Hyponatremia hit the headlines with the publication of data on the prevalence of the condition in Ironman finishers. Scarily, over 10% of athletes tested had hyponatremia! But what is this potentially race-ruining condition and how can it be avoided?

What is hyponatremia?

Hyponatremia is a medical term describing low (hypo) blood sodium levels (natremia – Na is the chemical symbol for sodium). There are a few different causes of the condition, but the one of interest to athletes is when dilution of sodium levels in the blood is driven by excessive drinking. This can be exacerbated by the loss of sodium in sweat during prolonged exercise. This variant of the condition is known as ‘Exercise Associated Hyponatremia’, or EAH.

The symptoms of hyponatremia

Maintaining blood sodium levels within a healthy range (135-145mmols per litre) is critical to homeostasis and optimal bodily function. When blood sodium levels drop below this ideal range initial symptoms can include:

  • Nausea
  • Lethargy
  • Muscle cramps
  • Weakness/fatigue
  • Headaches
  • Restlessness

Because of how finely balanced your blood sodium levels need to be for good health, even mild hyponatremia during exercise is bad news. It can seriously undermine your performance well before it starts to make you properly ill. In severe cases of hyponatremia, the symptoms can potentially escalate into seizures and coma. The end result can even be death, if things go uncorrected for long enough. This is because, in order to try to preserve sodium concentrations in the blood, the body shifts excess fluid it can’t otherwise excrete from the blood plasma into it’s own cells, causing them to swell up. This swelling is devastating when it occurs in brain cells and is what leads to the condition becoming fatal. About 14 deaths, including one at Ironman Frankfurt in 2015, have been directly attributed to hyponatremia during sporting events since 1981. However, as the results from the recent Ironman study show, the occurrence of non-fatal EAH is likely to be a lot higher.

What causes hyponatremia?

As already alluded to, for athletes the primary cause of hyponatremia is the over-consumption of fluids (especially drinks low in sodium). A popular theory has emerged that the prevalence of over-drinking (and therefore hyponatremia) has increased in recent decades because the pitfalls of dehydration have been so effectively publicised since the 1980s that most athletes believe that they need to drink well before they feel thirsty, and that a ‘more is better’ approach applies to hydration. In my conversations with athletes I do see many of them drinking very large amounts routinely in an attempt to make sure their pee is ‘clear’ all of the time, as they see this as a primary indicator of being ‘well hydrated’. And that applies right up to the pro level. So, I would say that there’s still widespread lack of appreciation of the fact that too much fluid intake can be as detrimental for health and performance as too little. But this is slowly starting to change with more publicity about hyponatremia in the non-scientific press as sports like triathlon have become more popular. Many experts also feel that the very large sodium losses in sweat seen in some individuals — as a result of high sweat rates over long periods of time and/or the very high sweat sodium concentrations — can contribute to increased susceptibility to developing hyponatremia. And I agree with that. There are quite a lot of interesting case studies that back this up, both in healthy people with high sweat/sodium losses and those with Cystic Fibrosis, who’s genetic disorder causes them to lose lots of sodium in their sweat. However, it’s also fair to say that this area is the subject of ongoing debate.

How can you avoid hyponatremia?

In theory, avoiding hyponatremia is pretty straightforward, you just have to avoid drinking more than you sweat and pee out, so that dilution of your blood does not occur. For quite a while some experts (notably Prof Tim Noakes, with many others following his lead) have been advocating a ‘drink water to thirst’ approach for this very reason. When healthy people drink water purely to the dictates of thirst during exercise, it has been demonstrated time and again that they don’t tend to take in more than they sweat out and, as a result, become gradually dehydrated, making hyponatremia all but impossible. This strategy is often backed up with evidence to support the fact that that mild dehydration does not necessarily negatively impact performance. That’s almost certainly true to a degree and if you’re keen to dive deeper into that topic you can read my thoughts here But this approach leaves athletes to train for and compete in any event, of any length or intensity, and in all conditions, with nothing more than this relatively vague statement to guide their hydration strategy. It also ignores the valuable contribution of supplementing fluid intake with additional sodium to help aid fluid retention, maintain blood sodium levels and replace some of that lost in sweat. At a certain point the usefulness of ‘drink to thirst’ guidelines effectively ends. And that point is probably when you’re exercising for more than 2 hours, assuming you began well hydrated (for advice on how to do that, this blog is worth a read).

