How Long does Suboxone Stay in your System?

What is Suboxone?


Suboxone® is a prescription medicine that contains the active components buprenorphine and naloxone. These two combined medications in each dose of Suboxone are classified into two: Buprenorphine as a partial opioid agonist and Naloxone as an opioid antagonist.

It is indicated for treatment of opioid dependence in adults and should be used as part of a complete treatment plan including counseling and psychosocial support [1,2].




Picture 1: Suboxone Film (sublingual film)
Image Source: Restorative Solutions. Available from:http://restorative.solutions/dodson-directive/



Picture 2: Suboxone Tablets
Image Source: Restorative Solutions. Available from: http://restorative.solutions/dodson-directive/


What is Buprenorphine?


Buprenorphine (pronunciation: ‘bu-pre-‘nor-feen) is an opioid medication used to treat opioid addiction. It is a semi-synthetic opioid from an alkaloid of the poppy Papaver somniferum which is called thebaine.

Buprenorphine is a partial agonist, meaning it produces less side effects like respiratory depression that can only be seen with full agonist opioid.

Formulations of buprenorphine include Suboxone, Buprenex, Subutex, Cizdol, Bunavail, Temgesic, Zubsolv, Butrans, and Norspan available either as buprenorphine hydrochloride alone or a combination of buprenorphine and naloxone [3, 4].


What is Naloxone?


Naloxone (pronunciation: nə-läk-sōn) is a synthetic drug similar to morphine, which blocks the opiate receptors in the nervous system. It works by competitively antagonizing receptors for opioids.

To explain it simply, naloxone binds with the opioid receptors in the brain without stimulating them. It is a drug used to reverse the effects of opioids, especially in overdose. Naloxone is also useful in reducing respiratory or mental depression caused by opioids [5].


How Buprenorphine Works

  • Opioid receptor is empty. A person becomes less sensitive and requires more opioids to produce the same effect if they become tolerant to opioids. The patient feels discomfort whenever there is an insufficient amount of opioid receptors being activated. That is when withdrawal happens. 
  • Opioid receptors filled with full-agonist. Euphoria and the stop of withdrawal for a period of time (4-24 hours) are caused by the strong opioids of heroin and painkillers. To the point of an uncontrollable addiction, the brain starts to crave opioids and the cycle repeats accelerates.
  • Opioid replaced and blocked by Buprenorphine. Buprenorphine battles with the full agonist opioid for the receptor. It has a stronger affinity to receptors that eliminates existing opioids and blocks others from binding. As a partial agonist, buprenorphine has a restricted opioid effect, enough to stop withdrawal but not enough in causing intensive euphoria. 
  • Over time (24-72 hours) buprenorphine dissipates, but still creates restricted opioid effect that is enough to stop withdrawal and continues to block other opioids from binding to the opioid receptors.


Side Effects


The primary side effects of buprenorphine are similar to other opioid agonists, which include the following [6]:

  • Headache or other pain;
  • Tongue pain, inflammation inside your mouth;
  • Increased sweating (diaphoresis); or
  • Swelling of the extremities
  • Sleep problems (insomnia);
  • Diarrhea or dehydration


Duration of Buprenorphine + Naloxone (Suboxone)


The half-life of Suboxone is 20-70 hours, depending on the route of administration and interaction with other drugs administered to the body.

Furthermore, buprenorphine has the capability to stay and attach to opiate receptors for over 24 hours, effectively incapacitating the receptors to make use of other stronger opiates less appealing [4,7].


How Long does Saboxone Stay in the Body?


This drug has a relatively short half-life. 

In most people, it will be undetectable in the urine after 2-4 days of complete abstinence. In saliva, it only stays for 1-3 days. Hair drug tests usually have a longer detection time of 90 days. Suboxone would last in the blood stream the longest. Some people put it at around 17 days, others at longer periods of time.

How long it stays inside the body depends on the dosage, usage, body fat, and metabolism. If you are taking in 8mg of Suboxone, possibly it will take 5 days for the drug to be excreted from your system. With 4mg of Suboxone, it will take 30-72 hours; while it usually takes 24-36 hours for 2mg of Suboxone to be taken out of your body [8,9].


How Long does Suboxone Block Opiates?


Blocking of opiates depends on duration and dosage of the drug administered. A dose of 4 mg once would only block opiates for 1 to 3 days; a dose of 16 mg or more will block opiates for 3 to 5 days.


How Long does Suboxone Stay in our System for Drug Tests?


It depends on the amount of Suboxone taken and the metabolism of a person. Suboxone could stay 3 to 5 days or maybe a week in your system [10].

 

Withdrawal Symptoms


Buprenorphine withdrawal symptoms are unpleasant but it depends on the brand of drugs used wherein it could be milder with Subutex than Suboxone. Common withdrawal symptoms include:

  • Muscle, joint, and bone pain
  • Inability to sleep (insomnia)
  • Irritability
  • Diarrhea
  • Restless leg syndrome (RLS)
  • Excessive sweating (diaphoresis)
  • Involuntary shaking (tremors)
  • Nausea and vomiting
  • Raise blood pressure (hypertension)
  • Raised heart rate (tachycardia)
Suboxone withdrawal lasts for 3 months or 90 days. The process usually differs from person to person. 

