**5.4 Practice considerations**

*Weight Management*

an additive property on hyponatremia.

authors).

by "increas[ing] water retention" [15]. Notably, the worsened water retention is particularly problematic for patients on desmopressin, and complete resolution of symptoms occurred after desmopressin was tapered and meloxicam stopped, with normalization in plasma sodium [15] (**Figure 1**, used with permission from

Fabrazzo et al. [16] discuss three cases involving delorazepam, olanzapine and fluvoxamine, respectively, in which patients with various presentations of bipolar disorder were hospitalized, and hyponatremia was discovered on admission. Workup revealed SIADH. Multiple interventions were trialed, including administration of hypertonic saline, and decreasing doses of various medications. It was not until the offending medications were removed that patients demonstrated resolution of their hyponatremia. Notably, olanzapine, fluvoxamine and delorazepam were being administered in conjunction with other medications that may have contributed to the hyponatremia. In the case of the patient taking delorazepam, they also were prescribed oxcarbazepine, which ultimately was replaced with gabapentin. In the case of the patient taking olanzapine, he also was taking delorazepam and oxcarbazepine. Likewise, the patient on fluvoxamine was also taking oxcarbazepine. These medications in conjunction with one another appear to have

**5.2 Other medications and interactions implicated in hyponatremia**

**5.3 Additional considerations for antipsychotics and hyponatremia**

Antipsychotic medications alone have been reported in the literature to be associated with hyponatremia; however, recently, the long-acting risperidone injectable treatment has been implicated in hyponatremia as well. In this case, the patient did not improve simply with the removal of risperidone, due to the extended half-life, and ultimately required Tolvaptan administration [17]. The half-life of these medications may be an important factor in determining the management of subsequent hyponatremia. Along a similar vein, Fabrazzo et al. [16] detail that hyponatremia and other electrolyte derangements are often only detected in patients with psychiatric diagnoses when they are hospitalized. This is a critical consideration for clinicians in terms of practice, particularly whether there is an impetus for psychiatrists

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**Figure 1.**

*Plasma sodium levels over time.*

There currently are no routine guidelines for screening of electrolyte abnormalities among patients with psychiatric diagnoses and this should be further evaluated given the range of dangerous consequences of hyponatremia, including seizure, as demonstrated in at least one of the cases delineated above [15].
