How to manage hyponatremia in patients with alcohol use disorder?

From the Guidelines

Hyponatremia in patients with alcohol use disorder should be managed by addressing the underlying causes, correcting sodium levels, and providing alcohol cessation support, with the goal of improving morbidity, mortality, and quality of life. The management of hyponatremia in these patients requires careful assessment of the severity and acuity of hyponatremia, as severe cases (sodium <120 mEq/L) with neurological symptoms require more urgent correction 1.

Key Considerations

• For symptomatic patients, administer 3% hypertonic saline at 1-2 mL/kg/hr with frequent monitoring, aiming for sodium correction of 4-6 mEq/L in the first 24 hours to avoid osmotic demyelination syndrome.
• For chronic, asymptomatic hyponatremia, fluid restriction to 1-1.5 L/day is often sufficient.
• Thiamine supplementation (100 mg IV or IM daily for 3-5 days, then 100 mg orally daily) is essential before glucose administration to prevent Wernicke's encephalopathy, as supported by guidelines from the French Association for the Study of the Liver and the French Alcohol Society 1.
• Correct other electrolyte abnormalities, particularly hypokalemia and hypomagnesemia, which are common in these patients.
• Nutritional support with B-vitamins and folate is important.
• The underlying mechanism of hyponatremia in alcohol use disorder often involves beer potomania (excessive fluid intake with poor solute intake), inappropriate ADH secretion, and direct effects of alcohol on renal water handling.
• During alcohol withdrawal, monitor for syndrome of inappropriate antidiuretic hormone secretion (SIADH), which may worsen hyponatremia.
• Long-term management should include alcohol cessation support, such as pharmacological treatment with baclofen or acamprosate, and nutritional rehabilitation to prevent recurrence, as recommended by the EASL clinical practical guidelines 1.

Pharmacological Treatment

• Baclofen and acamprosate can be used to achieve alcohol abstinence in patients with alcoholic liver disease, as suggested by the KASL clinical practice guidelines 1.
• Brief interventions, such as motivational interviewing and counseling, can be effective in reducing risky drinking behavior and risk of alcoholic liver disease, as supported by the KASL clinical practice guidelines 1.

Psychosocial Treatment

• Psychosocial treatment, including individual psychotherapy, group therapy, and cognitive behavioral therapy, can help patients understand and obtain insight into their pathological pattern of drinking.
• Social support from family and friends is necessary for successful therapy, and community alcohol counseling centers can provide regular abstinence meetings, family meetings, and psychoeducation.

From the Research

Hyponatremia and Alcohol Use Disorder

• Hyponatremia is a common electrolyte disorder that can be caused by various factors, including excessive alcohol consumption 2.
• The relationship between hyponatremia and alcohol use disorder is complex, and hyponatremia can be both a cause and a consequence of alcohol use 2.
• Alcohol use disorder can lead to hyponatremia through several mechanisms, including:
  • Hypovolemia due to dehydration and poor dietary intake
  • Pseudohyponatremia due to severe hypertriglyceridemia
  • Beer potomania syndrome, characterized by excessive beer consumption and low solute intake
  • Reset osmostat syndrome and cerebral salt wasting syndrome, although these are less common

Management of Hyponatremia in Patients with Alcohol Use Disorder

• The management of hyponatremia in patients with alcohol use disorder requires a comprehensive approach that addresses both the underlying cause of hyponatremia and the alcohol use disorder itself 3, 4, 5.
• Treatment of hyponatremia should be based on the patient's fluid volume status, with hypovolemic hyponatremia treated with normal saline infusions, euvolemic hyponatremia treated with fluid restriction and/or vaptans, and hypervolemic hyponatremia treated with management of the underlying cause and fluid restriction 3, 4.
• In patients with severely symptomatic hyponatremia, bolus hypertonic saline may be necessary to rapidly correct the serum sodium level, but overly rapid correction should be avoided to prevent osmotic demyelination syndrome 3, 4.
• The treatment of alcohol use disorder may involve medications such as disulfiram, acamprosate, and naltrexone, as well as behavioral therapies and support groups 6.