Should I just drink to thirst to avoid hyponatremia?

If avoiding hyponatremia is your one and only objective, then drinking to thirst is probably ok advice to follow. But, in my view, it starts to get more complicated when you consider that most athletes want to perform at their best, not just ‘survive’ a race. Yes, dehydration has historically been over emphasised, but it can, beyond a certain point, still cause massive performance issues primarily because it manifests itself in reduced blood volume and increased blood viscosity (thickness), both of which impair cardiovascular function and heat dissipation. Anyone who has become dehydrated and tried to exercise effectively will know this only too well! The negative effects of dehydration are especially relevant in events that are very long and hot (such as Ironman races and ultra marathons) and for athletes who’re training hard and sweating a lot on back to back days. That’s because, in these scenarios, the volume of sweat and sodium losses can be quite dramatic. Simply drinking water ‘to thirst’ on these occasions is not always adequate to maintain blood plasma volumes to a degree that’s compatible with peak performance. It’s a lot more productive to think of dehydration as existing on the opposite end of the scale to hyponatremia, and to aim to strike a balance between these two extremes.

The role of sodium in avoiding hyponatremia

It’s long been known that taking sodium in with drinks increases fluid retention in the blood stream. Also, sweat contains a relatively large (and variable) amount of sodium in it so, when sweat output is high, the net loss of sodium can be substantial too. Sodium is a finite resource in the body and, as a result, supplementation can help to maintain both blood volume and blood sodium levels much better than drinking water alone, especially at times when sweat losses are high. Sodium also helps reduce the rate of dilution in the bloodstream when compared to just taking in water alone. This was shown very neatly in a 2015 study where triathletes were given either extra sodium supplements or a placebo pill to take alongside regular sports drinks during a middle distance race in hot weather. The ‘extra sodium’ group replaced around 71% of their sodium losses during the event, with the ‘placebo’ group only replacing about 20%. The results showed better maintenance of blood volume, higher blood sodium levels post-race and faster finishing times in the sodium group than in those taking the placebo.

Personalising your sodium intake

Where I would go one step further with this argument is in the idea of personalising your sodium supplementation to take into account your personal fluid and sodium losses. The amount of sodium you lose in your sweat can vary massively from athlete to athlete and sweat rates can also vary dramatically. We’ve tested athletes who lose an estimated 40 grams of sodium in the course of a single ten hour Ironman, compared with others who lose just 3 grams during the same period. The idea that a single strategy for fluids and sodium supplementation could work equally well for both of these athletes makes no sense at all. You can start to understand your individual electrolyte needs by taking our free online Fuel & Hydration Planner or you can find out exactly how much sodium you lose in your sweat by taking our Sweat Test. Whilst sodium supplementation should not be seen as a way to compensate for over-drinking to avoid hyponatremia, it can be extremely useful in helping to maintain hydration levels at times when your sweat losses are high. It helps by increasing the retention of fluid in your bloodstream and maintaining your blood sodium levels. So, personalising your sodium and fluid intake not only reduces the risk of hyponatremia, but maximise your performance when sweat losses are high. Personalisation is best achieved through a combination of data collection (taking a Sweat Test) and some good ol’ fashioned trial and error in training and events.

Further Reading

  • Should you really just ‘drink water to thirst’?
  • High sweat sodium losses can aid the development of hyponatremia
  • Severe hyponatremia and altitude sickness put this athlete in a coma
  • Why sodium is crucial to athletes performing at their best

What is hyponatremia?

Hyponatremia means that the sodium level in the blood is below normal. Your body needs sodium for fluid balance, blood pressure control, as well as the nerves and muscles. The normal blood sodium level is 135 to 145 milliequivalents/liter (mEq/L). Hyponatremia occurs when your blood sodium level goes below 135 mEq/L. When the sodium level in your blood is too low, extra water goes into your cells and makes them swell. This swelling can be dangerous especially in the brain, since the brain cannot expand past the skull.

