1/ #UncleBob has some thoughts about thiazide induced hyponatremia. I hope this takes less than #5goodminutes
Thiazides inhibit NaCl reabsorption in the DILUTING SEGMENT. This is the simple explanation for why patients can develop hyponatremia.
2/ Often there are other contributing factors. For example, if you have a borderline tea and toast diet (normal Na prior to starting the thiazide), the thiazide can unmask the dietary cause. The patient goes from a very dilute urine to much closer to isothenuria.
3/ In some patients, thiazides do result in volume contraction, and thus ADH stimulation, adding to the risk. I personally would be interested in the urine osms, but one can definitely treat empirically first.
4/ Treatment is tricky in this patient because once we remove the thiazide the patient can once again dilute their urine. If they have an excess of water, they could have a very significant water diuresis and thus the Na would rise too quickly.
5/ I would restrict fluids and check Na frequently. If the patient has an elevated urine osms, then we will need a more complex management. Given the very low sodium, we must be extremely careful. Please ask questions if I have not covered the explanations well.
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