Symptomatic life-threating hyponatremia complicating severe COPD exacerbation, pulmonary edema and pulmonary hypertension-a critical role for conivaptan

Macaulay Onuigbo ,Nneoma Agbasi,Thuyanh Culver,Mark Henry Alon,Yasser Sammour,Adel Zurob,Muhammad Adeel Rishi ,Abdul Moiz Khan ,Emeka Amadi

doi:10.15171/jrip.2018.23

Abstract

Hyponatremia, the most common electrolyte abnormality in hospitalized patients, is associated with increased morbidity and mortality. Phase 3 clinical trials and subsequent studies including the Study of Ascending Levels of Tolvaptan in Hyponatremia 1 and 2 (SALT 1 and 2) clearly demonstrated the efficacy of vasopressin antagonists in increasing plasma sodium levels. The vaptans, oral tolvaptan and intravenous conivaptan, are vasopressin antagonists but as recently as 2015, there remained conflicting recommendations for their use by different expert committees in patients with hyponatremia. This circumstance was blamed on limited patient experiences and limited research data. We recently encountered worsening life-threatening symptomatic hyponatremia, unresponsive to hypertonic 3% saline infusion, and impending respiratory failure in a 62-year old obese Caucasian male patient who was further complicated by advanced chronic obstructive pulmonary disease (COPD), pulmonary hypertension and acutely decompensating diastolic heart failure, albeit with stable CKD II creatinine levels. Intravenous loop diuretics may have helped with heart failure but potentially would have aggravated the already critically low sodium levels. He demonstrated a brisk response to intravenous conivaptan administration. Intravenous conivaptan is sine qua non the absolute ideal therapeutic agent for acutely decompensating congestive heart failure with concurrent life-threatening hyponatremia.

Highlights

Hyponatremia is the most common electrolyte abnormality in hospitalized patients and is associated with increased morbidity and mortality [1,2,3,4,5,6]
Implication for health policy/practice/research/medical education: We report a 62-year-old obese hypertensive Caucasian male patient with advanced chronic obstructive pulmonary disease (COPD), pulmonary hypertension and acutely decompensating diastolic heart failure who presented with severe symptomatic life-threatening hyponatremia
There is accumulating evidence-base in the literature to strongly support the use of the vaptans in the management of severe symptomatic treatment-resistant hyponatremia especially in association with heart failure, advanced chronic obstructive pulmonary disease (COPD) and/or pulmonary hypertension [6,8,9,10,11]

Summary

Introduction

Hyponatremia is the most common electrolyte abnormality in hospitalized patients and is associated with increased morbidity and mortality [1,2,3,4,5,6]. Past medical history was significant for multiple admissions with COPD exacerbation and congestive diastolic heart failure, chronic bilateral lower extremity edema, hyponatremia exacerbations in the past, previous lumbar fusion L4-L5, hypertension, ongoing tobacco use after quitting in 2014, glucose intolerance and proximal left femoral-popliteal bypass He was admitted following the sudden loss of consciousness or syncope and a fall with some facial injury that required ENT surgical intervention in the emergency department. Intravenous furosemide infusion at 20 mg/h was again considered for management of the accompanying acutely decompensating heart failure but this consideration was promptly discarded for fear of further worsening hyponatremia Instead, he was transferred to the coronary care unit (CCU), nocturnal noninvasive positive airway pressure therapy was continued and intravenous conivaptan was started to improve hyponatremia and simultaneously achieve ‘diuresis’ through vaptandependent aquaresis. His admission weight was 132 kg and his weight on discharge was 120.5 kg; his BMI had decreased from 35.4 kg/m2 on admission to 32.3 kg/m2 on discharge

Discussion

Conclusion