 DOI: 10.7759/cureus.57535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/03/2024] [Indexed: 05/07/2024] Open
Abstract
Hyponatremia is an adverse effect of many antiseizure medications (ASMs). It occurs with interference with the normal balance of electrolytes within the body. Various risk factors associated with the development of hyponatremia in patients taking these medications include age, gender, dosage, and combinations with other drugs. ASMs such as carbamazepine (CBZ), oxcarbazepine (OXC), and valproic acid have a higher risk of hyponatremia. Hyponatremia induced by an antiseizure medication can occur through various mechanisms depending on the drug's specific mechanism of action. Hyponatremia can be a potentially fatal side effect. Patients taking these medications need to be monitored closely for the signs and symptoms of hyponatremia. Acute hyponatremia, defined as developing in <48 hours, is more likely to show symptoms than chronic hyponatremia. Signs of acute hyponatremia include delirium, seizures, decerebrate posturing, and cerebral edema with uncal herniation. Chronic hyponatremia, defined as developing in >48 hours, can cause lethargy, dizziness, weakness, headache, nausea, and confusion. Hyponatremia is associated with longer hospital stays and increased mortality. Treatment varies based on the degree of severity of hyponatremia. Choosing a treatment option should include consideration of the drug causing the electrolyte disturbance, the patient's risk factor profile, and the severity of symptoms as they present in the individual patient. Healthcare providers should be aware of hyponatremia as a potential side effect of ASMs, the signs and symptoms of hyponatremia, the different treatment options available, and the potential complications associated with rapid correction of hyponatremia.
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Affiliation(s)
| | - Jibin Mathew
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Michael Heisler
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Harish Siddaiah
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Peyton Moore
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Christopher L Robinson
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences University of the Pacific, Stockton, USA
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
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Strýček O, Všianský V, Doležalová I, Kočvarová J, Pail M, Brázdil M. Eslicarbazepine-induced hyponatremia: A retrospective single-center real clinical practice study. Epilepsia Open 2024; 9:404-408. [PMID: 37593899 PMCID: PMC10839350 DOI: 10.1002/epi4.12814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/15/2023] [Indexed: 08/19/2023] Open
Abstract
Hyponatremia is a typical side effect of antiseizure drugs from the dibenzazepine family. The study investigated the prevalence of hyponatremia in patients with epilepsy who were treated with eslicarbazepine. We aimed to determine the prevalence of hyponatremia, reveal the factors leading to the discontinuation of treatment, and identify possible risk factors for the development of hyponatremia including the dose dependency. The medical records of 164 patients with epilepsy taking eslicarbazepine in our center were analyzed. The overall prevalence of hyponatremia was 30.5%. The prevalence of mild hyponatremia, seen in 14%-20% of patients, was not dose dependent. The prevalence of moderate and severe hyponatremia was significantly dose dependent. The severity of hyponatremia was significantly dose dependent. Severe hyponatremia was found in 6.1% of patients. Hyponatremia was asymptomatic in the majority of cases, and in 48% did not require any management. Hyponatremia was the reason for discontinuation in 6.2% of patients. The major risk factor for developing hyponatremia was older age. The study shows that eslicarbazepine-induced hyponatremia is usually mild and asymptomatic. It usually does not require any management and seldom leads to treatment discontinuation. Hyponatremia is dose dependent. Another major risk for developing hyponatremia (besides dose) is older age.
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Affiliation(s)
- Ondřej Strýček
- Brno Epilepsy Center, First Department of Neurology, St. Anne's University Hospital and Faculty of MedicineMasaryk University, Member of ERN‐EpiCAREBrnoCzech Republic
- Central European Institute of Technology (CEITEC)Masaryk UniversityBrnoCzech Republic
| | - Vít Všianský
- Brno Epilepsy Center, First Department of Neurology, St. Anne's University Hospital and Faculty of MedicineMasaryk University, Member of ERN‐EpiCAREBrnoCzech Republic
| | - Irena Doležalová
- Brno Epilepsy Center, First Department of Neurology, St. Anne's University Hospital and Faculty of MedicineMasaryk University, Member of ERN‐EpiCAREBrnoCzech Republic
- Central European Institute of Technology (CEITEC)Masaryk UniversityBrnoCzech Republic
| | - Jitka Kočvarová
- Brno Epilepsy Center, First Department of Neurology, St. Anne's University Hospital and Faculty of MedicineMasaryk University, Member of ERN‐EpiCAREBrnoCzech Republic
| | - Martin Pail
- Brno Epilepsy Center, First Department of Neurology, St. Anne's University Hospital and Faculty of MedicineMasaryk University, Member of ERN‐EpiCAREBrnoCzech Republic
- Central European Institute of Technology (CEITEC)Masaryk UniversityBrnoCzech Republic
| | - Milan Brázdil
- Brno Epilepsy Center, First Department of Neurology, St. Anne's University Hospital and Faculty of MedicineMasaryk University, Member of ERN‐EpiCAREBrnoCzech Republic
- Central European Institute of Technology (CEITEC)Masaryk UniversityBrnoCzech Republic
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Inoue M, Nakai K, Tanaka S, Mitsuiki K, Tokumoto M, Tsuruya K, Kitazono T, Nakano T. Prevalence of hyponatremia and associated factors in patients with chronic kidney disease: the Fukuoka Kidney Disease Registry (FKR) study. Clin Exp Nephrol 2023; 27:1023-1031. [PMID: 37642786 DOI: 10.1007/s10157-023-02395-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 08/11/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Hyponatremia is a common and important electrolyte disorder. However, the prevalence and factors associated with hyponatremia in patients with chronic kidney disease (CKD) are unknown. METHODS We studied the factors associated with hyponatremia (< 135 mEq/L) in CKD patients registered in the Fukuoka Kidney Disease Registry (FKR) study using a logistic regression model variable selected using the variable reduction method. RESULTS We analyzed the baseline characteristics of 4367 participants with CKD (age, 64 ± 16 years; male, 56.1%). Hyponatremia was detected in 2.0% of the patients at baseline, and multivariate logistic analysis showed that the independent factors for hyponatremia were body mass index (odds ratio [OR] 0.91; 95% confidence interval [CI] 0.85-0.97), prescription of benzodiazepine (OR 2.31; 95% CI 1.39-3.86), blood hemoglobin level (OR 0.76; 95% CI 0.65-0.88), and serum C-reactive protein level (OR 1.27; 95% CI 1.04-1.54). CONCLUSION The cross-sectional analysis using baseline data from the FKR study revealed independent factors associated with hyponatremia in patients with decreased kidney function. Longitudinal analyses of the FKR cohort are needed to evaluate the effects of these factors on the prognosis of hyponatremia in patients with CKD.
