Here’s a case scenario where sodium chloride supplements were added, and why I think it is important to recognize what that may mean. KD is a 63-year-old female with a history of bipolar disorder with depressive episodes, GERD, trigeminal neuralgia, constipation, hypertension, and edema. Current medications include omeprazole, sertraline, sucralfate, carbamazepine, lisinopril, hydrochlorothiazide, and docusate. Upon routine lab check, her most recent sodium was 127 mEq/L. She hasn’t had any neurological symptoms.
Her provider would like to help increase the sodium level for fear of it dropping lowering and causing symptomatic hyponatremia. He recommended fluid restriction and also prescribed sodium chloride supplements to help raise the level.
As a pharmacist, when I see an order for sodium chloride supplements or I notice a patient has difficulty with hyponatremia, I immediately go to the medication and diagnosis list. Medications for depression (such as SSRIs), as well as medications for bipolar disorder or seizures disorders (i.e. carbamazepine), are well known to cause SIADH.
I would want to review this patient’s recent medical history to figure out if this low sodium has been chronic and when exactly it started. The diuretic could complicate issues in addition to the SSRI and carbamazepine. Correlating the timing of the lower sodium levels to any changes in the medication regimen would be very important.
If it was felt that the carbamazepine or SSRI needed to be changed due to SSRI risk, it would be nice to know what psych medications that the patient has tried in the past. Dose reduction and identifying potential alternatives could be potential options here to help address the sodium level if it remains low.
Of course, we are going to want to continue to monitor sodium levels. In addition, patient education about the signs and symptoms of hyponatremia would also be important.
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Would there be a potential for less risk of SIADH with another SSRI or would you consider a different class entirely to avoid that risk?
Thanks for the message Adam, I’m not aware of any less risk of SIADH with specific SSRIs but maybe there’s are article out there somewhere?!?!
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4874104/
This article sums up Adam’s question. Hope it helps.