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Furosemide/sacubitril/valsartan Dehydration and hyponatraemia: case report

An 82-year-old woman developed dehydration during treatment with furosemide and hyponatraemia during treatment with sacubitril/valsartan [routes not stated]. The woman had a significant history of HFrEF, diabetes mellitus type 2, hypertension, atrial fibrillation, and non-ischaemic cardiomyopathy status post biventricular implantable cardioverter defibrillator. She had been receiving treatment with furosemide 20mg daily, rosuvastatin, warfarin, carvedilol, losartan and aspirin for at least past 2 years with no reports of adverse events. Her baseline sodium concentration ranged from 138–142 mmol/L. For optimisation of heart failure treatment, losartan was stopped and she was initiated with sacubitril/valsartan [Entresto] 24mg/26mg twice daily. She had no complaints on subsequent follow-up. At her 5 month clinic visit, she presented with a chief complaint of fatigue and the inability to completely void her bladder. At that time, dehydration secondary to furosemide was suspected. Therefore, the woman’s furosemide was discontinued. At that time, blood test showed sodium concentration of 139 mmol/L. After 2 weeks of discontinuation of furosemide, she presented to the emergency department disoriented, confused and with swollen ankles. At that time, she was suspected to have developed an episode of acute heart failure exacerbation with secondary dilutional hyponatraemia. Subsequent blood test showed sodium concentration of 126 mmol/L and pro-BNP concentration of 5424 pg/mL. The woman was therefore reinitiated with IV furosemide, while sacubitril/valsartan was switched to valsartan. During her hospitalisation, she received IV furosemide. When she became euvolemic, she was reinitiated on her dose of furosemide. After 2 days of hospitalisation, her sodium concentration returned to baseline. Subsequently, she was discharged. At the time of discharge, treatment with furosemide and valsartan were continued along with her other home medications. After 2 weeks of discharge, at a follow-up appointment, she remained normonatraemic and she had no complaints. Therefore, she was reinitiated with sacubitril/valsartan 24mg/26mg twice daily, while valsartan was discontinued and other chronic medications were continued, including her diuretic therapy. After 2 weeks, at a follow-up appointment, she was found to be clinically stable and euvolemic. However, she exhibited a sodium concentration of 130 mmol/L (hyponatraemia) and a BNP concentration of 7980 pg/mL. Therefore, sacubitril/valsartan therapy discontinued due to suspicion of sacubitril/valsartan-induced hyponatraemia and losartan was initiated. At a subsequent follow-up, normal sodium concentrations (range: 141–143 mmol/L) was noted with no evidence of fluid overload. Fuzaylova I, et al. Sacubitril/Valsartan (Entresto)-Induced Hyponatremia. Journal of Pharmacy Practice 33: 696-699, No. 5, Oct 2020. Available from: URL: http:// doi.org/10.1177/0897190019828915

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