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Affiliation(s)
- Megumi Inoue
- Division of Nephrology and Dialysis Center, Japanese Red Cross Fukuoka Hospital, Fukuoka, Japan
| | - Kentaro Nakai
- Division of Nephrology and Dialysis Center, Japanese Red Cross Fukuoka Hospital, Fukuoka, Japan
| | - Shigeru Tanaka
- Department of Medicine and Clinical Science, Graduated School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 8128582, Japan
| | - Koji Mitsuiki
- Division of Nephrology and Dialysis Center, Japanese Red Cross Fukuoka Hospital, Fukuoka, Japan
| | - Masanori Tokumoto
- Division of Nephrology and Dialysis Center, Japanese Red Cross Fukuoka Hospital, Fukuoka, Japan
| | - Kazuhiko Tsuruya
- Department of Nephrology, Nara Medical University, Kashihara, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduated School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 8128582, Japan
| | - Toshiaki Nakano
- Department of Medicine and Clinical Science, Graduated School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 8128582, Japan.
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LoPinto-Khoury C. Long-Term Effects of Antiseizure Medications. Semin Neurol 2022; 42:583-593. [PMID: 36216358 DOI: 10.1055/a-1958-0802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Most patients with epilepsy will benefit from seizure control with one of an array of chronic antiseizure medications. Knowledge of the potential long-term effects of these medications is critical to prevent adverse consequences on overall health. Antiseizure medications vary in their capacities to affect the brain and peripheral nerves, hormones, bone mineralization, cardiovascular risk, renal health, hepatic, hematological, and dermatological systems. Understanding of pathophysiology and population risk has evolved, although most of the data available are still on older generation antiseizure medications such as phenytoin, carbamazepine, and valproic acid. The enzyme-inducing properties of some antiseizure medications make their effects on cardiovascular risk and bone health detrimental. Few clear guidelines exist for monitoring long-term effects of medication therapy for epilepsy. When selecting an antiseizure medication, consideration should be given to the individual patient's risks of adverse consequences on other organ systems. During monitoring of patients on chronic therapy, screening tools such as metabolic panels and bone density measurements can help stratify risk and guide management.
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Affiliation(s)
- Carla LoPinto-Khoury
- Department of Neurology, Lewis Katz Temple School of Medicine, Philadelphia, Pennsylvania
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Hochbaum M, Kienitz R, Rosenow F, Schulz J, Habermehl L, Langenbruch L, Kovac S, Knake S, von Podewils F, von Brauchitsch S, Hamacher M, Strzelczyk A, Willems LM. Trends in antiseizure medication prescription patterns among all adults, women, and older adults with epilepsy: A German longitudinal analysis from 2008 to 2020. Epilepsy Behav 2022; 130:108666. [PMID: 35339390 DOI: 10.1016/j.yebeh.2022.108666] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/07/2022] [Accepted: 03/07/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The prescription patterns of antiseizure medication (ASM) are subject to new scientific evidence and sociodemographic and practical aspects. This study analyzed trends in ASM prescription patterns among all adults with epilepsy, with special consideration for women of childbearing potential (WOCBP) and older adult (≥65 years old) patients. METHODS Data from four questionnaire-based cohort studies, conducted in 2008, 2013, 2016, and 2020, were analyzed for ASM prescription frequencies and common mono- and dual therapy regimens. Statistical comparisons were performed with the Chi-square test and one-way analysis of variance. RESULTS Overall, the individual prescription patterns among 1,642 adult patients with epilepsy were analyzed. A significant increase in the prescription frequency of third-generation ASMs, from 59.3% to 84.2% (p = 0.004), was accompanied by a decrease in the frequency of first- and second-generation ASMs (5.4% to 2.1% and 34.9% to 12.6%, respectively). This trend was accompanied by a significant decrease in the use of enzyme-inducing ASMs, from 23.9% to 4.6% (p = 0.004). Among frequently prescribed ASMs, prescriptions of carbamazepine (18.6% to 3.1%, p = 0.004) and valproate (15.4% to 8.7%, p = 0.004) decreased, whereas prescriptions of levetiracetam (18.0% up to 32.4%, p = 0.004) increased significantly. The prescription frequency of lamotrigine remained largely constant at approximately 20% (p = 0.859). Among WOCBP, the prescription frequencies of carbamazepine (11.4% to 2.0%, p = 0.004) and valproate (16.1% to 6.1%, p = 0.004) decreased significantly. Levetiracetam monotherapy prescriptions increased significantly (6.6% to 30.4%, p = 0.004) for WOCBP, whereas lamotrigine prescriptions remained consistent (37.7% to 44.9%, p = 0.911). Among older adult patients, a significant decrease in carbamazepine prescriptions (30.1% to 7.8%, p = 0.025) was the only relevant change in ASM regimens between 2008 and 2020. In patients with genetic generalized epilepsies, levetiracetam was frequently used as an off-label monotherapy (25.0% to 35.3%). CONCLUSION These results show a clear trend toward the use of newer and less interacting third-generation ASMs, with lamotrigine, levetiracetam, and lacosamide representing the current ASMs of choice, displacing valproate and carbamazepine over the last decade. In WOCBP, prescription patterns shifted to minimize teratogenic effects, whereas, among older adults, the decrease in carbamazepine use may reflect the avoidance of hyponatremia risks and attempts to reduce the interaction potential with other drugs and ASMs. Levetiracetam is frequently used off-label as a monotherapy in patients with genetic generalized epilepsy.
