Li Tian, Li Gui-Shuang
Qilu Hospital of Shandong University, Jinan.
Department of Cardiology, Jining No. 1 People's Hospital, Jining, Shandong Province, China.
Medicine (Baltimore). 2019 Jul;98(27):e16229. doi: 10.1097/MD.0000000000016229.
Tolvaptan (TLV) is a selective vasopressin type 2 receptor antagonist, which has an active effect on patients with congestive heart failure especially combined with hyponatremia. Increasingly, evidence has demonstrated that low-dose tolvaptan can dramatically relieve patients' dyspnea and the dose would not cause severe electrolyte abnormalities. Even hypernatremia is a major adverse effect of tolvaptan, treatment with tolvaptan shows good security and is well-tolerated. Few cases have reported that patients who developed severe hypernatremia induced by low-dose Tolvaptan.
A 68-year-old man was admitted to our hospital with dyspea and general fatigue. He was diagnosed with acute decompensated heart failure due to ischemic cardiomyopathy. In order to improve fluid retention and relieve his dyspnea, low-dose TLV (7.5 mg qd) was performed. After the 3-day treatment using TLV, we observed that he became delirious and his limbs shook uncontrollably. High serum sodium 173 mmol/L was noted compared to the results of the first examination (137 mmol/L). After intensive rescue, serum sodium was restored to normal (135 mol/L). Later, when the patient refused continuous renal replacement therapy (CRRT), we tried again to use a lower dose of TLV to improve diuretic resistance. Two days later, Serum sodium rose again (162 mmol/L).
During the course of therapy, we did not strictly require the patient to control the fluid intake. No other medication could cause elevation of serum sodium. Therefore, we suspected a high sensitivity to the side effect of TLV.
Stop the use of TLV and encourage the patient to drink plenty of water. Gastric tube was inserted orally to increase the intake of fresh water.
His serum sodium decreased gradually and his psychiatric symptom recovered. During this period, Overall condition of the patient was stable. After being discharged from the hospital, the patient eventually died of cardiac arrest due to critically ill heart failure.
Hypernatremia is a severe side effect of TLV. For critical patients, TLV should be used at a low dose and electrolyte should be detected in time.
托伐普坦（TLV）是一种选择性血管加压素2型受体拮抗剂，对充血性心力衰竭尤其是合并低钠血症的患者有积极作用。越来越多的证据表明，低剂量托伐普坦可显著缓解患者的呼吸困难，且该剂量不会导致严重的电解质异常。即使高钠血症是托伐普坦的主要不良反应，但使用托伐普坦治疗显示出良好的安全性且耐受性良好。很少有病例报道低剂量托伐普坦导致严重高钠血症。
一名68岁男性因呼吸困难和全身乏力入院。他被诊断为缺血性心肌病所致急性失代偿性心力衰竭。为改善液体潴留并缓解其呼吸困难，给予低剂量托伐普坦（7.5毫克，每日一次）治疗。使用托伐普坦治疗3天后，我们观察到他出现谵妄，四肢 uncontrollably 颤抖。与首次检查结果（137毫摩尔/升）相比，血清钠高达173毫摩尔/升。经过积极抢救，血清钠恢复正常（135毫摩尔/升）。后来，当患者拒绝持续肾脏替代治疗（CRRT）时，我们再次尝试使用更低剂量的托伐普坦来改善利尿抵抗。两天后，血清钠再次升高（162毫摩尔/升）。
在治疗过程中，我们未严格要求患者控制液体摄入量。没有其他药物可导致血清钠升高。因此，我们怀疑患者对托伐普坦的副作用高度敏感。
停用托伐普坦，鼓励患者大量饮水。经口插入胃管以增加淡水摄入量。
他的血清钠逐渐下降，精神症状恢复。在此期间，患者总体状况稳定。出院后，患者最终因重症心力衰竭心脏骤停死亡。
高钠血症是托伐普坦的严重副作用。对于重症患者，应低剂量使用托伐普坦并及时检测电解质。
