Rechallenge after Siadh

[Attending1985]

---

Members don't see this ad.

I have a patient on a combination of trileptal 1800 mg daily, citalopram 60 mg trazodone. Had been on them for years. Ended up hospitalized with a sodium of 120 after a bout of diarrhea and vomiting. Nephrology saw and it was siadh with some component of hypovolemia.
She’s recovered now and wants to restart her citalopram. Has tried many meds in the past and this has been most effective.
Do you guys think it’s reasonable to try the citalopram at 20 mg with weekly sodiums? Never had a case like this before.

 

[Stagg737]

Completely appropriate. Once they stabilize, we re-trial patients on antidepressants post-hyponatremia without problems all the time. Getting Na levels somewhat regularly while you're retitrating is an appropriatley cautious approach. I would be far more wary about restarting the oxcarb as that's a much more common cause of serious hypoNa and a med I've seen it cause severe hypoNa several times (Na<110 in a couple of cases).

 

[Attending1985]

Completely appropriate. Once they stabilize, we re-trial patients on antidepressants post-hyponatremia without problems all the time. Getting Na levels somewhat regularly while you're retitrating is an appropriatley cautious approach. I would be far more wary about restarting the oxcarb as that's a much more common cause of serious hypoNa and a med I've seen it cause severe hypoNa several times (Na<110 in a couple of cases).

Thanks so much. Everything I’m reading is saying not to rechallenge with same agent but in her case others haven’t worked.

 

[Crayola227]

Just curious why the trileptal and the trazodone on board before?

 

[Attending1985]

Just curious why the trileptal and the trazodone on board before?

I inherited this patient less than a year ago. Trazodone was for insomnia. Trileptal was for a questionable bpad diagnosis.

 

[Celexa]

I have a patient on a combination of trileptal 1800 mg daily, citalopram 60 mg trazodone. Had been on them for years. Ended up hospitalized with a sodium of 120 after a bout of diarrhea and vomiting. Nephrology saw and it was siadh with some component of hypovolemia.
She’s recovered now and wants to restart her citalopram. Has tried many meds in the past and this has been most effective.
Do you guys think it’s reasonable to try the citalopram at 20 mg with weekly sodiums? Never had a case like this before.

Hope they scanned her chest. A colleague had a pt where medicine tried to pin the siadh on the long term meds. Turned out to be lung cancer.

But I agree with the others assuming proper workup was done its reasonable to retry citalopram and monitor if the pt is reliable and will get the

 

[Merovinge]

This is a Trileptal SE until proven to me otherwise. I would absolutely be comfortable returning to the SSRI if that's what the patient wanted with some lab monitoring.

 

[Stagg737]

This is a Trileptal SE until proven to me otherwise. I would absolutely be comfortable returning to the SSRI if that's what the patient wanted with some lab monitoring.

Idk that I would even consider this a Trileptal side effect at that point. Generally long-term meds don't cause sudden changes like this without an inciting factor. It certainly could have contributed, but if it is a necessary med (which is sounds like it's probably not) then it could probably also be cautiously re-trialed. If trying it again would definitely do more frequent lab monitoring than the standard 6-12 months both initially and chronically for while though.

 

[Merovinge]

Idk that I would even consider this a Trileptal side effect at that point. Generally long-term meds don't cause sudden changes like this without an inciting factor. It certainly could have contributed, but if it is a necessary med (which is sounds like it's probably not) then it could probably also be cautiously re-trialed. If trying it again would definitely do more frequent lab monitoring than the standard 6-12 months both initially and chronically for while though.

I have a different view of long-term as CAP, but I have had multiple patients develop hyponatremia on a stable dosage of Trileptal that they had been taking for 6+ months. This is such an often missed side effect. I have a medium view on the medication as there have been rare cases where it has markedly improved symptoms with low side effect burden, but I also see many patients with little improvement or undetected hyponatremia.

 

[Attending1985]

Idk that I would even consider this a Trileptal side effect at that point. Generally long-term meds don't cause sudden changes like this without an inciting factor. It certainly could have contributed, but if it is a necessary med (which is sounds like it's probably not) then it could probably also be cautiously re-trialed. If trying it again would definitely do more frequent lab monitoring than the standard 6-12 months both initially and chronically for while though.

I've done some reading on this after this happened and it looks like some studies have found that the longer people are on it the risk for SIADH increases.

Oxcarbazepine and Hyponatremia - PMC

Background and Objectives: Hyponatremia is one of the most common adverse effects in patients treated with oxcarbazepine (OXC). Different risk factors for OXC-induced hyponatremia have been described as age, female gender, dosage, and combination ...

pmc.ncbi.nlm.nih.gov

 

[Crayola227]

I have a different view of long-term as CAP, but I have had multiple patients develop hyponatremia on a stable dosage of Trileptal that they had been taking for 6+ months. This is such an often missed side effect. I have a medium view on the medication as there have been rare cases where it has markedly improved symptoms with low side effect burden, but I also see many patients with little improvement or undetected hyponatremia.

Agree have seen SIADH with anticonvulsants. Thought this was understood as a known side effect of this class even if uncommon.

 

[Stagg737]

I've done some reading on this after this happened and it looks like some studies have found that the longer people are on it the risk for SIADH increases.

Oxcarbazepine and Hyponatremia - PMC

Background and Objectives: Hyponatremia is one of the most common adverse effects in patients treated with oxcarbazepine (OXC). Different risk factors for OXC-induced hyponatremia have been described as age, female gender, dosage, and combination ...

pmc.ncbi.nlm.nih.gov

Will have to read this fully later, but do they account for acute changes that would induce the hyponatremia? Acute vs. gradual onset of hypoNa? Or are they just comparing groups and saying those who are on it longer are at greater risk? I would completely believe that, but I still question the actual cause of acute symptom onset any time we see a new side effect for a med a patient has been on chronically.

 

[hallowmann]

This is a Trileptal SE until proven to me otherwise. I would absolutely be comfortable returning to the SSRI if that's what the patient wanted with some lab monitoring.

Exactly this. I've seen Trileptal cause hyponatremia on tons of patients and certainly at varying times in treatment. I highly doubt it had anything to do with the Celexa, but if you want to be cautious, periodic sodiums is not unreasonable. I would probably take the chance on Lexapro though, but that's just my personal preference, especially if this patient needed 60 mg of Celexa.

 

[MedMan80]

I hardly use Trileptal but seen loads of folks on it, what is the evidence for it?