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Affiliation(s)
- Maja Hochbaum
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CEPTeR), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Ricardo Kienitz
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CEPTeR), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CEPTeR), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Juliane Schulz
- Department of Neurology, University Hospital Greifswald, Greifswald, Germany
| | - Lena Habermehl
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg, Germany
| | - Lisa Langenbruch
- Epilepsy Center Münster-Osnabrück, Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University, Münster, Germany; Department of Neurology, Klinikum Osnabrück, Osnabrück, Germany
| | - Stjepana Kovac
- Epilepsy Center Münster-Osnabrück, Department of Neurology with Institute of Translational Neurology, Westfälische Wilhelms-University, Münster, Germany
| | - Susanne Knake
- LOEWE Center for Personalized Translational Epilepsy Research (CEPTeR), Goethe-University Frankfurt, Frankfurt am Main, Germany; Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg, Germany
| | - Felix von Podewils
- Department of Neurology, University Hospital Greifswald, Greifswald, Germany
| | - Sophie von Brauchitsch
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CEPTeR), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Mario Hamacher
- Department of Neurology, University Hospital Greifswald, Greifswald, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CEPTeR), Goethe-University Frankfurt, Frankfurt am Main, Germany.
| | - Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CEPTeR), Goethe-University Frankfurt, Frankfurt am Main, Germany
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Saputra BD, Levita J, Mustarichie R. Efficacy, Safety, and Drug–Drug Interactions for Insomnia Therapy in COVID-19 Patients. J Multidiscip Healthc 2022; 15:137-152. [PMID: 35087274 PMCID: PMC8789249 DOI: 10.2147/jmdh.s337053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/23/2021] [Indexed: 12/20/2022] Open
Abstract
Coronavirus disease-19 (COVID-19) is a systemic viral infection. COVID-19 patients show diverse clinical presentations ranging from asymptomatic, mild symptoms to severe symptoms characterized by severe respiratory distress. Sleep disorders or insomnia is one of the psychiatric problems that arise during the COVID-19 pandemic. The term used to define this particular insomnia is coronasomnia or COVID-19 insomnia. Data show that the prevalence of this problem is increasing, especially in the confirmed COVID-19 patient group. Anti-insomnia drugs such as hypnotics, sedatives, and anxiolytics are the easiest option. As with drugs generally, anti-insomnia drugs are associated with various safety issues, especially in people with COVID-19. Therefore, their use may be hazardous. The literature review aims to make health practitioners aware of the anti-insomnia drugs that have the best efficacy and safety issues that are clinically relevant from the use of anti-insomnia drugs and the interactions of anti-insomnia drugs with various drugs used in the treatment of COVID-19. The articles were explored on PubMed and Cochrane Library, whereas the drug–drug interactions between the anti-insomnia and COVID-19 drugs were searched on Drugs.com Interaction Checker and Lexiomp-interact. Overall anti-insomnia drugs have efficacy in improving sleep parameters. Orexin receptor antagonist drugs have good efficacy in increasing WASO, LPS, and SE with an acceptable safety profile. Meanwhile, the combination of zolpidem, lorazepam, and diphenhydramine improved TST parameters better than other drugs. Side effects such as drowsiness and dizziness were among the most commonly reported effects. Therefore, attention and monitoring of the use of anti-insomnia drugs in COVID-19 patients need to be carried out by considering the side effects and interactions that are very risky.
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Affiliation(s)
- Billy Dwi Saputra
- Undergraduate Program of Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Sumedang, 45363, Indonesia
| | - Jutti Levita
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Sumedang, 45363, Indonesia
| | - Resmi Mustarichie
- Department of Pharmaceutical Analysis and Medicinal Chemistry, Faculty of Pharmacy, Universitas Padjadjaran, Sumedang, 45363, Indonesia
- Correspondence: Resmi Mustarichie Department of Pharmaceutical Analysis and Medicinal Chemistry, Faculty of Pharmacy, Universitas Padjadjaran, Sumedang, 45363, IndonesiaTel +6222-84288888 Ext 3510 Email
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Pinkhasov A, Xiong G, Bourgeois JA, Heinrich TW, Huang H, Coriolan S, Annamalai A, Mangal JP, Frankel S, Lang M, Raj YP, Dandois M, Barth K, Stewart AL, Rado J, Pesek J, Sanders A, Spearman-McCarthy EV, Gagliardi J, Fiedorowicz JG. Management of SIADH-related hyponatremia due to psychotropic medications - An expert consensus from the Association of Medicine and Psychiatry. J Psychosom Res 2021; 151:110654. [PMID: 34739943 PMCID: PMC10911096 DOI: 10.1016/j.jpsychores.2021.110654] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 10/03/2021] [Accepted: 10/22/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Hyponatremia is the most common electrolyte imbalance encountered in clinical practice and is associated with negative healthcare outcomes and cost. SIADH is thought to account for one third of all hyponatremia cases and is typically an insidious process. Psychotropic medications are commonly implicated in the etiology of drug induced SIADH. There is limited guidance for clinicians on management of psychotropic-induced SIADH. METHODS After an extensive review of the existing literature, clinical-educators from the Association of Medicine and Psychiatry developed expert consensus recommendations for management of psychotropic-induced SIADH. A risk score was proposed based on risk factors for SIADH to guide clinical decision-making. RESULTS SSRIs, SNRIs, antipsychotics, carbamazepine, and oxcarbazepine have moderate to high level of evidence demonstrating their association with SIADH. Evaluation for an avoidance of medications that cause hyponatremia is particularly important. Substitution with medication that is less likely to cause SIADH should be considered when appropriate. We propose an algorithmic approach to monitoring hyponatremia with SIADH and corresponding treatment depending on symptom severity. CONCLUSIONS The proposed algorithm can help clinicians in determining whether psychotropic medication should be stopped, reduced or substituted where SIADH is suspected with recommendations for sodium (Na+) monitoring. These recommendations preserve a role for clinical judgment in the management of hyponatremia with consideration of the risks and benefits, which may be particularly relevant for complex patients that present with medical and psychiatric comorbidities. Further studies are needed to determine whether baseline and serial Na+ monitoring reduces morbidity and mortality.
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Affiliation(s)
- Aaron Pinkhasov
- Department of Psychiatry, NYU Langone Hospital-Long Island, NY, United States of America; Psychiatry and Medicine, NYULI - SOM, NY, United States of America.
