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

Background: Co-administration of hypertonic saline 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 7/1/18 and 6/30/23 at four University of Pittsburgh Medical Center hospitals with a plasma sodium ≤120 mEq/L at admission or during hospitalization who were treated with hypertonic saline. 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 SIAD (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 to cases treated without proactive desmopressin (n=140). Despite a lower baseline plasma sodium (110.2±6.3 vs. 115.2±7.2 mEq/L, p<0.001), correction by >8 mEq/L (6.8% vs. 27.1%, p=0.009) or >10 mEq/L (0% vs. 15%, p=0.014) within the first 24 hours was significantly less frequent in the proactive desmopressin group. Hospital mortality (6.8% vs. 6.4%, p>0.99), length of hospital (12.5 d vs. 11.7 d, p=0.624) and ICU stays (6 d vs. 5.5 d, p=0.578), fluid overload (9.1% vs.9.5%, p>0.99), and worsening of hyponatremia (2.3% vs. 1.5%, p>0.99) were similar in the two groups but plasma sodium was checked significantly more often in the proactive desmopressin group (20.9 vs. 17.4, p<0.001). No cases of osmotic demyelination syndrome and no deaths from cerebral edema were identified.

Conclusions: Treating severe hyponatremia with hypertonic saline and proactive desmopressin was associated with lower rates of overcorrection without significant adverse events compared to hypertonic saline without proactive desmopressin.