Hyponatremia in hospitalized patients: the potential role of tolvaptan

Hyponatremia (typically defined as serum sodium level < 135 mEq/L) is a common electrolyte abnormality among hospitalized patients. Whether present at admission or acquired during hospitalization, hyponatremia is associated with higher mortality and longer hospital stays. Failure to adequately investigate and treat hyponatremia may also be associated with adverse outcomes. The presence and severity of clinical symptoms largely depend on the rate and extent of the decline in serum sodium; rapid or large decreases may cause serious neurologic complications. The approach to treatment depends on the presence and severity of symptoms, the timing of their onset, the underlying etiology, and the patient's volume status. Patients with euvolemic or hypervolemic hyponatremia usually have inappropriately elevated levels of arginine vasopressin, which stimulates water reabsorption even in the presence of low serum osmolality. Tolvaptan is an orally active, selective V2-receptor antagonist that blocks the effects of arginine vasopressin in the renal collecting duct to promote aquaresis without increasing sodium or potassium excretion; as a result, it increases serum sodium in a controlled manner. Tolvaptan offers a mechanism-based treatment option for patients with euvolemic or hypervolemic hyponatremia who have serum sodium levels < 125 mEq/L or persistent symptoms resistant to fluid restriction.