| | - Glen Xiong
- University of California at Davis, CA, United States of America
| | - James A Bourgeois
- Psychiatry, Baylor Scott & White Health, TX, United States of America
| | - Thomas W Heinrich
- Psychiatry and Behavioral Medicine and Family and Community Medicine, Medical College of Wisconsin, WI, United States of America
| | - Heather Huang
- Psychiatry and Internal Medicine, University of WI, WI, United States of America
| | - Shanice Coriolan
- NYU Langone Hospital - Long Island, NY, United States of America
| | - Aniyizhai Annamalai
- Psychiatry and Internal Medicine, Yale School of Medicine, CT, United States of America
| | - Jed P Mangal
- Psychiatry, Uniformed Services University of the Health Sciences, MD, United States of America
| | - Steven Frankel
- Psychiatry, University of Minnesota Medical School, MN, United States of America; Psychiatry, UCSF, Medical School, University of Minnesota, MN, United States of America
| | - Michael Lang
- Internal Medicine and Psychiatry, Brody School of Medicine at East Carolina University, NC, United States of America
| | - Y Pritham Raj
- Depts of Internal Medicine & Psychiatry, Oregon Health & Science University, United States of America
| | | | - Kelly Barth
- Psychiatry and Internal Medicine, Medical University of South Carolina, SC, United States of America
| | - Anne Louise Stewart
- Consultation-Liaison Psychiatry, University of Texas Southwestern, TX, United States of America
| | - Jeffrey Rado
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, IL, United States of America
| | - Justin Pesek
- Baylor Scott & White Health, TX, United States of America
| | - Aaron Sanders
- Baylor Scott & White Health, TX, United States of America
| | - E Vanessa Spearman-McCarthy
- Internal Medicine and Psychiatry, Medical College of Georgia, Augusta University, GA, United States of America
| | - Jane Gagliardi
- Psychiatry and Behavioral Sciences, Duke University School of Medicine, NC, United States of America
| | - Jess G Fiedorowicz
- Mental Health, The Ottawa Hospital, ON, Canada; Ottawa Hospital Research Institute, Department of Psychiatry, School of Epidemiology and Public Health, ON, Canada; University of Ottawa, and uOttawa Brain and Mind Research Institute, ON, Canada
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Beydoun A, DuPont S, Zhou D, Matta M, Nagire V, Lagae L. Current role of carbamazepine and oxcarbazepine in the management of epilepsy. Seizure 2020; 83:251-263. [PMID: 33334546 DOI: 10.1016/j.seizure.2020.10.018] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/30/2020] [Accepted: 10/22/2020] [Indexed: 02/08/2023] Open
Abstract
Epilepsy is one of the most common neurological disorders, affecting approximately 50 million people worldwide. Despite a dramatic increase in treatment options over the past 30 years, it still ranks fourth in the world's disease burden. There are now close to 30 antiepileptic drugs (AEDs), with more than two thirds introduced to the market after carbamazepine (CBZ) and one third after its derivative, oxcarbazepine (OXC). Following the introduction of these newer AEDs, the role of CBZ and OXC in the therapeutic armamentarium for seizure control and effective epilepsy management needs to be reviewed. The main guidelines list both CBZ and OXC as first-line options or second-line alternatives for the treatment of focal-onset epilepsy and primary generalized tonic-clonic seizures. While evidence suggests that overall AEDs have similar efficacy, some newer AEDs may be better tolerated than CBZ. In line with this, there have been changes in treatment patterns, with many variations across different countries. However, CBZ remains among the two or three most prescribed drugs for focal epilepsy in many countries, and is widely used across Europe, Africa, South America, and Asia, where it represents a good compromise between cost, availability, and effectiveness. OXC is among the first-choice options for the initial treatment of focal-onset seizures in several countries, including the US and China, where the oral suspension is commonly prescribed. This review provides guidance on the optimal use of these two drugs in clinical practice, including in children, the elderly, and in pregnancy.
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Affiliation(s)
- Ahmad Beydoun
- Department of Neurology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Sophie DuPont
- Epilepsy Unit and Rehabilitation Unit, Hôpital de la Pitié-Salpêtrière, AP-HP, Centre de recherche de l'Institut du cerveau et de la moelle épinière (ICM), UMPC-UMR 7225 CNRS-UMRS 975 Inserm, Paris, France; Université Paris Sorbonne, Paris, France
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Maha Matta
- Novartis Pharma Services, Dubaï, United Arab Emirates
| | | | - Lieven Lagae
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium.
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Zerah L, Bihan K, Kohler S, Mariani LL. Iatrogenesis and neurological manifestations in the elderly. Rev Neurol (Paris) 2020; 176:710-723. [PMID: 32389421 DOI: 10.1016/j.neurol.2019.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 11/22/2019] [Accepted: 11/26/2019] [Indexed: 12/20/2022]
Abstract
Older people are often exposed to polypharmacy in a multimorbidity context. Inappropriate polypharmacy is often harmful, increasing the risk of inappropriate prescriptions and therefore adverse drug events (ADEs). Five to 20% of all hospital admissions are related to ADE in older people, among which 40 to 70% could be prevented. However, identifying ADEs and drug-related admissions in the elderly is challenging because ADEs often present as common geriatric problems such as falls, delirium, which might be due to the aging process, underlying diseases, and/or medications. In the pharmacovigilance database of the World Health Organization, drug-related neurological manifestations are the third reported cause of ADEs in the elderly, and neurological drugs are the third leading class of medications involved in ADEs. We must therefore be particularly vigilant, both in our prescriptions but also in our diagnoses to avoid prescribing inappropriate treatments and detect ADEs. Even though multiple pharmacologic changes occur in the elderly (absorption, distribution, drug metabolism and excretion), most of medications are still often prescribed at the same daily dosage as in young adults. When prescribing any drug for old patients, we should remember that daily intake should be adapted to these specificities, keeping in mind the old well-known aphorism "start low, go slow". In this review, we describe the main drug-related neurological manifestations (drug-induced movement disorders, falls, seizures, delirium, hypoglycemia, stroke, hyponatremia, peripheral neuropathy and myopathy, and serotonin syndrome) and the main drugs associated with neurological manifestations (dopamine receptor blocking agents, antithrombotics, anticholinergics, beta-lactams, antidepressants, benzodiazepines, mood stabilizers).
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Affiliation(s)
- L Zerah
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpitaux Universitaires Pitié-Salpêtrière-Charles Foix, Département de gériatrie, 75013 Paris, France
| | - K Bihan
- Sorbonne Université, Assistance Publique Hôpitaux de Paris, Regional Pharmacovigilance Center, Department of Pharmacology, Pitié-Salpêtrière Hospital, Paris, France
| | - S Kohler
- Hôpital Bretonneau, Service de Gériatrie à Orientation Psychiatrique - DMU INVICTUS - Paris nord Université - Assistance Publique-Hôpitaux de Paris, Paris, France
| | - L-L Mariani
- Sorbonne University, Assistance Publique-Hôpitaux de Paris, Brain and Spine Institute, ICM, Inserm U 1127, CNRS UMR 7225, Department of Neurology, Pitié-Salpêtrière Hospital, 75013 Paris, France.
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11
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Sharma K, Vakil A, Sokwala A, Sokhi D. Phenytoin Toxicity Treatment with Haemodialysis in Epilepsy due to Glioblastoma Multiforme: Case Report and Review of the Literature. Case Rep Neurol 2020; 11:344-350. [PMID: 31911779 DOI: 10.1159/000504470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 10/30/2019] [Indexed: 01/01/2023] Open
Abstract
Phenytoin is one of the most commonly used anticonvulsants in the developing world, but lack of monitoring and concurrent medications can easily lead to toxicity. We report the case of a 35-year-old female on phenytoin for symptomatic epilepsy due to previously treated glioblastoma multiforme, who presented with status epilepticus 1 week after being treated for a urinary tract infection. She was loaded with phenytoin and levetiracetam as per emergency protocol but had a persistently low level of consciousness, and her preloading phenytoin level result came back in the toxic range. She was managed conservatively, but after 4 days with no change she was dialyzed and her level of consciousness improved within 24 h, allowing for safe discharge home shortly after. Our case illustrates the option of haemodialysis in phenytoin-toxic patients who do not improve with conservative measures or who may need urgent reduction due to potentially fatal complications of phenytoin toxicity.
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Affiliation(s)
- Karishma Sharma
- Department of Medicine, Faculty of Health Sciences, Aga Khan University (East Africa) Medical College, Nairobi, Kenya
| | - Aditi Vakil
- School of Medicine, University of Nairobi, Nairobi, Kenya
| | - Ahmed Sokwala
- Department of Medicine, Faculty of Health Sciences, Aga Khan University (East Africa) Medical College, Nairobi, Kenya
| | - Dilraj Sokhi
- Department of Medicine, Faculty of Health Sciences, Aga Khan University (East Africa) Medical College, Nairobi, Kenya
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Iskander C, McArthur E, Nash DM, Gandhi-Banga S, Weir MA, Muanda FT, Garg AX. Identifying Ontario geographic regions to assess adults who present to hospital with laboratory-defined conditions: a descriptive study. CMAJ Open 2019; 7:E624-E629. [PMID: 31641060 PMCID: PMC6944071 DOI: 10.9778/cmajo.20190065] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND In 2007, an electronic repository called the Ontario Laboratories Information System (OLIS) was introduced to allow health care providers timely access to laboratory test results. Since not all laboratories began submitting their data to OLIS simultaneously, we sought to create a date-dependent table of geographic regions (forward sortation areas [FSAs]) from which people would likely present to a hospital linked to OLIS. METHODS In this descriptive study, we used administrative data to capture adults in Ontario who presented to the emergency department for any reason from 2007 to 2017. To assess changes over time, we classified all emergency department visits into fiscal quarters. The primary outcome measure was the proportion of people in a given FSA presenting to an emergency department at an OLIS-linked hospital (v. a hospital not linked to OLIS). To be included in the catchment area, at least 90% of all emergency department visits in a given quarter from a given FSA must have occurred at an OLIS-linked hospital. RESULTS By Dec. 31, 2017, 323 (61.4%) of 526 Ontario FSAs were in the catchment area (a population of about 8.5 million). There were no differences in selected demographic characteristics or comorbidities between people residing within the catchment area of OLIS-linked hospitals and those residing in the catchment area of unlinked hospitals on Dec. 31, 2017. We used the FSA information to construct a date-dependent table of geographic areas likely to have hospital laboratory data available in OLIS for future studies. INTERPRETATION We identified relevant Ontario geographic regions from which people would likely present to a hospital linked to OLIS. These geographic regions constitute a catchment area that may be used in future studies to capture adults who present to an OLIS-linked hospital with laboratory-defined conditions such as acute kidney injury, hyperkalemia and hyponatremia.
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Affiliation(s)
- Carina Iskander
- Departments of Epidemiology and Biostatistics (Iskander, Nash, Muanda, Garg) and Medicine (Weir), Western University, London, Ont.; ICES (McArthur, Nash, Gandhi-Banga, Weir, Muanda, Garg); Epidemiology and Benefit-Risk Evaluation (Gandhi-Banga), Sanofi Pasteur, Toronto, Ont
| | - Eric McArthur
- Departments of Epidemiology and Biostatistics (Iskander, Nash, Muanda, Garg) and Medicine (Weir), Western University, London, Ont.; ICES (McArthur, Nash, Gandhi-Banga, Weir, Muanda, Garg); Epidemiology and Benefit-Risk Evaluation (Gandhi-Banga), Sanofi Pasteur, Toronto, Ont
| | - Danielle M Nash
- Departments of Epidemiology and Biostatistics (Iskander, Nash, Muanda, Garg) and Medicine (Weir), Western University, London, Ont.; ICES (McArthur, Nash, Gandhi-Banga, Weir, Muanda, Garg); Epidemiology and Benefit-Risk Evaluation (Gandhi-Banga), Sanofi Pasteur, Toronto, Ont
| | - Sonja Gandhi-Banga
- Departments of Epidemiology and Biostatistics (Iskander, Nash, Muanda, Garg) and Medicine (Weir), Western University, London, Ont.; ICES (McArthur, Nash, Gandhi-Banga, Weir, Muanda, Garg); Epidemiology and Benefit-Risk Evaluation (Gandhi-Banga), Sanofi Pasteur, Toronto, Ont
| | - Matthew A Weir
- Departments of Epidemiology and Biostatistics (Iskander, Nash, Muanda, Garg) and Medicine (Weir), Western University, London, Ont.; ICES (McArthur, Nash, Gandhi-Banga, Weir, Muanda, Garg); Epidemiology and Benefit-Risk Evaluation (Gandhi-Banga), Sanofi Pasteur, Toronto, Ont
| | - Flory Tsobo Muanda
- Departments of Epidemiology and Biostatistics (Iskander, Nash, Muanda, Garg) and Medicine (Weir), Western University, London, Ont.; ICES (McArthur, Nash, Gandhi-Banga, Weir, Muanda, Garg); Epidemiology and Benefit-Risk Evaluation (Gandhi-Banga), Sanofi Pasteur, Toronto, Ont
| | - Amit X Garg
- Departments of Epidemiology and Biostatistics (Iskander, Nash, Muanda, Garg) and Medicine (Weir), Western University, London, Ont.; ICES (McArthur, Nash, Gandhi-Banga, Weir, Muanda, Garg); Epidemiology and Benefit-Risk Evaluation (Gandhi-Banga), Sanofi Pasteur, Toronto, Ont.
