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Common Electrolyte Disorders: Hyponatremia

A 75-year-old man with a past medical history significant for hypertension, diabetes mellitus, dyslipidemia, and depression presented with headache, severe nausea, and confusion. His medications included amlodipine, metformin, atorvastatin, and duloxetine. On physical examination, he appeared euvolemic and was alert and oriented only to person. Laboratory studies revealed a plasma sodium level of 120 mEq/L, plasma glucose level of 240 mg/dL, plasma osmolality of 270 mOsm/kg, urine sodium level of 45 mEq/L, urine osmolality of 350 mOsm/kg, and a thyroid-stimulating hormone level within normal limits. The patient was diagnosed with the syndrome of inappropriate antidiuresis, likely secondary to recent initiation of the selective serotonin reuptake inhibitor duloxetine, which was discontinued during his hospital stay. The patient was treated with hypertonic saline, followed by loop diuretics, and then isotonic saline. He was maintained on free water restriction throughout treatment. His mental status returned to baseline by day 3. He was subsequently discharged with instructions to discontinue duloxetine and follow-up with his psychiatrist to consider an alternative medication.