What causes hyponatremia?

A low sodium level in your blood may be caused by too much water or fluid in the body. This «watering down» effect makes the amount of sodium seem low. Low blood sodium can also be due to losing sodium from the body or losing both sodium and fluid from the body. Hyponatremia can be the result of illnesses and medications. Some causes that may be related to kidney disease include:

  • Kidney failure — the kidneys cannot get rid of extra fluid from the body
  • Congestive heart failure — excess fluid builds up in the body
  • Diuretics (water pills) — makes the body get rid of more sodium in the urine
  • Antidepressants and pain medication — may cause more sweating or urinating than normal
  • Severe vomiting or diarrhea — the body loses a lot of fluid and sodium
  • Excessive thirst (primary polydipsia) — causes too much fluid intake

What are the symptoms of hyponatremia?

There may be no symptoms if you have mild hyponatremia. You may have symptoms when the level of sodium in your blood goes too low or drops too fast. In severe cases, you may have one or more of the following:

  • Nausea or vomiting.
  • Headache, confusion, or fatigue
  • Low blood pressure
  • Loss of energy
  • Muscle weakness, twitching, or cramps
  • Seizures or coma
  • Restlessness or bad temper

How do you treat hyponatremia?

Treatment is based on the cause and the seriousness of your hyponatremia. You may have to cut back on the amount of liquids you drink if you have extra water in your body. Your healthcare provider may also adjust your diuretic (water pill) use to raise the level of blood sodium. You may also need one or more of the following:

  • Intravenous (IV) fluid — Sodium solutions may be given through your vein to increase the amount of sodium in your blood. This is usually done in the hospital.
  • Sodium retaining medicines: These medicines help your kidneys get rid of large amounts of urine. This makes the extra water leave your body and keeps the sodium inside your body.
  • Dialysis: If your kidneys are not working well you may need to have dialysis to decrease the extra water in your body.

If you would like more information, please contact us. © 2015 National Kidney Foundation. All rights reserved. This material does not constitute medical advice. It is intended for informational purposes only. Please consult a physician for specific treatment recommendations. Last Reviewed: 08/11/2022 In hyponatremia, the level of sodium in blood is too low.

  • A low sodium level has many causes, including consumption of too many fluids, kidney failure, heart failure, cirrhosis, and use of diuretics.
  • Symptoms result from brain dysfunction.
  • At first, people become sluggish and confused, and if hyponatremia worsens, they may have muscle twitches and seizures and become progressively unresponsive.
  • The diagnosis is based on blood tests to measure the sodium level.
  • Restricting fluids and stopping use of diuretics can help, but severe hyponatremia is an emergency requiring use of drugs, intravenous fluids, or both.

Certain conditions may cause people to drink too much water (polydipsia), which can contribute to the development of hyponatremia. Thiazide diuretics (sometimes called water pills) are a common cause of hyponatremia. These drugs increase sodium excretion, which increases water excretion. Thiazide diuretics are usually well-tolerated but can cause hyponatremia in people prone to low sodium, particularly the elderly. Vasopressin (also called antidiuretic hormone) is a substance naturally produced in the body that helps regulate the amount of water in the body by controlling how much water is excreted by the kidneys. Vasopressin decreases water excretion by the kidneys, which retains more water in the body and dilutes the sodium. The pituitary gland produces and releases vasopressin when the blood volume (amount of fluid in the blood vessels) or blood pressure goes down or when levels of electrolytes (such as sodium) become too high. Pain, stress, exercise, a low blood sugar level, and certain disorders of the heart, thyroid gland, kidneys, or adrenal glands can stimulate the release of vasopressin from the pituitary gland. The following are some of the drugs that stimulate the release of vasopressin or enhance its action at the kidney:

  • Antipsychotic and antidepressant drugs
  • Aspirin, ibuprofen, and many other nonprescription pain relievers (analgesics)
  • Carbamazepine (an anticonvulsant)
  • Chlorpropamide (which lowers the blood sugar level)
  • Clofibrate (which lowers cholesterol levels)
  • Ecstasy (3,4-methylenedioxymethamphetamine [MDMA])
  • Oxytocin (used to induce labor)
  • Vasopressin (synthetic antidiuretic hormone)
  • Vincristine (a chemotherapy drug)

