How to manage overcorrection of hyponatremia (low sodium levels in the blood)?

From the Guidelines

To treat overcorrection of hyponatremia, it is crucial to promptly administer hypotonic fluids and consider adding desmopressin to lower serum sodium back to a safer level and prevent further complications, as excessive correction can lead to central pontine myelinolysis or seizures 1. When managing overcorrection of hyponatremia, the primary goal is to reduce the serum sodium concentration to a safer level and then allow it to rise more gradually, not exceeding 8-9 mmol/L per 24 hours, to avoid complications such as central pontine myelinolysis or seizures, as highlighted in the treatment guidelines for liver cirrhosis and related complications 1. Key considerations in the treatment approach include:

• Administering hypotonic fluids such as D5W (5% dextrose in water) to provide free water and dilute serum sodium.
• Considering the addition of desmopressin (DDAVP) at a dose of 1-2 mcg intravenously or subcutaneously every 6-8 hours to prevent further water excretion by the kidneys.
• Monitoring serum sodium levels frequently, typically every 2-4 hours during active treatment, to ensure the correction rate is controlled and to prevent overcorrection or undercorrection.
• Addressing the underlying cause of the initial hyponatremia to prevent recurrence, which may involve fluid resuscitation for hypovolemic hyponatremia or discontinuation of intravenous fluid therapy and free water restriction for hypervolemic hyponatremia, as outlined in the guidelines for liver cirrhosis 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment of Overcorrection of Hyponatremia

To treat overcorrection of hyponatremia, the following strategies can be employed:

• Administer desmopressin to control high rates of serum sodium concentration correction in severe hyponatremia, as recommended by 2
• Use hypertonic saline with caution, as its administration can lead to overcorrection, and consider individualized dosing models, as suggested by 3
• Monitor serum sodium levels closely and adjust treatment accordingly to prevent overcorrection, as emphasized by 4
• Be aware of common pitfalls that can lead to overcorrection, such as miscommunications between healthcare providers or unexpected hypoosmotic polyuria, as discussed in 5

Prevention of Overcorrection

To prevent overcorrection of hyponatremia:

• Use a proactive strategy of desmopressin administration with hypertonic saline, as associated with a lower incidence of exceeding serum sodium concentration correction targets, according to 2
• Consider the use of urea or tolvaptan as second-line therapies in patients with syndrome of inappropriate antidiuretic hormone (SIADH), as mentioned in 4
• Avoid fixed dosing of bolus hypertonic saline, as it may expose patients with low or high body weight to overcorrection or undercorrection, as found in 3

Key Considerations

When treating hyponatremia, it is essential to:

• Recognize the risks of overcorrection and take steps to prevent it, as highlighted by 5
• Individualize treatment based on patient characteristics, such as body weight, and monitor serum sodium levels closely, as suggested by 3
• Be aware of the limitations of current guidelines and the need for better quality research to guide clinicians in managing severe hyponatremia, as noted by 2 and 6