Title: Risk of Overcorrection in Rapid Intermittent Bolus vs Slow Continuous Infusion Therapies of Hypertonic Saline for Patients With Symptomatic Hyponatremia: The SALSA Randomized Clinical Trial<br/>Author: Caleb Chan<br/><a href='http://umem.org/profiles/resident/1583/'>[Click to email author]</a><hr/><div style="margin: 0px; padding: 0px; border: 0px; font-variant-numeric: inherit; font-variant-east-asian: inherit; font-stretch: inherit; font-size: 12pt; line-height: inherit; font-family: Calibri, Arial, Helvetica, sans-serif; vertical-align: baseline; color: rgb(0, 0, 0);">
<b><u>Significance: </u></b></div>
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There have been few high-quality studies regarding s<span style="margin: 0px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; color: inherit;">low continuous infusion (SCI) of hypertonic vs. rapid intermittent bolus (RIB) therapy for patients with symptomatic hyponatremia</span></div>
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<b><u>Study Design:</u></b></div>
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Multicenter, open-label RCT with 178 patients (both ED and inpatient) with corrected Na of 125 mml/L or lower with moderate/severe symptoms</div>
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-Moderate symptoms: nausea, headache, drowsiness, general weakness, and malaise</div>
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-Severe symptoms: vomiting, stupor, seizure, and coma (Glasgow Coma Scale [GCS] score ≤8)</div>
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Relevant excluded patient populations: liver disease/cirrhotics, uncontrolled diabetics, primary polydypsia, anuric, hypotensive</div>
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<b><u>Intervention:</u></b></div>
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<span style="margin: 0px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; color: inherit;">Slow continuous infusion (SCI) of hypertonic vs. Rapid intermittent bolus (RIB) therapy<span style="margin: 0px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; color: inherit;"> </span></span></div>
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(see treatment algorithms for specifics)</div>
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<b><u>Results:</u></b></div>
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<b>Primary outcome: </b><span style="margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; font-size: 12pt; line-height: inherit; vertical-align: baseline;">No difference in rates of overcorrection </span></div>
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15 of 87 (17.2%) patients in the RIB group vs. 22 of 91 (24.2%) patients in the SCI group </div>
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-(absolute risk difference, −6.9% [95% CI, −18.8% to 4.9%]; P = .26)</div>
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<b>Other outcomes:</b></div>
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<span style="margin: 0px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; color: inherit;">RIB group showed a lower incidence of relowering treatment than the SCI group </span></div>
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<span style="margin: 0px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; color: inherit;">-(absolute risk difference, −15.8% [95% CI, −30.3% to −1.3%]; P = .04; NNT, 6.3)</span></div>
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<span style="margin: 0px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; color: inherit;">RIB group had higher proportion of patients achieving target correction rate within 1 hour than the SCI group </span></div>
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<span style="margin: 0px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; color: inherit;">-(absolute risk difference, 14.6% [95% CI, 2%-27.2%]; P = .02; NNT, 6.8)</span></div>
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No significant differences between the groups were observed in:</div>
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- symptoms at 24 and 48 hours after treatment initiation</div>
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- first time to an increase in sNa 5 mmol/L or greater after treatment initiation</div>
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- incidence of target correction rate</div>
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- time from treatment initiation to achievement of sNa greater than 130 mmol/L</div>
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- length of hospital stay </div>
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There were no cases of osmotic demyelination syndrome in either group</div>
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<b><u>Take-home point:</u></b></div>
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Rapid intermittent boluses of hypertonic saline may be just as effective as slow continuous infusions for certain patient populations with moderate/severe symptomatic hyponatremia (and may actually have decreased rates of need for re-lowering treatment)</div>
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<b><u>Limitations:</u></b></div>
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-smaller study</div>
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-high number of dropout due to protocol violation</div>
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-remember that ODS is multifactorial (liver disease, chronic alcoholism, malnutrition)</div>
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<fieldset><legend>References</legend>
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<span background-color:="" font-size:="" helvetica="" open="" segoe="" style="font-family: HelveticaNeue, ">Baek SH, Jo YH, Ahn S, et al. Risk of overcorrection in rapid intermittent bolus vs slow continuous infusion therapies of hypertonic saline for patients with symptomatic hyponatremia: the salsa randomized clinical trial. </span><i background-color:="" font-size:="" helvetica="" open="" segoe="" style="box-sizing: content-box; font-family: HelveticaNeue, ">JAMA Intern Med</i><span background-color:="" font-size:="" helvetica="" open="" segoe="" style="font-family: HelveticaNeue, ">. Published online October 26, 2020.</span></p>
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