Hyponatraemic coma induced by desmopressin and ibuprofen in a woman with von Willebrand's disease

Abstract

A middle-aged woman was admitted to the hospital after being found unconscious at home. A brain CT scan excluded an intracranial bleed or other focal abnormality. Laboratory analysis showed hyponatraemia (sodium: 121 mmol L(-1)) and a low plasma osmolality, with normal sodium excretion and urine osmolality. A diagnosis of hyponatraemic coma was made. The patient was treated with water restriction; 24 h later the sodium was 135 mmol L(-1) and the patient was neurologically fully recovered. The patient, who suffered from von Willebrand's disease, had received desmopressin and ibuprofen for analgesia 2 days before after a dental intervention. She had received desmopressin several times in the past without any complications. A few patients treated with desmopressin for coagulation abnormalities have been reported to develop water intoxication and severe hyponatraemia resulting in seizures and coma. By inhibiting prostaglandin synthesis, non-steroid anti-inflammatory agents (NSAIDs) potentiate the effect of water reabsorption in the renal tubules of vasopressin, therefore enhancing water retention. Desmopressin and NSAIDs should not be used in combination in patients with bleeding disorders, but it is often followed in clinical practice. In addition, this is probably not an unusual situation in patients treated with desmopressin for other 'non-haemorrhagic' indications. This report emphasizes the need for practitioners to be aware of this rare but severe complication.

Ibuprofen Can Induce Syndrome of Inappropriate Diuresis in Healthy Young Patients

“…NSAIDs can adversely affect the kidney because they can induce sodium retention and antagonize the action of diuretics, impair free-water clearance, and cause hyponatremia [12]. Similar cases have been described in the past, but the patients suffered from chronic diseases such as advanced chronic renal failure [13], von Willebrand's disease [14], or were extremely old (>80 y) [15]. …”

Severe hyponatraemia during therapy with ramipril

“…We hypothesise that the development of hyponatraemia in patients taking ACEIs who are susceptible may be multifactorial. In addition, in the early stages of presentation the patient was treated with non-steroidal anti-inflammatory drugs (NSAIDs), which potentiate the effect of ADH8 and chlorpromazine which is associated with SIADH 9. Combined drug therapy commonly followed in clinical practice, the effect of NSAID, chlorpromazine and ramipril therapy, may have contributed to the development of hyponatraemia.…”

Nacionalna priporočila za obravnavo bolnikov s hemofilijo

“…Hiponatremijo zelo redko povzročijo tudi indometacin in nekatera druga nesteroidna protivnetna zdravila, ker zavirajo sintezo prostaglandinov in tako okrepijo učinek DDAVP na resorpcijo vode v ledvičnih kanalč-kih. Zato odsvetujejo sočasno dajanje DDAVP in nesteroidnih protivnetnih zdravil (83).…”