Other causes of hyponatremia include

  • Blockage of the small intestine
  • Burns, if severe
  • Consumption of too much water, as occurs in some mental disorders
  • Diarrhea
  • Drugs such as barbiturates, carbamazepine, chlorpropamide, clofibrate, diuretics (most common), opioids, tolbutamide, and vincristine
  • Kidney disorders
  • Vomiting

The brain is particularly sensitive to changes in the sodium level in blood. Therefore, symptoms of brain dysfunction, such as sluggishness (lethargy) and confusion, occur first. If the sodium level in blood falls quickly, symptoms tend to develop rapidly and be more severe. Older people are more likely to have severe symptoms. As hyponatremia becomes more severe, muscle twitching and seizures may occur. People may become unresponsive, aroused only by vigorous stimulation (stupor), and eventually cannot be aroused (coma). Death may follow.

  • Measurement of sodium level in the blood

Hyponatremia is diagnosed by measuring the sodium level in blood. Determining the cause is more complex. Doctors consider the person’s circumstances, including other disorders present and drugs taken. Blood and urine tests are done to evaluate the amount of fluid in the body, the concentration of blood, and content of urine.

  • Restricting fluid intake

Mild hyponatremia can be treated by restricting fluid intake to less than 1 quart (about 1 liter) per day. If a diuretic or other drug is the cause, the dose is reduced or the drug is stopped. If the cause is a disorder, it is treated. Occasionally, people are given a sodium solution intravenously, a diuretic to increase excretion of fluid, or both, usually slowly, over several days. These treatments can correct the sodium level. Severe hyponatremia is an emergency. To treat it, doctors slowly increase the level of sodium in the blood with intravenous fluids and sometimes with a diuretic. Newer drugs, called vaptans, are sometimes needed. Increasing the sodium level too rapidly can result in severe and often permanent brain damage.
NOTE:
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Overview

What is hyponatremia?

Hyponatremia is a term for having a blood sodium level that is lower than normal. If you have blood tests, you’ll see it listed as “sodium” or “Na+” in your lab results. Sodium and potassium levels in your blood are important. The correct ratio of these elements to the amount of total water in your body needs to stay in balance to make sure you stay healthy. Actually, the main problem in a vast number of situations is too much water that dilutes the Na+ value. As a result, water moves into body cells, causing them to swell. This swelling causes a major problem in brain cells, which is a change in mental status that can progress to seizures or coma. Many diseases and medications can cause hyponatremia. Most people recover fully with their healthcare provider’s help. Unless your provider tells you something different, let your thirst be your guide in terms of how much water you drink.

Who is most at risk for hyponatremia?

Anyone can develop hyponatremia, but it is more likely to happen to people who:

  • Have kidney failure.
  • Have congestive heart failure.
  • Have diseases that affect the lungs, liver or brain.
  • Have conditions related to hormone levels and the endocrine system.
  • Have had surgery.
  • Take certain medications like some types of diuretics or some types of antidepressants.

How common is hyponatremia?

Hyponatremia is very common. It’s actually the most common chemical abnormality seen among people who are in the hospital and seen in outpatient clinics. Rates of hyponatremia are higher among people admitted to hospital care units or with the medical conditions mentioned earlier.

Symptoms and Causes

What causes hyponatremia?

In general, having too much water in your body is usually the main problem. The excess water dilutes the sodium levels. Much less frequently, hyponatremia is due to significant sodium loss from your body. Too much water in your body causes your blood to become watered down. A good example is people who run in long races or run on hot days. They lose both salt and water in their sweat and often replace these losses with mostly water. This combination can be deadly because it dilutes the remaining sodium in the body. It’s also possible to lose too much sodium from your body. Common causes include:

  • Using diuretics: Diuretics can cause you to increase the amount of sodium you excrete in urine (pee). Some people even call diuretics “water pills.”
  • Drinking too much alcohol: If you drink too much a lot of the time (chronic drinking) or binge-drink, you could pee more and lose fluid because you throw up.
  • Untreated diarrhea: This can cause dehydration and hyponatremia.
  • Taking certain medications: These include selective serotonin reuptake inhibitors (SSRIs) and carbamazepine (Tegretol®). SSRIs are commonly used to treat depression and carbamazepine to treat epilepsy and mania.

