Posters
Presentation Type
Poster
Discipline Track
Clinical Science
Abstract Type
Case Report
Abstract
Introduction: Hyponatremia, defined as serum sodium below 135mEq/L( normal range:136-145mEq/l), is a medical emergency associated with various complications. Sodium is an important electrolyte that helps regulate fluid balance and nerve/muscle function. Severe hyponatremia may not show obvious symptoms initially but can eventually manifest as nausea, vomiting, fatigue, impaired movement, and in extreme cases, seizures, coma, respiratory failure, or even death.
Thiazide diuretics have been associated with hyponatremia with a sodium level as low as 99mEq/L. In our case, the patient was on bumetanide, a loop diuretic and she developed hyponatremia which worsened with additional metolazone treatment to a sodium level of 102mEq/L with minimal symptoms.
Case presentation: An 82-year-old woman presented to emergency department in South Texas with dyspnea, cough, weakness, fatigue, and headache. She had a history of depression, dementia, obesity, arthritis, osteoporosis, hypertension, hyperlipidaemia, coronary artery disease, chronic atrial fibrillation, and hypertrophic obstructive cardiomyopathy with mitral regurgitation. Her medication regimen included amlodipine 5mg daily, apixaban twice daily, bumetanide 1mg daily, metolazone
2.5mg daily, metoprolol succinate 100mg daily, simvastatin 20mg daily, prednisone 10mg for 5 days, hydrocodone-acetaminophen every 4 hours as needed, and multiple drugs for dementia and depression including aripiprazole 5mg nightly, brexpiprazole 1mg daily, clonazepam 1mg three times daily, donepezil 5mg nightly, duloxetine 60mg twice daily, and zolpidem12.5 mg nightly.
On initial evaluation, her vital signs were within normal range, and her BMI was 38.7. On physical examination, she was in mild distress, with diminished breath sounds at the bi-basilar lobes, and poor inspiratory effort. She had a normal heart rate and rhythm with a 3/6 harsh mid-peaking systolic ejection murmur loudest at the left mid-sternal border and a 2/6 harsh systolic ejection murmur at the apex consistent with HOCM. Labs revealed severe hyponatremia (sodium of 102) along with hypokalemia (2.8mEq/L), hypochloremia (70mEq/L ), hypo-osmolarity (serum osmolarity of 227mOsmol/kgH2O and urine osmolarity of 324), and urine sodium of 43mEq.
The patient was admitted to the ICU for hypo-osmolar hypovolemic hyponatremia and pneumonia. She received appropriate treatment, including fluid resuscitation and antibiotics. Throughout her ICU stay, she remained neurologically stable with caution exercised to prevent rapid correction of sodium levels. Over six days, serum sodium gradually normalized and stabilized at 133.
The patient recently had metolazone 2.5 mg daily added to her usual bumetanide 1 mg daily in February 2023 to optimize her heart failure regimen. She also took multiple antipsychotic and antidepressant medications, contributing to her chronic hyponatremia. The combination of diuretic therapy, antipsychotic medication, and antidepressant medication(duloxetine) were identified as the probable causes.
Conclusion: Recording on of the lowest serum sodium levels in a minimally symptomatic patient, this case emphasizes the importance of recognizing drug-induced hyponatremia in patients with complex medical histories and multiple medications. Careful assessment and monitoring of medication regimens, particularly in older adults, are crucial to minimize the risk of drug interactions and adverse effects. Collaborative efforts among healthcare providers are essential to optimize medication management and prevent complications associated with hyponatremia and its correction.
Academic/Professional Position
Resident
Recommended Citation
Kondapavuluru, Roy; Garcia Cruz, Jian; Kakarla, Manaswini; Maganti, Ram; Pingilati, Akshay; and Suarez Parraga, Andres, "When medications collide: Demystifying Drug-Induced Hyponatremia in a complex medical case" (2024). Research Symposium. 36.
https://scholarworks.utrgv.edu/somrs/2023/posters/36
Included in
When medications collide: Demystifying Drug-Induced Hyponatremia in a complex medical case
Introduction: Hyponatremia, defined as serum sodium below 135mEq/L( normal range:136-145mEq/l), is a medical emergency associated with various complications. Sodium is an important electrolyte that helps regulate fluid balance and nerve/muscle function. Severe hyponatremia may not show obvious symptoms initially but can eventually manifest as nausea, vomiting, fatigue, impaired movement, and in extreme cases, seizures, coma, respiratory failure, or even death.
Thiazide diuretics have been associated with hyponatremia with a sodium level as low as 99mEq/L. In our case, the patient was on bumetanide, a loop diuretic and she developed hyponatremia which worsened with additional metolazone treatment to a sodium level of 102mEq/L with minimal symptoms.
Case presentation: An 82-year-old woman presented to emergency department in South Texas with dyspnea, cough, weakness, fatigue, and headache. She had a history of depression, dementia, obesity, arthritis, osteoporosis, hypertension, hyperlipidaemia, coronary artery disease, chronic atrial fibrillation, and hypertrophic obstructive cardiomyopathy with mitral regurgitation. Her medication regimen included amlodipine 5mg daily, apixaban twice daily, bumetanide 1mg daily, metolazone
2.5mg daily, metoprolol succinate 100mg daily, simvastatin 20mg daily, prednisone 10mg for 5 days, hydrocodone-acetaminophen every 4 hours as needed, and multiple drugs for dementia and depression including aripiprazole 5mg nightly, brexpiprazole 1mg daily, clonazepam 1mg three times daily, donepezil 5mg nightly, duloxetine 60mg twice daily, and zolpidem12.5 mg nightly.
On initial evaluation, her vital signs were within normal range, and her BMI was 38.7. On physical examination, she was in mild distress, with diminished breath sounds at the bi-basilar lobes, and poor inspiratory effort. She had a normal heart rate and rhythm with a 3/6 harsh mid-peaking systolic ejection murmur loudest at the left mid-sternal border and a 2/6 harsh systolic ejection murmur at the apex consistent with HOCM. Labs revealed severe hyponatremia (sodium of 102) along with hypokalemia (2.8mEq/L), hypochloremia (70mEq/L ), hypo-osmolarity (serum osmolarity of 227mOsmol/kgH2O and urine osmolarity of 324), and urine sodium of 43mEq.
The patient was admitted to the ICU for hypo-osmolar hypovolemic hyponatremia and pneumonia. She received appropriate treatment, including fluid resuscitation and antibiotics. Throughout her ICU stay, she remained neurologically stable with caution exercised to prevent rapid correction of sodium levels. Over six days, serum sodium gradually normalized and stabilized at 133.
The patient recently had metolazone 2.5 mg daily added to her usual bumetanide 1 mg daily in February 2023 to optimize her heart failure regimen. She also took multiple antipsychotic and antidepressant medications, contributing to her chronic hyponatremia. The combination of diuretic therapy, antipsychotic medication, and antidepressant medication(duloxetine) were identified as the probable causes.
Conclusion: Recording on of the lowest serum sodium levels in a minimally symptomatic patient, this case emphasizes the importance of recognizing drug-induced hyponatremia in patients with complex medical histories and multiple medications. Careful assessment and monitoring of medication regimens, particularly in older adults, are crucial to minimize the risk of drug interactions and adverse effects. Collaborative efforts among healthcare providers are essential to optimize medication management and prevent complications associated with hyponatremia and its correction.