Guidelines Introduced for the Management of Hyponatremia Secondary to Physical Activity

By Jessica Pyhtila, PharmD, BCGP, BCPS

The journal Wilderness & Environmental Medicine recently published a set of clinical practice guidelines from the Wilderness Medical Society about the management of exercise-associated hyponatremia, or EAH. This medical condition is characterized by a serum sodium level of less than 135 mmol/L that occurs up to 24 hours after physical activity.

The guidelines note that many kinds of prolonged physical activities have been linked to EAH, including in marathon runners, hikers, and climbers, and that it can occur in all climates. However, only a minority of EAH sufferers are symptomatic, with most cases being asymptomatic incidental findings. One study cited in the guidelines noted a rate of asymptomatic EAH as high as 51% in some marathon runners.

The authors state that the majority of EAH cases appear to be due to overingestion of hypotonic fluids like water and sports drinks. This may occur in combination with stimulation of antidiuretic hormone, which makes the body conserve water. Often, the patient drinks fluids in excess of their sweat and urine losses. In addition, antidiuretic hormone may be stimulated by nonspecific stresses, vomiting, hypoglycemia, heat or medications like NSAIDs or SSRIs. As a result, the guidelines recommend that sustained overhydration be avoided. Instead, the authors recommend that fluid intake be guided by thirst, unless there is a rapid and excessive fluid loss. Further, the guidelines state that salty snacks like crackers be available. However, the authors note that salty snacks will not help prevent EAH if the patient continues to overdrink.

The authors state that EAH can be mild or severe, with the main distinction being neurologic manifestations like altered mental status that occur in severe EAH. Importantly, the guidelines note that misdiagnosis of EAH is common, with the condition often misdiagnosed as heat exhaustion or exertional heat stroke. This is clinically important because the treatment strategies for heat exhaustion are the opposite of what treatment should be for EAH, namely fluid repletion in heat exhaustion versus fluid restriction in EAH. In addition, salty snacks and hypertonic solutions should be offered if tolerated in mild EAH. Severe EAH requires hospitalization, and the guidelines recommend that receiving caregivers be alerted to any suspected diagnosis of EAH so that appropriate fluid management, namely the withholding of hypotonic solutions, can be planned.

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