What are the signs and symptoms of hyponatremia?

Hyponatremia causes neurologic symptoms ranging from confusion to seizures to coma. The severity of the symptoms depends on how low the sodium levels are in the bloodstream and how quickly they fall. In many cases, blood sodium levels fall gradually, producing only mild symptoms as the body has time to make adjustments. Symptoms are more serious when blood sodium levels fall quickly. Other signs and symptoms of moderate to severe hyponatremia include:

  • Muscle cramps or weakness.
  • Nausea and vomiting.
  • Lethargy, or low energy.
  • Headache.
  • Mental status changes.

Hyponatremia is very dangerous for many organs, but especially for the brain.

Diagnosis and Tests

How is hyponatremia diagnosed?

Your provider will do a diagnostic workup if your blood sodium is low. The workup will include measuring urine sodium, potassium and creatinine concentrations. It will also include blood tests that indirectly show your total body water, your levels of sodium (Na+) and, in some case, levels of hormones that regulate water uptake by the kidneys. Your provider will also take a medical history and ask you questions, as well as do a physical exam. These steps will help them find out how low your sodium level is and why you have hyponatremia. Your provider may ask you:

  • What kind of sports you participate and how you train.
  • What kind of prescription medications you take.
  • What kind of medical conditions and surgeries you have or have had in the past.
  • How much alcohol you drink, especially beer.
  • Whether you take illegal substances like 3,4-methylenedioxymethamphetamine (MDMA, but also called Molly, E or Ecstasy).

Management and Treatment

How is hyponatremia treated?

You and your provider will work together to find the best treatment for the low blood sodium levels. Treatment depends on the underlying cause and the severity of your symptoms. If you have mild symptoms, your provider makes small adjustments to correct the problem. Treatment may be short-term or long-term. A short-term treatment includes:

  • Limiting water intake.
  • Adjusting or stopping medications.
  • Treating underlying causes.

A long-term treatment plan may include:

  • Limiting water intake.
  • Adjusting or stopping medications, or adding newer medications.
  • Adding salt to your diet.

If you have moderate to severe hyponatremia, you probably will need to go to the hospital for thorough medical evaluation and treatment. People with most serious cases of hyponatremia will probably get replacement sodium intravenously (straight into a vein). They’ll also have to limit their water consumption. Your provider may prescribe a medication like tolvaptan (Samsca®) or conivaptan (Vaprisol®) to correct blood sodium levels. Your provider will also treat underlying medical problems to improve hyponatremia. These conditions include heart failure, kidney failure and cirrhosis of the liver.

Are there complications associated with hyponatremia?

In many cases, hyponatremia causes extra water to move out of the bloodstream and into body cells, including brain cells. Severe hyponatremia causes this to occur quickly, resulting in swollen brain tissue. If left untreated, complications can include:

  • Mental status changes.
  • Seizures.
  • Coma.
  • Death.

Prevention

Can I prevent hyponatremia?

If you have certain underlying medical conditions, you may be more likely to have low blood sodium levels. You can lower your risk for hyponatremia by following your treatment plan and restricting your water intake to levels recommended by your healthcare provider. You should always tell your provider about any new symptoms right away. If your provider is monitoring your blood sodium levels, you’ll need to take blood tests. Here are some tips that may help you prevent hyponatremia:

  • Don’t drink too much beer and/or other forms of alcohol.
  • Drink enough water, but not too much water.
  • Don’t take MDMA.
  • If you’re an athlete, don’t forget to include electrolytes when you’re hydrating during sporting events.
  • Take care of yourself by managing your medical conditions consistently and well.
  • Eat a balanced diet, including food with high value protein content.

Outlook / Prognosis

What are the outcomes after treatment for hyponatremia?

