Plasma Sodium Correction Rates in Patients with Severe Hyponatremia Treated with Hypertonic Saline with and without Proactive Desmopressin

Key Points Proactive desmopressin was associated with reduced overcorrection of hyponatremia compared with reactive/rescue desmopressin or no desmopressin. No significant differences in adverse events were observed between proactive, reactive/rescue, and no desmopressin strategies. Plasma sodium was checked more often in the proactive desmopressin group. Background Coadministration of hypertonic saline (HTS) 3% and desmopressin from the outset of treatment (“DDAVP clamp” or proactive desmopressin) has been suggested to prevent inadvertent overcorrection of hyponatremia, but its effectiveness and safety remain uncertain. Methods We identified adult patients hospitalized between July 1, 2018, and June 30, 2023, at four University of Pittsburgh Medical Center hospitals with a plasma sodium (PNa) ≤120 mEq/L at admission or during hospitalization who were treated with HTS. We compared outcomes between patients who were treated with proactive desmopressin and those who either did not receive desmopressin or received it using a reactive/rescue strategy. Results A total of 184 patient admissions (57.6% female, mean age 60.6 years) met inclusion and exclusion criteria. Hyponatremia was chronic in 93.5% of patients; leading causes were syndrome of inappropriate antidiuresis (51.6%), hypovolemia (25.5%), and low solute intake (15.8%), and 20.1% had seizures. Cases treated with proactive desmopressin ( n =44) were compared with cases treated without proactive desmopressin ( n =140). Despite a lower baseline PNa (110.2±6.3 versus 115.2±7.2 mEq/L, P < 0.001), correction by >8 mEq/L (6.8% versus 27.1%, P = 0.009) or >10 mEq/L (0% versus 15%, P = 0.014) within the first 24 hours was significantly less frequent in the proactive desmopressin group. Hospital mortality (6.8% versus 6.4%, P > 0.99), length of hospital (12.5 versus 11.7 days, P = 0.624) and intensive care unit stays (6 versus 5.5 days, P = 0.578), fluid overload (9.1% versus 9.5%, P > 0.99), and worsening of hyponatremia (2.3% versus 1.5%, P > 0.99) were similar in the two groups, but PNa was checked significantly more often in the proactive desmopressin group (20.9 versus 17.4, P < 0.001). No cases of osmotic demyelination syndrome and no deaths from cerebral edema were identified. Conclusions Treating severe hyponatremia with HTS and proactive desmopressin was associated with lower rates of overcorrection without significant adverse events compared with HTS without proactive desmopressin.