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13
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The unmasking of hidden severe hyponatremia after long-term combination therapy in exacerbated bipolar patients: a case series. Int Clin Psychopharmacol 2019; 34:206-210. [PMID: 30998596 DOI: 10.1097/yic.0000000000000265] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hyponatremia is occasionally unmasked in psychiatric patients during hospitalization after routine blood and urinary tests, and correlates in most cases with an inappropriate secretion of antidiuretic hormone, mainly due to iatrogenic factors. Only a few studies have regarded the combination of psychotropic drugs as triggers of chronic, asymptomatic hyponatremia in bipolar patients, who require to be hospitalized because of the exacerbation of their mental illness. We presented three clinical cases of patients affected by a long-term psychiatric disorder and under polypharmacotherapy for several months. After excluding other potential factors, we hypothesized that pharmacological treatment with a mood stabilizer (oxcarbazepine) associated with a benzodiazepine (delorazepam), a second-generation antipsychotic (olanzapine) or an antidepressant (fluvoxamine), triggered severe hyponatremia ([Na+] ≤125 mEq/L), serum hypo-osmolarity, and elevated inappropriate urine osmolarity added to more diluted sodium concentration. When we discontinued the treatment, clinical conditions of our patients improved, despite the previous administration of hypertonic saline jointly with water restriction. Psychiatrists should consider that bipolar patients on long-term polypharmacotherapy may present a higher risk of severe hyponatremia not clinically detectable. Consequently, routine laboratory tests should be periodically repeated as they represent the only available tool to unmask such electrolyte imbalances.
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Wechsler RT, Radtke RA, Smith M, Vossler DG, Strom L, Trinka E, Cheng H, Grinnell T, Blum D, Vieira M, Moreira J, Rocha F. Serum sodium levels and related treatment-emergent adverse events during eslicarbazepine acetate use in adults with epilepsy. Epilepsia 2019; 60:1341-1352. [PMID: 31260089 PMCID: PMC6852335 DOI: 10.1111/epi.16069] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/15/2019] [Accepted: 05/20/2019] [Indexed: 12/15/2022]
Abstract
Objective To examine the frequency of hyponatremia and potentially related symptoms in clinical trials of eslicarbazepine acetate (ESL) in adults with focal‐ (partial‐) onset seizures. Methods This post hoc, exploratory analysis included data from three controlled phase 3 trials of adjunctive ESL (400‐1200 mg once daily), two phase 3 trials of ESL monotherapy (1200‐1600 mg once daily), and their open‐label extension studies. Exploratory endpoints included clinical laboratory measurements of serum sodium concentrations ([Na+]), incidences of hyponatremia‐related treatment‐emergent adverse events (TEAEs), and incidences of TEAEs that are potential symptoms of hyponatremia. Results The controlled trials of adjunctive ESL and ESL monotherapy included 1447 (placebo, n = 426; ESL, n = 1021) and 365 (ESL, n = 365) patients, respectively; 639 and 274 patients continued onto uncontrolled, open‐label extensions. In the controlled and uncontrolled trials ≤3.3% of patients taking ESL had a minimum postdose [Na+] measurement ≤125 mEq/L, <9% had a >10 mEq/L decrease in [Na+] from baseline, <6% had a hyponatremia‐related TEAE, and <2% discontinued the controlled trials due to a hyponatremia‐related TEAE. Hyponatremia appeared to be more frequent in the monotherapy (vs adjunctive therapy) trials; in the controlled trials of adjunctive ESL and ESL monotherapy, incidence generally increased with increasing ESL dose. The majority of patients with an investigator‐reported TEAE of “hyponatremia” or “blood sodium decreased” did not have a corresponding laboratory [Na+] measurement ≤125 mEq/L. Some symptoms potentially related to hyponatremia (including nausea and vomiting) were more frequent in patients with a minimum postdose [Na+] measurement ≤125 mEq/L. Significance Reductions in serum sodium concentrations and hyponatremia‐related TEAEs occurred in a small number of patients taking ESL. Suspected hyponatremia should be confirmed and monitored via [Na+] measurements.
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Affiliation(s)
| | | | | | - David G Vossler
- University of Washington, Valley Medical Center, Renton, Washington
| | - Laura Strom
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Eugen Trinka
- Uniklinikum Salzburg, Christian-Doppler-Klinik, Salzburg, Austria
| | - Hailong Cheng
- Sunovion Pharmaceuticals, Inc., Marlborough, Massachusetts
| | - Todd Grinnell
- Sunovion Pharmaceuticals, Inc., Marlborough, Massachusetts
| | - David Blum
- Sunovion Pharmaceuticals, Inc., Marlborough, Massachusetts
| | - Mariana Vieira
- BIAL - Portela & Cª., S.A., Coronado (S. Romão e S. Mamede), Portugal
| | - Joana Moreira
- BIAL - Portela & Cª., S.A., Coronado (S. Romão e S. Mamede), Portugal
| | - Francisco Rocha
- BIAL - Portela & Cª., S.A., Coronado (S. Romão e S. Mamede), Portugal
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15
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Kaur U, Chauhan I, Gambhir IS, Chakrabarti SS. Antiepileptic drug therapy in the elderly: a clinical pharmacological review. Acta Neurol Belg 2019; 119:163-173. [PMID: 30953298 DOI: 10.1007/s13760-019-01132-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 03/28/2019] [Indexed: 01/02/2023]
Abstract
Seizure disorder is the third most common neurological disorder in the elderly after stroke and dementia. With the increasing geriatric population, the situation of clinicians seeing more and more elderly epilepsy patients is very likely. Not only is the diagnosis of epilepsy tedious in the elderly, its management raises many challenging issues for the treating physicians. Altered physiology, age-related decline in organ function, and plasma protein binding and altered pharmacodynamics make the elderly patients with seizure disorder a difficult group to treat. This is further complicated by the presence of comorbidities and polypharmacy which increase the chances of drug interactions. The adverse effects that might be tolerated well in younger populations may be disastrous for the aged. Although the newer antiepileptic drugs are found to have a favorable safety profile, there is relative scarcity of randomized-controlled trials involving older and newer antiepileptics in the geriatric population. This review tries to compile the available literature on management of epilepsy in the elderly population including evidence of safety and efficacy of newer and older antiepileptics with special reference to the 'geriatric giants'. It also deals with the interactions between antiepileptic medications and other commonly prescribed drugs in the elderly such as anti-hypertensives and antiischemic agents. The recommended guidelines of various international bodies are also analyzed from the perspective of elderly with seizure disorder.
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Affiliation(s)
- Upinder Kaur
- Department of Pharmacology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Indal Chauhan
- Department of Pharmacology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Indrajeet Singh Gambhir
- Department of Geriatric Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Sankha Shubhra Chakrabarti
- Department of Geriatric Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India.
