RETRACTED: Vasopressin Receptor Antagonists for the Correction of Hyponatremia in Chronic Heart Failure: An Underutilized Therapeutic Option in Current Clinical Practice?

Abstract

In the congestive heart failure (CHF) setting, chronic hyponatremia is very common. The present review aims at addressing topics relevant to the pathophysiology of hyponatremia in the course of CHF as well as its optimal treatment, including the main advantages and the limitations resulting from the use of the available dietary and pharmacological measures approved for the treatment of this electrolytic trouble. A narrative review is carried out in order to represent the main modalities of therapy for chronic hyponatremia that frequently complicates CHF. The limits of usual therapies implemented for CHF-related chronic hyponatremia are outlined, while an original analysis of the main advancements achieved with the use of vasopressin receptor antagonists (VRAs) is also executed. The European regulatory restrictions that currently limit the use of VRAs in the management of CHF are substantially caused by financial concerns, i.e., the high costs of VRA therapy. A thoughtful reworking of current restrictions would be warranted in order to enable VRAs to be usefully associated to loop diuretics for decongestive treatment of CHF patients with hyponatremia.

Symptomatic life-threating hyponatremia complicating severe COPD exacerbation, pulmonary edema and pulmonary hypertension-a critical role for conivaptan

“…We have presented in generally great detail, the diagnostic and therapeutic complexities involved in the management of hyponatremia especially when this is complicated by co-existing pulmonary edema, acutely decompensating heart failure and pulmonary hypertension in the context of advanced COPD. We were able to achieve excellent 'diuresis' using the aquaresis-inducing properties of intravenous conivaptan, an ADH antagonist (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11). Notedly, dyspnea, edema and volume overload promptly resolved as confirmed by follow up symptomatic relief, resolution of physical examination findings and improvement evident in the follow up chest radiograph (Figure 1).…”

“…Finally, treatment with intravenous conivaptan facilitated improvement of severe symptomatic hyponatremia in our patient, and simultaneously, the resulting aquaresis led to a rapid and sustained improvement in his dyspnea from pulmonary edema. There is accruing evidence in the literature that the vaptans, intravenous conivaptan and oral tolvaptan, have now earned a place in the therapeutic armamentarium to manage symptomatic acutely decompensating heart failure complicated by severe hyponatremia and volume overload (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11). Subsequently, the administration of loop diuretics appears to be usually well tolerated without necessarily a need for the prolonged use of the vaptans.…”

“…As recently as 2015, there existed conflicting recommendations for the use of vaptans by different expert committees in patients with hyponatremia and this was blamed on limited patient experiences and limited research data (7). Nevertheless, there is now accumulating evidence-base in the literature to strongly support the use of the vaptans in the management of severe symptomatic treatment-resistant hyponatremia especially in association with heart failure, advanced chronic obstructive pulmonary disease (COPD) and/or pulmonary hypertension (6,(8)(9)(10)(11). Vasopressin antagonists block the vasopressin receptors V1 and V2.…”

Diagnosis and Management of Hyponatremia

“…Low potassium levels should be increased. Additional therapeutic options are urea or vaptans . Severe hyponatremia unresponsive to these measures may require limited hypertonic saline administration …”