ENDOCRINOLOGY IN THE TIME OF COVID-19-2021 UPDATES: The management of diabetes insipidus and hyponatraemia

Abstract

COVID-19 has changed the nature of medical consultations, emphasizing virtual patient counseling, with relevance for patients with diabetes insipidus (DI) or hyponatremia. The main complication of desmopressin treatment in DI is dilutional hyponatraemia. Since plasma sodium monitoring is not always possible in times of COVID-19, we recommend to delay the desmopressin dose once a week until aquaresis occurs allowing excess retained water to be excreted. Patients should measure their body weight daily. Patients with DI admitted to the hospital with COVID-19 have a high risk for mortality due to volume depletion. Specialists must supervise fluid replacement and dosing of desmopressin. Patients after pituitary surgery should drink to thirst and measure their body weight daily to early recognize the development of postoperative SIAD. They should know hyponatraemia symptoms. Hyponatraemia in COVID-19 is common with a prevalence of 20 to 30% and is mostly due to SIAD or hypovolemia. It mirrors disease severity and is an early predictor for mortality. Hypernatraemia may also develop in COVID-19 patients, with a prevalence of 3-5%, especially in ICU, and derives from different multifactorial reasons, e.g. due to insensible water losses from pyrexia, increased respiration rate and use of diuretics. Hypernatraemic dehydration may contribute to the high risk of acute kidney injury in COVID-19. IV fluid replacement should be administered with caution in severe cases of COVID-19 because of the risk of pulmonary oedema.

Management of cranial diabetes insipidus: clinical outcomes and patient perception of care

“…Safe in-hospital management of CDI extends beyond timely desmopressin dosing; close monitoring of fluid balance and serum sodium concentration are also key (8,11). Daily measurement of serum sodium and documentation of fluid balance were performed in fewer than half of hospital admissions, these are two further benchmarks that require addressing in future quality improvement projects.…”

Delay in desmopressin therapy: Disaster in waiting

“…Specifically, the 2018 Society for Endocrinology guidelines recommend that intravenous or intramuscular administration of desmopressin be used in the setting of excessive and inappropriate urine output for patients with central DI 11 . The 2021 COVID‐19 update to the guidelines further clarifies that that intravenous route should be preferred over other routes of administration based on the potential for reduced absorption 12 …”

“…11 The 2021 COVID-19 update to the guidelines further clarifies that that intravenous route should be preferred over other routes of administration based on the potential for reduced absorption. 12 Herein we describe how rapidly severe hypernatremia can develop after desmopressin therapy is withheld in patients with central DI as well as parental routes of desmopressin administration when enteral administration is not possible.…”

COVID-19 and the pituitary gland

“…Absorption of nasal desmopressin may be limited or variable, due to nasal congestion or for other reasons; oral or systemic administration is recommended during COVID-19 infection. [7] Even in the absence of COVID-19 in the patients themselves, many, perhaps most, patients during the pandemic at its height experienced interruptions in care and/or less direct physical interaction with clinical staff as it was replaced by virtual consultations via some form of telemedicine. These changes in care delivery resulted from concerns about patient safety during visits to clinical environments or were necessary due to the re-allocation of staff and resources away from the care of apparently stable medical conditions to look after those with active infection.…”