How to manage hyponatremia overcorrection?

Management of Hyponatremia Overcorrection

When hyponatremia overcorrection occurs, immediate intervention with desmopressin (1-2 μg IV/SC every 6-8 hours) along with 5% dextrose in water infusion should be implemented to reverse the overcorrection and prevent osmotic demyelination syndrome (ODS). 1, 2

Identifying Overcorrection

Overcorrection of hyponatremia is defined as:

• Increase in serum sodium >8 mEq/L in 24 hours
• Increase in serum sodium >18 mEq/L in 48 hours

High-Risk Patients for ODS

• Alcoholism
• Malnutrition
• Liver disease
• Severe hyponatremia (<120 mEq/L)
• Metabolic derangements
• Low cholesterol
• Prior encephalopathy 1

Management Algorithm for Overcorrection

Step 1: Immediate Intervention

• Stop all ongoing sodium-containing fluids
• Administer desmopressin 1-2 μg IV/SC every 6-8 hours to prevent further water diuresis 1, 2
• Simultaneously administer 5% dextrose in water (D5W) to actively lower sodium levels 2

Step 2: Calculate Required Free Water

• The amount of D5W needed can be calculated based on:
  • Current sodium level
  • Target sodium level (to bring correction rate back within safe limits)
  • Patient's weight

Step 3: Monitoring

• Check serum sodium every 2-4 hours until stabilized 1
• Adjust D5W rate based on sodium measurements
• Continue desmopressin until sodium correction rate is controlled

Evidence-Based Effectiveness

Research demonstrates that desmopressin is highly effective in both preventing and reversing inadvertent overcorrection. In a retrospective study, all patients treated with desmopressin as a preventive measure avoided exceeding the 24-hour or 48-hour correction limits 2. Even when overcorrection had already occurred, desmopressin with concurrent D5W administration successfully lowered sodium levels in all cases without serious adverse effects 2, 3.

The most recent evidence from a large retrospective study (2025) confirms that desmopressin effectively halts rapid sodium correction in a dose-dependent manner, with higher doses (≥2 μg versus 1 μg) producing more significant reductions in serum sodium 3.

Special Considerations

For Patients on CRRT

• For patients requiring continuous renal replacement therapy, administer a calculated amount of D5W prefilter to prevent overcorrection while maintaining adequate effluent volume 4

Dose-Response Relationship

• Higher desmopressin doses (≥2 μg) combined with IV free water produce greater reductions in serum sodium
• In some cases, sodium levels dropped by ≥5 mmol/L within 12 hours after desmopressin administration 3

Prevention of Overcorrection

To prevent overcorrection in the first place:

• Identify patients at high risk for overcorrection (those with low ADH states show 45% risk of overcorrection) 3
• Use initial urinary sodium and osmolality measurements to anticipate correction risks 3
• Follow guideline-recommended correction rates: 4-6 mEq/L in first few hours, not exceeding 8 mEq/L in 24 hours 1, 5
• Consider prophylactic desmopressin in high-risk patients 3

Common Pitfalls

1. Delayed recognition: Failure to monitor sodium levels frequently enough during initial treatment
2. Inadequate response: Using desmopressin alone without concurrent D5W when active lowering is needed
3. Insufficient dosing: Using too low a dose of desmopressin in severe overcorrection cases
4. Overlooking risk factors: Failing to identify patients at high risk for ODS who require more cautious correction

By following this algorithm and maintaining vigilant monitoring, clinicians can effectively manage hyponatremia overcorrection and minimize the risk of the devastating neurological consequences of osmotic demyelination syndrome.