Poster Presentation ESA-SRB-ANZOS 2025 in conjunction with ENSA

AVP-D’s salty unseen opponents (128708)

Carmela Caputo 1 , Nupoor Tomar 1 , Sasha Beitner 2
  1. St Vincent's Hospital Melbourne, Doncaster, VIC, Australia
  2. General Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia

68711991019c1-Figure+1+Serum+Sodium+levels+and+management+with+desmopressin+(DDAVP)+reintroduction.jpgA 59-year-old woman with idiopathic arginine vasopressin deficiency (AVP-D) presented for knee replacement and developed severe hyponatraemia due to opioid and NSAIDs use with her desmopressin (100 mcg mane/midi, 200 mcg nocte). Post operative analgesia was celecoxib, oxycodone and oxycodone/naloxone.

On day 4 her sodium was 128 mmol/L [135-145], despite being 136mmol/l the day prior. The patient continued desmopressin. 

Sodium was 119 mmol/L the next morning. Her weight had increased by 6kg. Examination was unremarkable. Immediate management was withholding desmopressin, fluid restriction of 500 ml/day, and monitoring electrolytes thrice daily. Her sodium level was 117 mmol/L by midday that day. 15 hours after her last desmopressin dose, she became polyuric. Sodium dropped to 113 mmol/L by 6 pm. She received 500 millilitres of 3% saline over several hours correcting her serum sodium to 120 mmol/L in 8 hours. Oral 100mcg desmopressin was given to prevent further rapid sodium correction. Over the next 24 hours, her sodium level increased from 120 mmol/L to 134 mmol/L. Desmopressin continued to be administered based on polyuria onset BD (figure 1). There were no neurological sequalae. Dosing was regularly reviewed with urine output, daily weights, electrolytes. Oxycodone was used cautiously. NSAIDs were not restarted. On discharge her weight had returned to baseline and sodium had been stable on desmopressin 100mcg morning and night.

There are 14 case reports of severe hyponatraemia when desmopressin is combined with NSAIDs and/or opioid medications. To improve outcomes and reduce mortality in AVP-D patients, future guidelines should recognise the risk of hyponatremia from commonly used medications. Mechanisms of actions for hyponatraemia due to NSAIDs/opiods are via AVP independent pathways that attenuate diuresis, enhance water permeability and so promote water retention. 

  1. Adrogue, H.J., B.M. Tucker, and N.E. Madias, Diagnosis and Management of Hyponatremia: A Review. JAMA, 2022. 328(3): p. 280-291. Lee, Y., et al., Korean Society of Nephrology 2022 recommendations on controversial issues in diagnosis and management of hyponatremia. Korean J Intern Med, 2022. 37(6): p. 1120-1137.
  2. Fralick, M., et al., Desmopressin and the risk of hyponatremia: A population-based cohort study. PLoS Med, 2019. 16(10): p. e1002930. 2. Achinger, S.G., et al., Desmopressin acetate (DDAVP)-associated hyponatremia and brain damage: a case series. Nephrol Dial Transplant, 2014. 29(12): p. 2310-5. 3. Fleseriu, M., et al., Hormonal Replacement in Hypopituitarism in Adults: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab, 2016. 101(11): p. 3888-3921. 4. Baldeweg, S.E., et al., SOCIETY FOR ENDOCRINOLOGY CLINICAL GUIDANCE: Inpatient management of cranial diabetes insipidus. Endocr Connect, 2018. 7(7): p. G8-G11.