OBJECT DRUGS

• Thiazide Diuretics

PRECIPITANT DRUGS

SSRI and SNRI:

• Citalopram (Celexa)
• Clomipramine (Anafranil)
• Desvenlafaxine (Pristiq, etc.)
• Duloxetine (Cymbalta)
• Escitalopram (Lexapro)
• Fluoxetine (Prozac, etc.)
• Fluvoxamine (Luvox, etc.)
• Imipramine (Tofranil, etc.)
• Levomilnacipran (Fetzima)
• Milnacipran (Savella)
• Paroxetine (Paxil, etc.)
• Sertraline (Zoloft)
• Venlafaxine (Effexor)
• Vilazodone (Viibryd)
• Vortioxetine (Brintellix)

Comment:

Selective serotonin reuptake inhibitors (SSRI) and selective serotonin/norepinephrine reuptake inhibitors (SNRI) have been reported to cause syndrome of inappropriate antidiuretic hormone (SIADH) with hyponatremia. Thiazide diuretics increase sodium excretion, and can have additive hyponatremic effects.

Class 3: Assess Risk & Take Action if Necessary

• Consider Alternative: Avoid the use of these drugs in patients receiving thioridazine.
• Use Alternative:
• Antidepressants: Some evidence suggests that mirtazapine (Remeron) is less likely to cause hyponatremia, but more evidence is needed.
• Monitor: Monitor for symptoms of hyponatremia: confusion, disorientation, nausea, headache, weakness, fatigue, muscle cramps. If the hyponatremia is severe, it can lead to seizures, coma and death. In predisposed patients such as elderly women it may be prudent to measure baseline serum sodium and again a week or so after the second drug was started. Hyponatremia usually occurs within 2 to 3 weeks of starting therapy of adding the second drug.