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

From the Guidelines

To manage overcorrection of hyponatremia, relowering with electrolyte-free water or desmopressin may be considered, with the goal of lowering serum sodium by 2-4 mEq/L to prevent osmotic demyelination syndrome (ODS) 1. The management of overcorrection of hyponatremia is crucial to prevent ODS, a rare but potentially devastating complication. According to the 2021 practice guidance by the American Association for the Study of Liver Diseases, the risk of ODS may be mitigated with multidisciplinary, coordinated care, and liver transplantation need not be prohibited by hyponatremia alone 1. Some key points to consider in managing overcorrection of hyponatremia include:

• The goal rate of change of serum sodium should not exceed 10-12 mEq in a 24-hour period, with an average risk of ODS, and a lower goal of 4-6 mEq/L per day, not to exceed 8 mEq per 24-hour period in patients at high risk of ODS 1.
• Patients at high risk of ODS include those with advanced liver disease, alcoholism, more severe cases of hyponatremia, malnutrition, severe metabolic derangements, low cholesterol, and prior encephalopathy 1.
• The use of tromethamine (also called tris[hydroxymethyl]aminomethane) may reduce the risk of ODS 1.
• Intraoperative administration of large amounts of products containing sodium, such as packed red blood cells and fresh frozen plasma, as well as saline solutions, may raise serum sodium too rapidly, increasing the risk of ODS 1. By carefully managing the correction of hyponatremia and monitoring for signs of ODS, clinicians can reduce the risk of this potentially devastating complication and improve patient outcomes.

From the FDA Drug Label

Unless properly diagnosed and treated hyponatremia can be fatal Therefore, fluid restriction is recommended and should be discussed with the patient and/or guardian. All patients receiving desmopressin acetate therapy should be observed for the following signs of symptoms associated with hyponatremia: headache, nausea/vomiting, decreased serum sodium, weight gain, restlessness, fatigue, lethargy, disorientation, depressed reflexes, loss of appetite, irritability, muscle weakness, muscle spasms or cramps and abnormal mental status such as hallucinations, decreased consciousness and confusion. Severe symptoms may include one or a combination of the following: seizure, coma and/or respiratory arrest.

To manage overcorrection of hyponatremia, fluid restriction is recommended. It is crucial to monitor patients closely for signs and symptoms of hyponatremia, such as:

• Headache
• Nausea/vomiting
• Decreased serum sodium
• Weight gain
• Restlessness
• Fatigue
• Lethargy
• Disorientation
• Depressed reflexes
• Loss of appetite
• Irritability
• Muscle weakness
• Muscle spasms or cramps
• Abnormal mental status, including hallucinations, decreased consciousness, and confusion. In severe cases, patients may experience seizure, coma, and/or respiratory arrest. 2

From the Research

Management of Over Correction of Hyponatremia

To manage over correction of hyponatremia, several strategies can be employed:

• Desmopressin administration: Desmopressin can be used to control high rates of serum sodium concentration correction in severe hyponatremia 3, 4.
• Proactive strategy: A proactive strategy of desmopressin administration with hypertonic saline can be associated with a lower incidence of exceeding serum sodium concentration correction targets 3, 5.
• Reactive strategy: A reactive strategy, where desmopressin is administered based on changes in serum sodium concentration or urine output, can also be effective 4.
• Rescue strategy: A rescue strategy, where desmopressin is administered after serum sodium correction targets are exceeded or when osmotic demyelination appears imminent, can be used in certain cases 3, 6.
• Monitoring: Close monitoring of plasma sodium levels is crucial to prevent overcorrection and osmotic demyelination syndrome 7, 5.

Prevention of Osmotic Demyelination Syndrome

To prevent osmotic demyelination syndrome, the following measures can be taken:

• Cautious correction: Hyponatremia should be corrected at a rate of no more than 8 mEq/L per day in patients at high risk of osmotic demyelination syndrome 3, 4.
• Desmopressin and dextrose: Concomitant administration of desmopressin and dextrose 5% water can be used to gradually relower serum sodium concentration in cases of overcorrection 6.
• Identification of high-risk patients: Patients with multiple risk factors, such as alcoholism, hypokalemia, malnutrition, and liver cirrhosis, should be identified and managed carefully to prevent osmotic demyelination syndrome 7.