Daily Sodium Monitoring and Fluid Intake Protocol: Preventing Recurrent Hospitalization in Adipsic Diabetes Insipidus

Abstract

Management of diabetes insipidus (DI) is usually facilitated by an intact thirst mechanism prompting water ingestion in times of rising osmolality. Maintenance of eunatremia can be quite difficult in patients with DI and adipsia because of the absence of this homeostatic mechanism. Few published protocols for management of these complex cases exist. We report a case of a 16-year-old girl who had a diagnosis of craniopharyngioma with preoperative hypopituitarism and central DI. She underwent transsphenoidal resection in 2013 and additionally developed postoperative cognitive impairment and hypothalamic dysfunction, including adipsia. She subsequently experienced widely dysregulated sodium levels, necessitating inpatient care ∼30% of days in 2014 and 2015. We created a protocol for this patient that uses a fixed daily dose of subcutaneous DDAVP combined with daily modulation of fluid intake based on daily serum sodium measurement. The protocol provides guidance for the day’s fluid intake based on both the current sodium result and the rate of change from the previous day. Since the adoption of the protocol in June 2016, the patient has had a dramatic reduction in hospitalizations. Use of a protocol for providing recommendations for fluid intake based on the sodium level and rate of change may help to maintain normal sodium levels in such patients, decreasing hospitalization and improving quality of life.

Persistent hypernatremia secondary to adipsic central diabetes insipidus in a patient with herpes-induced meningoencephalitis and COVID-19 infection: a case report

“… 24 In addition, the appropriate daily water intake should be carefully determined on the basis of regular weighing and the determination of serum sodium concentration. 11 , 25 Patients with amnesic disorders or behavioral issues need a caregiver to ensure their correct fluid intake and the administration of desmopressin.…”

Adipsic Diabetes Insipidus in Children: A Case Report and Practical Guide

“…Moreover, the 84% success rate achieved in the aforementioned study is subject to many issues regarding accuracy, frequent blood sampling, and availability of consumables, while still being lower than our goal of 100% control. Pabich et al managed a 16-year-old patient with fixed daily doses of sub-cutaneous DDAVP combined with daily modulation of fluid in-take based on daily serum sodium measurement, which led to a reduction in hospitalizations resulting from the serum sodium dysregulation [ 18 ]. Again, the daily sodium measurement is not an available choice at all times and is not always practical, especially in young children.…”

Adipsic Diabetes Insipidus—The Challenging Combination of Polyuria and Adipsia: A Case Report and Review of Literature

“…Concomitant intake of food is known to decrease the rate and extent of absorption by 40% hence, it is best to avoid any food consumption within an hour before and after administration of the sublingual desmopressin tablets. Recently detailed fluid administration protocol with daily sodium monitoring with fixed dose subcutaneous desmopressin has been described (28) demonstrating the difficulty in day-to day monitoring. Another recent case report (27) has also reported using the sublingual desmopressin form for ADI at the dose of 60 and 120 mcg daily.…”