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Diagnosis and Treatment > Medication

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Ruben H Willemsen Department of Paediatric Endocrinology, University of Cambridge, Cambridge, UK

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Violeta Delgado-Carballar Department of Paediatric Endocrinology, University of Cambridge, Cambridge, UK

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Daniela Elleri Department of Paediatric Endocrinology, University of Cambridge, Cambridge, UK

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Ajay Thankamony Department of Paediatric Endocrinology, University of Cambridge, Cambridge, UK

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G A Amos Burke Department of Paediatric Haematology and Oncology, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK

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James C Nicholson Department of Paediatric Haematology and Oncology, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK

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David B Dunger Department of Paediatric Endocrinology, University of Cambridge, Cambridge, UK

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Summary

An 11-year-old boy developed severe syndrome of inappropriate antidiuretic hormone secretion (SIADH) after diagnosis of an intracranial B-cell lymphoma. His sodium levels dropped to 118–120 mmol/L despite 70% fluid restriction. For chemotherapy, he required hyperhydration, which posed a challenge because of severe hyponatraemia. Tolvaptan is an oral, highly selective arginine vasopressin V2-receptor antagonist, which has been licensed in adults for the management of SIADH and has been used in treating paediatric heart failure. Tolvaptan gradually increased sodium levels and allowed liberalisation of fluid intake and hyperhydration. Tolvaptan had profound effects on urinary output in our patient with increases up to 8 mL/kg/h and required close monitoring of fluid balance, frequent sodium measurements and adjustments to intake. After hyperhydration, tolvaptan was stopped, and the lymphoma went into remission with reversal of SIADH. We report one of the first uses of tolvaptan in a child with SIADH, and it was an effective and safe treatment to manage severe SIADH when fluid restriction was not possible or effective. However, meticulous monitoring of fluid balance and sodium levels and adjustments of fluid intake are required to prevent rapid sodium changes.

Learning points:

  • Tolvaptan can be used in paediatric patients with SIADH to allow hyperhydration during chemotherapy.

  • Tolvaptan has profound effects on urinary output and meticulous monitoring of fluid balance and sodium 
levels is therefore warranted.

  • Tolvaptan was well tolerated without significant side effects.

Taxonomy:
Clinical Overview, Gland/Organ, Hypothalamus, Pituitary, Topic, Tumours and neoplasia, Hormone, AVP, Thyroxine (T4), TSH, Condition/ Syndrome, Non-Hodgkin lymphoma, SIADH, Patient Demographics, Age, Paediatric, Gender, Male, Ethnicity, Asian - Filipino, White, Country of Treatment, United Kingdom, Diagnosis and Treatment, Signs and Symptoms, Collapse, Headache, Hyponatraemia, Nausea, Rash, Vomiting, Investigation, Biopsy, Cortisol, Creatinine, CT scan, FT4, GH, MRI, Plasma osmolality, Sodium, TSH, Urea and electrolytes, Uric acid (blood), Urine 24-hour volume, Urine osmolality, Intervention, Fluid repletion, Fluid restriction, Medication, AVP receptor antagonists, Dexamethasone, Levothyroxine, Tolvaptan, Vaptans, Related Disciplines, Oncology, Paediatrics, Publication Details, Case Report Type, Novel treatment
DOI:
https://doi.org/10.1530/EDM-16-0066
Volume/Issue:
Volume 2016: Issue 1
Open access