Liver Cancer Patient With Hypervolemic Hyponatremia

Diagnosis

Hypervolemic hyponatremia in a patient with hepatocellular carcinoma*

Why VAPRISOL was chosen for treatment

MRI of the chest and abdomen showed new metastases in the liver, pleura, pericardium, and spine. The patient’s hyponatremia worsened during the hospital stay, accompanied by signs of mental confusion. Treatment with VAPRISOL was initiated to raise serum sodium in hypervolemic hyponatremia.

Initial Presentation

The patient is a 69-year-old white female admitted to the hospital for evaluation of dyspnea and right-sided pleural effusion. At admission, the patient was mildly hyponatremic, with a serum sodium of 130 mEq/L and a serum creatinine of 0.9 mg/dL.†

Medical History

Hepatocellular carcinoma unrelated to cirrhosis
Diabetes
Hyperlipidemia
Heart failure
Transient ischemic attack

Medications

Aspirin
Clopidogrel
Atorvastatin
Insulin
Telmisartan
Carvedilol

Exam Findings

Vital Signs	BP: 119/69 mm Hg, HR: 82 bpm, temperature: 99° F, RR: 18
Mental Status	Oriented to person, place, and time
Lungs	Diminished sounds on the right side
EKG	Normal sinus rhythm with left-axis deviation and borderline low voltage
X-ray	Prominent hilar lymph nodes, small pleural effusion noted on the right side
Other	1+ pedal edema, evidence of jugular venous distension
Labs	Albumin, INR, and bilirubin all within normal limits

Patient’s progression from admission through follow-up at day 4

	VITAL SIGNS			LAB VALUES
	BP (mm Hg)	HR (bpm)	Weight (lb)	Urine Output (cc)	Urine Osmolality (mOsm/kg-H₂₀)	Urine Na+ (mEq/L)	Serum Na+ (mEq/L)	NOTES
Upon Admission	119/69	82	165	—	625	55	130	Patient started on fluid restriction 1 L/day
Day 1	120/50	80	—	1100	—	—	122	A loading dose of VAPRISOL 20-mg IV was administered over 30 minutes followed by a 20-mg continuous infusion administered over 24 hours
Day 2	110/70	76	163	2500	153	5	128	VAPRISOL 20-mg IV continuous infusion administered over 24 hours
Day 3	136/68	74	162	1700	103	7	134	VAPRISOL 20-mg IV continuous infusion administered over 24 hours
Day 4	110/68	74	—	1100	—	—	136	VAPRISOL discontinued

*In patients with moderate to severe hepatic impairment, initiate VAPRISOL with a loading dose of 10 mg over 30 minutes followed by 10 mg/day as a continuous infusion for 2 to 4 days. If no rise in serum sodium, VAPRISOL may be titrated upward to 20 mg/day.

†In clinical studies of VAPRISOL, the adverse event profile in elderly patients was similar to that seen in the general population.¹

REFERENCE: 1. Vaprisol^® [Package Insert] Cumberland Pharmaceuticals Inc. Nashville, TN 2016

View Full Prescribing Information

Indication: VAPRISOL is indicated to raise serum sodium in hospitalized patients with euvolemic and hypervolemic hyponatremia.
Important Limitations: VAPRISOL has not been shown to be effective for the treatment of the signs and symptoms of heart failure and is not approved for this indication. It has not been established that raising serum sodium with VAPRISOL provides a symptomatic benefit to patients.

IMPORTANT SAFETY INFORMATION

CONTRAINDICATIONS
VAPRISOL is contraindicated in patients with hypovolemic hyponatremia. The coadministration of VAPRISOL with potent CYP3A inhibitors, such as ketoconazole, itraconazole, clarithromycin, ritonavir, and indinavir, is contraindicated. In addition, no benefit can be expected in patients unable to make urine.

WARNINGS & PRECAUTIONS
Hyponatremia associated with heart failure: Safety data on the use of VAPRISOL in these patients are limited. Consider other treatment options.
Overly rapid correction of serum sodium: Monitor serum sodium, volume and neurologic status and if the patient develops an undesirably rapid rate of rise of serum, VAPRISOL should be discontinued. If serum sodium concentration continues to rise, VAPRISOL should not be resumed. Serious neurologic sequelae, including osmotic demyelination syndrome, can result from over rapid correction of serum sodium. In susceptible patients, including those with severe malnutrition, alcoholism or advanced liver disease, slower rates of correction should be used.
Hypovolemia or Hypotension: For patients who develop hypovolemia or hypotension while receiving VAPRISOL, VAPRISOL should be discontinued, and volume status and vital signs should be monitored.
Infusion site reactions: Serious reactions have occurred. Administer through large veins and change infusion site every 24 hours.

ADVERSE REACTIONS
The most common adverse reactions (incidence ≥10%) reported in clinical trials were infusion site reactions (including phlebitis), pyrexia, hypokalemia, headache and orthostatic hypotension.

DRUG INTERACTIONS
Potent CYP3A inhibitors may increase the exposure of conivaptan and are contraindicated. Generally avoid CYP3A substrates. Exposure to coadministered digoxin may be increased and digoxin levels should be monitored.

USE IN SPECIAL POPULATIONS
Use in Patients with Hepatic Impairment
In patients with moderate to severe hepatic impairment, initiate VAPRISOL with a loading dose of 10 mg over 30 minutes followed by 10 mg/day as a continuous infusion for 2 to 4 days. If no rise in serum sodium, VAPRISOL may be titrated upward to 20 mg/day.