THIS PAGE IS UNDER CONSTRUCTION
Related Pages
References
Copyright 2019, Rajnish Mago, MD. All rights reserved. May not be reproduced in any form without express written permission.
Disclaimer: The content on this website is provided as general education for medical professionals. It is not intended or recommended for patients or other lay persons or as a substitute for medical advice, diagnosis, or treatment. Patients must always consult a qualified health care professional regarding their diagnosis and treatment. Healthcare professionals should always check this website for the most recently updated information.
Question from a Member:
What would be a good medication for OCD in a patient who had seizure due to hyponatremia?
I have a middle-aged patient who has a history of anorexia nervosa, hypertension, and transient ischemic attack.
She was hospitalized a couple of months ago after a seizure due to hyponatremia; serum sodium was 113 mEq/L. The hyponatremia was multifactorial due to hydrochlorothiazide (HCTZ), salt restriction (she was restricting it due to hypertension), and increased ingestion of water “to help her skin” and “wash her system.” When she was hospitalized with hyponatremia, she was not taking any psychotropic medications.
The HCTZ was discontinued and she improved. I started her on fluoxetine recently for depression and anxiety (obsessions). Fluoxetine helped her in the past for anxiety and obsessions and she is reluctant to take any other psychiatric medication because of her concerns of weight gain.
Her recent lab worked showed serum sodium of 132 mEq/ L (it was 136 mEq/L prior to that.)
What other treatment can I give her for OCD without putting her again at risk of hyponatremia?
SPMH responds
I definitely cannot give medical advice for a particular patient who is not under my care and whose full history I do not know, but I will share some of my thoughts regarding this kind of situation.
The question is: “What other treatment can I give her for OCD without putting her again at risk of hyponatremia?” All the standard, accepted medications for OCD are serotonergic and so none can be given “without putting her again at risk of hyponatremia.” A couple of other potential treatments for OCD are Deep TMS and N-acetylcysteine (NAC). Please click on these links to read about their potential utility in OCD. But, these are unlikely to be viable options as monotherapy and for the long term.
Under appropriate circumstances, behavior therapy can be as effective as a serotonergic antidepressant for the treatment of OCD. So, in situations like this, we should redouble our efforts to make sure that the patient is getting high quality, specific psychotherapy for her problems. This may reduce the need for medications but also, if (hopefully not), the medication has to be stopped due to worsening hyponatremia or for other reasons, the patient will not be left without any treatment at all.
If a serotonergic antidepressant is essential, what can be done to reduce the risk of hyponatremia?
Evaluate concomitant medications
Thiazide diuretics, non-steroidal anti-inflammatory drugs, and other medications that may also lead to hyponatremia should, of course, be avoided if at all possible.
Choice of antidepressant
Firstly, all serotonergic antidepressants can cause hyponatremia due to
Bupropion does not cause hyponatremia but is not suitable for this patient since treatment of OCD requires a serotonergic antidepressant. Also, she has a history of a seizure.
Mirtazapine is less likely to cause hyponatremia but, again, is not a choice for this particular patient.
Fluid restriction
A very important thing to do in patients with SIADH is to put the patient on strict fluid restriction. If the patient can be made to understand that the number of choices is limited and that fluid restriction may make it possible for her to continue fluoxetine, she may be willing to adhere to strict fluid restriction.
Typically, we start with asking the patient to restrict to 1200 to 1400 mL per day. Then, based on following the serum sodium levels, more drastic fluid restriction may be needed.
Beyond this, treatment must be done in consultation with a nephrologist or other physician.
Advanced treatment options
If continuing a serotonergic antidepressant is essential and water restriction is not sufficient to manage the hyponatremia, the nephrologist may recommend removing the salt restriction despite the history of hypertension. If edema develops, the nephrologist
Copyright 2019, Rajnish Mago, MD. All rights reserved. May not be reproduced in any form without express written permission.
Disclaimer: The content on this website is provided as general education for medical professionals. It is not intended or recommended for patients or other lay persons or as a substitute for medical advice, diagnosis, or treatment. Patients must always consult a qualified health care professional regarding their diagnosis and treatment. Healthcare professionals should always check this website for the most recently updated information.
Leave a Reply: