• Thomas E MacMillan, Terence Tang, and Rodrigo B Cavalcanti.
• Division of General Internal Medicine, and HoPingKong Centre for Excellence in Education and Practice, University Health Network, Toronto, ON, Canada. Electronic address: tom.macmillan@uhn.ca.
• Am. J. Med. 2015 Dec 1; 128 (12): 1362.e15-24.

BackgroundHyponatremia is common among inpatients and is associated with severe adverse outcomes such as osmotic demyelination syndrome. Current guidelines recommend serum sodium concentration correction targets of no more than 8 mEq/L per day in patients at high risk of osmotic demyelination syndrome. Desmopressin is recommended to control high rates of serum sodium concentration correction in severe hyponatremia. However, recommendations are based on limited data. The objective of this study is to review current strategies for DDAVP use in severe hyponatremia.MethodsSystematic literature search of 4 databases of peer-reviewed studies was performed and study quality was appraised.ResultsThe literature search identified 17 observational studies with 80 patients. We found 3 strategies for desmopressin administration in hyponatremia: 1) proactive, where desmopressin is administered early based on initial serum sodium concentration; 2) reactive, where desmopressin is administered based on changes in serum sodium concentration or urine output; 3) rescue, where desmopressin is administered after serum sodium correction targets are exceeded or when osmotic demyelination appears imminent. A proactive strategy of desmopressin administration with hypertonic saline was associated with lower incidence of exceeding serum sodium concentration correction targets, although this evidence is derived from a small case series.ConclusionsThree distinct strategies for desmopressin administration are described in the literature. Limitations in study design and sample size prevent definitive conclusions about the optimal strategy for desmopressin administration to correct hyponatremia. There is a pressing need for better quality research to guide clinicians in managing severe hyponatremia.Copyright © 2015 Elsevier Inc. All rights reserved.

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