What is the best course of action for a patient currently taking salt tabs (sodium supplements) to manage their condition, potentially related to adrenal insufficiency, and prevent complications such as hypernatremia or volume overload?

Management of Salt Tablet Supplementation

For patients currently on salt tablets, the primary decision hinges on the underlying indication: continue supplementation only if treating documented adrenal insufficiency or symptomatic orthostatic hypotension with confirmed hypovolemia, while discontinuing or reducing doses in patients with heart failure, chronic kidney disease, or risk of volume overload. 1, 2

Appropriate Indications for Continued Salt Supplementation

Adrenal Insufficiency

• Salt tablets are appropriate adjunctive therapy in Addison's disease when combined with fludrocortisone (0.1 mg daily) and glucocorticoids (hydrocortisone 10-30 mg daily or cortisone 10-37.5 mg daily). 1
• In salt-losing adrenogenital syndrome, fludrocortisone 0.1-0.2 mg daily is the primary treatment, with salt supplementation as needed. 1
• Monitor for hypertension development; if it occurs, reduce fludrocortisone to 0.05 mg daily rather than increasing salt intake. 1

Orthostatic Hypotension and Dehydration

• Salt supplementation (as tablets or dissolved in beverages) is reasonable for patients with syncope due to dehydration and orthostatic intolerance, provided they do not have cardiac dysfunction, heart failure, uncontrolled hypertension, or chronic kidney disease. 2
• Sodium supplementation improves plasma volume and orthostatic tolerance in dehydrated patients. 2
• Higher-sodium-content beverages with osmolality comparable to normal body osmolality rehydrate faster than lower-sodium-content alternatives. 2

Contraindications and High-Risk Situations Requiring Discontinuation

Heart Failure

• Patients with heart failure should NOT receive salt tablets; dietary sodium restriction to <2 g daily (equivalent to <5 g salt) is the standard recommendation. 2
• Salt restriction is critical for maintaining volume balance and preventing decompensation in heart failure patients. 2
• Increased sodium intake during travel or eating out can adversely affect sodium and volume balance, exacerbating heart failure symptoms through fluid retention. 2
• Patients with edematous states (heart failure, cirrhosis, nephrotic syndrome) have impaired ability to excrete both free water and sodium, placing them at risk for volume overload. 2

Chronic Kidney Disease

• In advanced chronic kidney disease (estimated glomerular filtration rate <30 ml/min/1.73 m²), daily sodium intake should be <3 g, making salt tablets inappropriate. 2
• Salt supplementation in patients with chronic kidney disease can lead to dangerous complications, including pericardial effusion accumulation and cardiac tamponade. 3

Risk of Hypernatremia

• Fatal hypernatremia from excessive salt intake, though rare, can occur with surprisingly small amounts—as little as 70-90 g of salt (1,200-1,500 mEq sodium) has caused death. 4
• Patients with renal concentrating defects (such as nephrogenic diabetes insipidus) could develop hypernatremia if administered excessive sodium supplementation. 2

Monitoring Requirements for Patients Continuing Salt Tablets

Clinical Assessment

• Monitor for signs of volume overload: peripheral edema, pulmonary congestion, weight gain, elevated blood pressure. 2
• Assess for hypertension development, which may require dose reduction or discontinuation. 1
• Watch for symptoms of hypernatremia: altered mental status, seizures, neurocognitive deficits. 5

Laboratory Monitoring

• Check serum sodium levels regularly; severe hypernatremia (>145 mEq/L) requires immediate intervention. 6, 5
• Monitor serum potassium, particularly in patients on mineralocorticoid receptor antagonists, as adequate salt consumption can attenuate MRA-induced hyperkalemia without affecting blood pressure. 7
• Assess renal function (blood urea nitrogen, creatinine) to detect worsening kidney function. 2

Alternative Management Strategies

For Hyponatremia

• Salt tablets may be appropriate for euvolemic hyponatremia alongside free water restriction. 5
• In hypovolemic hyponatremia, normal saline infusions are preferred over oral salt tablets for more controlled correction. 5
• Avoid overly rapid correction (>8-10 mEq/L per 24 hours in chronic hypernatremia) to prevent osmotic demyelination syndrome. 6, 8

For Medication-Induced Hypotension

• Consider reducing or withdrawing medications causing hypotension (diuretics, vasodilators, negative chronotropes) rather than adding salt supplementation. 2
• This approach is particularly important in older patients and those on multiple medications. 2

Common Pitfalls to Avoid

• Never use salt tablets as primary therapy for heart failure, cirrhosis, or nephrotic syndrome—these conditions require sodium restriction, not supplementation. 2
• Do not continue salt supplementation without clear documentation of the original indication and ongoing need. 2
• Avoid combining aggressive salt supplementation with conditions predisposing to fluid retention (pericardial effusion, renal dysfunction). 3
• Do not use salt tablets in patients with uncontrolled hypertension or those at risk for volume overload. 2