Trileptal & Salt Tablets
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Q:  Trileptal & Salt Tablets

My 23 yr old daughter has been on Trileptal for about a year after 4 yrs on Depakote. The Depakote was stopped because of weight gain, tiredness, hormonal problems and basic brain fog. The Trileptal works very well as far as stabilization, clear brain, and happy girl. Unfortunately, it causes major sodium depletion, so she is taking 10-15 salt tablets to offset this. Is this safe to do?
Thank you.

Dear Dianne -- 
First, I'd want to know if the "sodium depletion" (technically called hyponatremia, as below) was causing problems in some way.   Here's an article which shows how common this kind of problem is, and how few of those who had it also had symptoms

Neuropediatrics. 2002 Dec;33(6):298-300.  

Oxcarbazepine-induced hyponatremia and the regulation of serum sodium after replacing carbamazepine with oxcarbazepine in children.

Holtmann M, Krause M, Opp J, Tokarzewski M, Korn-Merker E, Boenigk HE.

Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Mannheim, Germany.

While severe hyponatremia is reported to be more frequent in adults treated with oxcarbazepine (OXC) than with carbamazepine (CBZ), there is not sufficient data about the incidence of hyponatremia in childhood during treatment with OXC. We evaluated changes in serum electrolyte balance in 75 children with epilepsy before and during treatment with OXC and after replacing carbamazepine (CBZ) therapy with OXC therapy. All patients had normal sodium serum levels at the onset of OXC. During treatment with OXC we found hyponatremia (Na +< 135 mmol/l) without clinical symptoms in 26.6 % of the children (n = 20), sodium levels below 125 mmol/l were observed in 2 children (2.6 %). Clinically relevant hyponatremia occurred in one girl only (1.3 %). In a subgroup of 27 children, in whom CBZ was directly replaced with OXC, hyponatremia without symptoms was found in one child under CBZ (3.7 %) and in six children under OXC (22.2 %). Dosage of OXC, serum levels of the active metabolite of OXC, antiepileptic comedication or patients' age and gender were of no predictive value for the development of hyponatremia. Electrolytes should be measured before establishing OXC and if clinically relevant side effects occur.

The forest you're supposed to be able to see from all those trees is this:  only one girl ("1.3%) in the sample had "clinically relevant hyponatremia" -- meaning, it was causing some sort of symptoms -- even though a quarter of the kids had low sodium by lab values. 

So, the first question is, does your daughter have symptoms?  If the answer was no, then trying to fix the lab value may not be necessary, although as you would surely worry, we don't really know about the long-term health consequences of running around for years with a low serum sodium.  I suppose there could be some risk there, not based on any known physiology, but just on the fact that serum sodium is one of the "oldest" regulated variables in animals since we came out of the sea (which we surely really did, bible-thumpers notwithstanding, because the physiology is just so explicable that way and hard to understand otherwise).  

The second is, I suppose, are there long-term health consequences to having to take all those salt pills?  There is one other way to raise serum sodium, which is the one we use on inpatient units when we see this kind of hyponatremia, and that's "fluid restriction".  Basically the poor girl would have to go around thirsty most of the time, but that is a pretty sure way to raise serum sodium, and might (you might have to ask an internal medicine doc' about this, or just perform the test yourselves) be a more effective way to raise sodium than "oral administration" (the tablets).  Assuming there, of course, that it had been decided that raising serum sodium was a necessary thing.  

I can understand wanting to hang on to this agent in light of the "happy girl" result.  As I'm sure you've thought through, at some point the gyrations required to stay on it might suggest moving on to a trial of something else, hoping for similar benefit without the hassle.  Good luck with the process. 

Dr. Phelps

Published January, 2005


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