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Hyponatraemia in Oncology: Magnitude of the problem: Proposed Management Algorithm for Syndrome of Anti Diuretic Hormone associated with Cancer A Joint Acute Oncology & Acute Medicine Project Bulusu V R, Jeffs Y P, Barclay C, Melvin A. Bedford Hospital Kempston Road, Bedford UK.

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Hyponatraemia in Oncology: Magnitude of the problem: Proposed Management Algorithm for Syndrome of Anti Diuretic Hormone associated with Cancer A Joint Acute Oncology & Acute Medicine ProjectBulusu V R, Jeffs Y P, Barclay C, Melvin A. Bedford Hospital Kempston Road, Bedford UK

Background: Hyponatraemia is defined as a serum Na+ of <135 mEq/l. SIADH secretion is a known metabolic complication of cancer resulting in hyponatraemia. Project designed to define the incidence of hyponatraemia and construct a management algorithm for SIADH. Traditional management of SIADH includes fluid restriction to < 1l/day, demeclocycline and hypertonic saline. Recently vasopressin-2 receptor antagonists have been introduced to treat SIADH.

Methods: Serum sodium results from April to September 2011 extracted from the biochemistry database (N=31,420). Severe Hyponatraemia defined as serum sodium <125 mEq/l; results were coded against the requester’s speciality.

Results: Severe hyponatraemia was documented in 447/31420, (1.4%) of all Na+ results. Biochemistry requests from Lung team (2.3%) and acute medicine team (3.3%) had the highest incidence. Full work up for SIADH was performed in <2%. We propose the following algorithm for cancer patients with SIADH.

Management algorithm for SIADH in Oncology

Hyponatraemia <135 mEq/l

Serum Na+ <110mEq/l or acute neurological symptoms ITU

Serum Na+ ≥125 mEq/l

OBSERVE

Hyponatraemia<125 mEq/l

Serum Osmolality <270 mOsm

Urine Osmolality >100 mOsmol

Elevated Urinary Na+ >25 mEq/l

Exclude

↓ T4

↓ Cortisol

Renal failure

Euvolemic

Acute Oncology

&

Endocrinology

Jointly review management plan

Acute Oncology Clinical Nurse Specialist

Patient informed of Management plan

SIADH

  • Information sheet for SIADH & consent
  • Review concomitant medications (drug interactions)
  • Oral Tolvaptan 15 mg od starting dose, ↑ to 60 mg as req
  • U/E LFTs on days 1, 3 and 5
  • Continue Tolvaptan for 5-7 days & review
  • Specific anticancer treatment

Conclusions: We propose a new management algorithm for the management of SIADH incorporating oral Tolvaptan, a vasopressin-2 receptor antagonist, avoiding the need for fluid restriction & demeclocyline. Patients with SIADH should be jointly managed by acute oncology and endocrinology specialist teams.

vrbulusu@gmail.com