What supplements can cause hyponatremia (low sodium levels)?

Supplements That Can Cause Hyponatremia

Several dietary supplements can cause hyponatremia (serum sodium <135 mmol/L), which can lead to serious complications including cerebral edema, seizures, and even death if not properly managed. 1

Common Supplements Associated with Hyponatremia

• Excessive free water intake during exercise - Often seen in endurance athletes who consume large amounts of water without adequate sodium replacement 2
• Herbal diuretics - Various herbal supplements with diuretic properties can cause hyponatremia similar to pharmaceutical diuretics 3
• Hypotonic fluid supplements - Sports drinks or recovery supplements that are too dilute (hypotonic) can worsen hyponatremia when consumed in large quantities 1, 4
• Very low-sodium dietary supplements - Supplements that promote extreme sodium restriction can contribute to hyponatremia, especially when combined with high water intake 2

Mechanisms of Supplement-Induced Hyponatremia

• Increased free water retention - Supplements that mimic or enhance antidiuretic hormone (ADH) effects can lead to inappropriate water retention 1
• Excessive sodium loss - Supplements with diuretic properties can cause increased urinary sodium excretion 5
• Syndrome of Inappropriate ADH (SIADH)-like effects - Some supplements may induce SIADH-like states, leading to water retention and dilutional hyponatremia 1
• Low solute intake - Supplements that severely restrict caloric or solute intake can impair free water excretion, worsening hyponatremia 6

High-Risk Populations

• Elderly patients - More susceptible to hyponatremia from supplements due to age-related changes in renal function and water regulation 1, 4
• Patients with heart failure, liver disease, or kidney disease - These conditions already predispose to water and sodium imbalances 7, 1
• Patients taking medications that affect sodium balance - Including diuretics, ACE inhibitors, and certain psychotropic medications 3
• Endurance athletes - Particularly vulnerable to exercise-associated hyponatremia when consuming large amounts of water or hypotonic fluids 2, 6

Clinical Presentation and Monitoring

• Mild symptoms include nausea, headache, confusion, and weakness 2
• Severe symptoms include seizures, coma, respiratory arrest, and death 1, 4
• Monitor serum sodium levels in patients taking supplements with known effects on water balance, especially in high-risk populations 1
• Assess volume status to determine appropriate management strategy (hypovolemic, euvolemic, or hypervolemic hyponatremia) 1

Prevention and Management

• Educate patients about appropriate fluid intake when using supplements, especially during exercise 2
• Advise against excessive water consumption with supplements that may affect sodium balance 7, 1
• For severe symptomatic hyponatremia, administer 3% hypertonic saline with careful monitoring 2
• Discontinue the offending supplement and treat the underlying cause 4
• Avoid rapid correction of chronic hyponatremia (not exceeding 8 mmol/L in 24 hours) to prevent osmotic demyelination syndrome 1

Common Pitfalls to Avoid

• Failing to recognize mild hyponatremia as clinically significant - Even mild hyponatremia is associated with cognitive impairment, gait disturbances, and increased risk of falls and fractures 4
• Overlooking supplement use when evaluating causes of hyponatremia 3
• Using fluid restriction inappropriately - This approach varies based on the type of hyponatremia (hypovolemic, euvolemic, or hypervolemic) 1
• Correcting sodium levels too rapidly - Can lead to osmotic demyelination syndrome, especially in patients with chronic hyponatremia 1
• Recommending home preparation of sodium chloride supplements - This can lead to dosing errors resulting in hypo- or hypernatremia 7