With treatment, many people recover fully from hyponatremia. Your healthcare provider can help even if you have long-term hyponatremia. Older adults and people who are in the hospital for a long time may have worse outcomes.

Living With

When should I call my healthcare provider?

If you develop any symptoms of hyponatremia, contact your healthcare provider immediately. Hyponatremia can become an emergency if your sodium level falls too much or too quickly.

Frequently Asked Questions

Are there types of hyponatremia?

You may hear about different kinds of hyponatremia. Types include:

  • Euvolemic hyponatremia: If the amount of sodium in your body stays the same, but your total body water increases, you have euvolemic hyponatremia.
  • Hypervolemic hyponatremia: If the total body water increase is larger than the increase in total body sodium, you have hypervolemic hyponatremia.
  • Hypovolemic hyponatremia: In this situation, the total body water decrease is bigger than the decrease in total body sodium.
  • Dilutional hyponatremia: This type of low blood sodium is also called “water intoxication.” It refers to drinking too much water without including electrolytes that supply necessary minerals like calcium, potassium and sodium. Most people, unless they have conditions that put them at risk for hyponatremia (see above) would have to drink large amounts of water over a short period of time to dilute their blood sodium.
  • Hyposmolar hyponatremia, also called hypotonic hyponatremia: Hyposmolality is a condition of having low levels of electrolytes (including sodium), proteins and nutrients. Hyponatremia can cause hyposmolality.

A note from Cleveland Clinic Salt might not seem like it could be dangerous. But low levels of sodium in your bloodstream can be very dangerous. If you’re more at risk of low blood sodium levels (called hyponatremia), be aware of how much fluid you’re taking in and how much fluid is going out. Water leaves our bodies in the form of sweat, urine and vomit. If you have any symptoms that worry you, like headaches or nausea, contact your healthcare provider, especially if you have chronic conditions like heart failure or kidney failure or endocrine system diseases. Balance in life is important, and so is balance in your bloodstream. Hyponatremia treatment is aimed at resolving the underlying condition. Depending on the cause of hyponatremia, you may simply need to cut back on how much you drink. In other cases of hyponatremia, you may need intravenous electrolyte solutions and medications. The following measures may help you prevent hyponatremia:

  • Treat associated conditions. Getting treatment for conditions that contribute to hyponatremia, such as adrenal gland insufficiency and thyroid problems can help prevent low blood sodium.
  • Educate yourself. If you have a medical condition that increases your risk of hyponatremia or you take diuretic medications, be aware of the signs and symptoms of low blood sodium. Always talk with your doctor about the risks of a new medication.
  • Take precautions during high-intensity activities. Athletes should drink only as much fluid as they lose due to sweating during a race. Thirst is generally a good guide to how much water or other fluids you need.
  • Consider drinking sports beverages during demanding activities. Ask your doctor about replacing water with sports beverages that contain electrolytes when participating in endurance events such as marathons, triathlons and other demanding activities.
  • Drink water in moderation. Drinking water is vital for your health, so make sure you drink enough fluids. But don’t overdo it. Thirst and the color of your urine are usually the best indications of how much water you need. If you’re not thirsty and your urine is pale yellow, you are likely getting enough water.

Call us at kingwood kidney associates 281-401-9540 to schedule your appointment to help prevent and treat hyponatremia You can also schedule your appointment online using the booking tool on this page. Book your examination today. Dr. Sowmya Puthalapattu
Sowmya Puthalapattu, MD, or Dr. Sowmya as she’s known to patients, is an experienced board-certified nephrologist and internal medicine physician at Kingwood Kidney Associates, with offices in Kingwood and The Woodlands, Texas. Dedicated to providing her patients with comprehensive individualized care, Dr. Puthalapattu believes in the importance of active listening and having an open and creative clinical mind to provide the right care to meet her patients’ needs. She is faculty and Subspeciality education coordinator for Nephrology at IM GME program HCA Kingwood . Her areas of specialty include chronic kidney disease, end-stage renal disease, hyponatremia, and high blood pressure.
A resident of The Woodlands, Texas, Dr. Puthalapattu spends her free time with her husband and two children. Her favorite activities include hiking and traveling.

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