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Maister AJ, Bogart GT. Acute hyponatremia with accompanying hyperammonemia secondary to divalproex sodium: A case report. Ment Health Clin 2018; 8:191-194. [PMID: 30155395 PMCID: PMC6063457 DOI: 10.9740/mhc.2018.07.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Divalproex sodium (DVP) is an antiepileptic medication that also has mood stabilizing properties for patients with mental health disorders. Currently, there are a small number of case reports discussing the incidence of hyponatremia that occurs as an adverse effect of DVP. After completion of a thorough literature search, we present the first case report describing acute hyponatremia with accompanying hyperammonemia secondary to DVP use. This case describes a 44-year-old male patient who experienced hyponatremia with accompanying hyperammonemia following initiation of DVP for schizoaffective disorder. This case highlights the need for clinicians to consider monitoring electrolytes, in addition to liver function and platelets, with the initiation of therapy or increase in daily dosage. Given the drug's action at voltage-gated sodium channels, changes in serum sodium could be expected.
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Affiliation(s)
- Ashley J Maister
- PGY1 Pharmacy Practice Resident, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Gregory T Bogart
- (Corresponding author) Clinical Pharmacist - Behavioral Health, Jefferson Health New Jersey, Cherry Hill, New Jersey,
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Watterworth BS, Noorani RJ. Intraoperative Use of Desmopressin for Treatment of Profound Hyponatremia in the Setting of Emergency Surgery: A Case Report. A A Pract 2018; 11:54-56. [PMID: 29634545 DOI: 10.1213/xaa.0000000000000738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Correction of profound hyponatremia requires careful planning and close monitoring to reduce the risks of neurologic injury. Although there are various suggested treatment strategies in the setting of a medical ward or intensive care unit, reports of intraoperative management to prevent rapid increases in serum sodium are lacking. We present a case of profound hyponatremia of 102 mmol/L in a patient who required emergent operative repair for bowel obstruction. This is the first case to our knowledge that demonstrates a perioperative fluid and desmopressin treatment strategy to prevent overly rapid changes of sodium concentration in a patient with severe hyponatremia.
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Affiliation(s)
- Blake S Watterworth
- From the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
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18
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Falhammar H, Lindh JD, Calissendorff J, Farmand S, Skov J, Nathanson D, Mannheimer B. Differences in associations of antiepileptic drugs and hospitalization due to hyponatremia: A population-based case-control study. Seizure 2018; 59:28-33. [PMID: 29730273 DOI: 10.1016/j.seizure.2018.04.025] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 04/27/2018] [Accepted: 04/29/2018] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Hyponatremia induced by antiepileptic drugs is common, but detailed evidence is lacking. This can be problematic for the treating neurologist confronted with a patient with severe hyponatremia in need of an alternative drug. The objective of this study was to examine the association between individual antiepileptic drugs and hospitalization due to hyponatremia. METHODS This was a register-based case-control study of patients in the general Swedish population. We included 14,359 individuals with a principal diagnosis of hyponatremia and 57,383 matched controls. The association between newly initiated (≤90 days) and ongoing antiepileptic treatment was investigated using multivariable logistic regression adjusting for concomitant drugs, medical conditions, previous hospitalizations and sociaoeconomic factors. RESULTS For newly initiated antiepileptic drugs, adjusted ORs (95% CI) for hospitalization due to hyponatremia, compared to controls, were: carbamazepine 9.63 (6.18-15.33); phenytoin 4.83 (1.14-25.76); valproate 4.96 (2.44-10.66); lamotrigine 1.67 (0.70-4.08); levetiracetam 9.76 (4.02-27.59) and gabapentin 1.61 (1.08-2.38). Newly initiated oxcarbazepine treatment was only found in the hyponatremia group and not in controls. Adjusted ORs (CI) for individuals with ongoing treatment ranged from 7.97 (3.70-18.50) for oxcarbazepine to 0.83 (0.64-1.06) for gabapentin. CONCLUSION There was a strong association between newly initiated treatment with carbamazepine, oxcarbazepine and levetiracetam, and hospitalization due to hyponatremia. The corresponding association for phenytoin and valproate was moderate. The risk for hyponatremia was lower during ongoing treatment. Lamotrigine and gabapentin had the lowest risk both during initiation and ongoing treatment and may be advantageous in patients at risk of developing hyponatremia.
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Affiliation(s)
- Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.
| | - Jonatan D Lindh
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska University Hospital Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Jan Calissendorff
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | - Shermineh Farmand
- Department of Clinical Science and Education at Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Jakob Skov
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - David Nathanson
- Department of Clinical Science and Education at Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Buster Mannheimer
- Department of Clinical Science and Education at Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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Antiepileptic drugs-induced hyponatremia: Review and analysis of 560 hospitalized patients. Epilepsy Res 2018; 143:7-10. [PMID: 29631131 DOI: 10.1016/j.eplepsyres.2018.03.023] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 03/27/2018] [Accepted: 03/28/2018] [Indexed: 12/31/2022]
Abstract
Recent evidence suggests that eslicarbazepine acetate (ESL) might be an appropriate alternative to carbamazepine (CBZ) and oxcarbazepine (OXC) due to its better safety profile. Hyponatremia may be one of the limiting safety problems in CBZ and OXC whereas it has been indicated that ESL is less sensitive for the adverse event. Since our clinical experience is different we investigated the incidence of hyponatremia in 560 consecutive adult inpatients treated at our center in 2015 by reviewing their medical records. Only CBZ, OXC and ESL were associated with hyponatremia. The incidence of hyponatremia induced by ESL was not statistically different from that induced by OXC (43% of patients with OXC and 33% with ESL, p > 0.05). Both were associated with hyponatremia more often than CBZ (16%). OXC-induced hyponatremia was dose-related, ESL-induced hyponatremia was not. Furthermore, both OXC- and ESL-induced hyponatremia occurred particularly often in elderly epilepsy patients. Thus, for elderly patients, both OXC and ESL should be considered with caution.
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Druschky K, Bleich S, Grohmann R, Engel RR, Kleimann A, Stübner S, Greil W, Toto S. Use and safety of antiepileptic drugs in psychiatric inpatients-data from the AMSP study. Eur Arch Psychiatry Clin Neurosci 2018; 268:191-208. [PMID: 28766129 DOI: 10.1007/s00406-017-0827-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 07/24/2017] [Indexed: 12/19/2022]
Abstract
The psychiatric utilization patterns and risks of antiepileptic drugs (AEDs) were assessed by using data from the drug safety programme Arzneimittelsicherheit in der Psychiatrie over the time period 1993-2013. In a total of 432,215 patients, the main indications for AED use were acute mania, schizoaffective disorder, and schizophrenic and organic psychoses. Valproic acid (VPA) was the most common substance across all of those groups, reaching administration rates of up to 50% since 2005, at which time carbamazepine (CBZ) administration consistently dropped below a rate of 10%. Lamotrigine (LTG) and pregabalin (PGB) increased in relevance after 2005 and 2010, respectively (with administration rates of up to 9%), whereas oxcarbazepine (OXC) was least prevalent (<3%). The mean rates of severe adverse drug reactions (ADRs) ranged from 6 cases per 1000 patients treated (VPA) to 19/1000 (OXC) and were significantly lower with treatment with VPA compared to OXC and CBZ. Hyponatremia was the leading ADR during treatment with OXC; severe allergic skin reactions were most often observed during treatment with CBZ and LTG, and severe oedema was most common during treatment with PGB. Severe hyponatremia induced by OXC was observed significantly more often in female patients than in male patients.
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Affiliation(s)
- Katrin Druschky
- Department of Neurology, University of Erlangen-Nuernberg, Schwabachanlage 6, 91054, Erlangen, Germany.
| | - Stefan Bleich
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Renate Grohmann
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University of Munich, Nussbaumstraße 7, 80336, Munich, Germany
| | - Rolf R Engel
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University of Munich, Nussbaumstraße 7, 80336, Munich, Germany
| | - Alexandra Kleimann
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Susanne Stübner
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University of Munich, Nussbaumstraße 7, 80336, Munich, Germany
| | - Waldemar Greil
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University of Munich, Nussbaumstraße 7, 80336, Munich, Germany.,Psychiatric Hospital Kilchberg, Kilchberg-Zurich, Switzerland
| | - Sermin Toto
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
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21
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Baftiu A, Feet SA, Larsson PG, Burns ML, Henning O, Sætre E, Molden E, Granas AG, Johannessen SI, Landmark CJ. Utilisation and polypharmacy aspects of antiepileptic drugs in elderly versus younger patients with epilepsy: A pharmacoepidemiological study of CNS-active drugs in Norway, 2004-2015. Epilepsy Res 2018; 139:35-42. [DOI: 10.1016/j.eplepsyres.2017.11.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 10/07/2017] [Accepted: 11/09/2017] [Indexed: 12/13/2022]
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22
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Filippatos TD, Makri A, Elisaf MS, Liamis G. Hyponatremia in the elderly: challenges and solutions. Clin Interv Aging 2017; 12:1957-1965. [PMID: 29180859 PMCID: PMC5694198 DOI: 10.2147/cia.s138535] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Decreased serum sodium concentration is a rather frequent electrolyte disorder in the elderly population because of the presence of factors contributing to increased antidiuretic hormone, the frequent prescription of drugs associated with hyponatremia and also because of other mechanisms such as the “tea and toast” syndrome. The aim of this review is to present certain challenges in the evaluation and treatment of hyponatremia in the elderly population and provide practical solutions. Hyponatremia in elderly subjects is mainly caused by drugs (more frequently thiazides and antidepressants), the syndrome of inappropriate antidiuretic hormone secretion (SIAD) or endocrinopathies; however, hyponatremia is multifactorial in a significant proportion of patients. Special attention is needed in the elderly population to exclude endocrinopathies as a cause of hyponatremia before establishing the diagnosis of SIAD, which then requires a stepped diagnostic approach to reveal its underlying cause. The treatment of hyponatremia depends on the type of hyponatremia. 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. In conclusion, both the evaluation and the treatment of hyponatremia pose many challenges in the elderly population.
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Affiliation(s)
- Theodosios D Filippatos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Andromachi Makri
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Moses S Elisaf
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - George Liamis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
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23
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Berghuis B, van der Palen J, de Haan GJ, Lindhout D, Koeleman BPC, Sander JW. Carbamazepine- and oxcarbazepine-induced hyponatremia in people with epilepsy. Epilepsia 2017; 58:1227-1233. [PMID: 28542738 DOI: 10.1111/epi.13777] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To ascertain possible determinants of carbamazepine (CBZ)- and oxcarbazepine (OXC)-induced hyponatremia in a large cohort of people with epilepsy. METHODS We collected data on serum sodium levels in people with epilepsy who were attending a tertiary epilepsy center while on treatment with CBZ or OXC. We defined hyponatremia as Na+ ≤134 mEq/L and severe hyponatremia as Na+ ≤128 mEq/L. RESULTS We identified 1,782 people who had used CBZ (n = 1,424) or OXC (n = 358), of whom 50 were treated with both drugs. Data on sodium level measurements were available in 1,132 on CBZ and in 289 on OXC. Hyponatremia occurred in 26% of those taking CBZ and 46% of those taking OXC. This was severe in 7% in the CBZ group and 22% in the OXC group. Hyponatremia was symptomatic in 48% and led to admissions in 3%. Age over 40 years, high serum levels of CBZ and OXC, and concomitant use of other antiepileptic drugs were the main risk factors for hyponatremia in both treatment groups. Female patients on OXC were at a higher risk than male patients of hyponatremia. The risk of hyponatremia on CBZ was significantly associated with the risk of hyponatremia on OXC within a subgroup that used both drugs consecutively. SIGNIFICANCE Hyponatremia is a common problem in people taking CBZ or OXC. Regular ascertainment of sodium levels in those taking either drug is recommended and results should be acted on.
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Affiliation(s)
- Bianca Berghuis
- Stichting Epilepsie Instellingen Nederland (SEIN), Zwolle, The Netherlands
| | - Job van der Palen
- Department of Epidemiology, Medical School Twente, Enschede, The Netherlands.,Department of Research Methodology, Measurement and Data Analysis, University of Twente, Enschede, The Netherlands
| | - Gerrit-Jan de Haan
- Stichting Epilepsie Instellingen Nederland (SEIN), Zwolle, The Netherlands
| | - Dick Lindhout
- Stichting Epilepsie Instellingen Nederland (SEIN), Zwolle, The Netherlands.,Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bobby P C Koeleman
- Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Josemir W Sander
- Stichting Epilepsie Instellingen Nederland (SEIN), Zwolle, The Netherlands.,NIHR UCL Hospitals Biomedical Research Centre, UCL Institute of Neurology, London, United Kingdom.,Chalfont Centre for Epilepsy, Chalfont St. Peter, United Kingdom
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