Withdrawal with Suboxone is not going to be easy because of the factors that may influence on how the body gets rid of it. It may vary depending on the dosage and duration of drug intake. The longer you took the drug, the higher the amount of Suboxone in your system, the more difficult it is for you to withdraw. 

During the withdrawal process, it is important to engage with healthy activities [11,12].


How Long does the Treatment Last?


Opioid addiction is a manifestation of brain changes resulting from chronic opioid use and misuse. The patient’s recovery is in great part a struggle to overcome the effects of these changes. Brain adaptations take time to develop and reverse. 

Patients should remain in treatment long enough to reverse the brain changes to the extent possible and learn coping mechanisms for what cannot be reversed. This is accomplished through deliberate reconditioning effort. 6-12 months is not an unusual treatment time frame, but longer period may be required, depending on the progress of the patient [13].

Getting off of Suboxone needs a serious medical help. It will not be easy, but indeed, it is possible. However, it is highly recommended to stay as productive and healthy as you can during withdrawal because it brings about faster recovery.

References:
  1. http://www.suboxone.com/treatment/suboxone-film
  2. How is treatment differ from drug abuse. Available from: http://psychcentral.com/lib/how-is-suboxone-treatment-different-than-drug-abuse/
  3. The National Alliance of Advocates for Buprenorphine Treatment. Available from: http://www.naabt.org/
  4. Buprenorphine. Available from: https://en.wikipedia.org/wiki/buprenorphine
  5. Naloxone. Available from: http://www.naloxone.org.uk/index.php/naloxoneseperator/naloxoneinformation/whatisnaloxone
  6. Side Effects. Available from: http://drugs.com/sfx/buprenorphine-naloxone-side-effects.html
  7. How long does Buprenorphine stay in your system. Available from: http://www.passadrugtestingforall.com/long-does-buprenorphine-stay-your-system-a-72.html
  8. How long does buprenorphine last. Available from: http://prescription-drug.addictionblog.org/how-long-does-buprenorphine-last/
  9. Steadyhealth. Available from: http://www.steadyhealth.com/topics/how-long-does-suboxone-stay-in-your-body-stay-active
  10. Healthtap. Available from: https://www.healthtap.com/
  11. The Ugly Truth about Withdrawal. Available from: http://lighthouserecoveryinstitute.com/suboxone-withdrawal-symptoms/
  12. Withdrawal Symptoms. Available from: http://mentalhealthdaily.com/2014/04/24/suboxone-buprenorphine-withdrawal-symptoms-how-long -do-they-last/
  13. The National Alliance of Advocates for Buprenorphine Treatment Documents. NAABT brochures.
      Read More »

      Hypokalemia - Symptoms, Causes, ECG and Treatment

      Hypokalemia

      Hypokalemia, is a medical condition that occurs when an individual has a lower than normal potassium level in their bloodstream.  For a healthy individual, the blood potassium level should be 3.6 to around 5.2 millimoles per liter. Getting low potassium levels such as 2.5mmol/L or below can be very dangerous. When a person gets these low levels, they should get medical attention immediately.[1,2]


      What is potassium and Its Uses? 

      The human body has several electrolytes that are crucial for cell function, and potassium is actually one of them. Potassium electrolytes are concentrated in the cells of the body, and they play a very important role. In the human body, only two percent of the total potassium is found in the blood stream.

      Any changes in the blood stream levels of potassium can greatly affect the functioning of the human body. Potassium has a great role of maintaining the electrical activities in the body cells. The body cells that have high electrical activity such as the nerves and muscles like the heart are seriously affected then the potassium levels in the body fall.[2,4]


      What are the causes of low potassium in the body?

      Many people believe that low potassium is commonly caused by poor dietary intake. However, this is not true.  The most common causes of hypokalemia is the loss of potassium from the gastrointestinal tract or from the kidney. Potassium levels in the body can fall from the GI tract due to the following reasons.
      • Diarrhea.
      • Vomiting
      • Ileostomy. Some patients who have had conditions that forced them to have a bowel surgery and get an ileostomy. Their stool output might sometimes contain huge amounts of potassium.
      • The use of laxative has also been linked to low potassium levels for some patients.
      • Villous adenoma is type of colon polyp, and it is said to cause hypokalemia in patients too. The polyp causes the patients colon to leak some amount of potassium.[4,7,9,10]

      Potassium can be lost from the kidney due to the following reasons.

      • Some diuretic medications, such as Hydrochlorothiazide and furosemide can cause the levels of potassium to fall.
      • When the levels of corticosteroids are elevated, the potassium levels go down. This can be caused by the use of medications such as prednisone or by some illnesses such as Cushing’s syndrome.
      • Elevated levels of aldosterone in the body can also lead to hypokalemia.  Aldosterone is a hormone in the human body that increases due to renal artery stenosis or due to adrenal tumors.
      • When the magnesium levels in the body are low, the levels of potassium go down too.
      • Renal tubular acidosis also causes hypokalemia.

      Hypokalemia can also be caused by the effects of the following medications.
      • Prednisone.
      • Aminoglycosides such as  gentamicin or tobramycin
      • Amphotericin B [4,10]

       

      Symptoms of Hypokalemia


      Potassium is an important element in the body.  Potassium greatly affects the manner your neuromuscular cells discharge energy and also how they regenerate this energy so that they can be able to fire again.  When your potassium levels are low, these cells are not able to repolarize and most of the time, they cannot fire repeatedly as expected.  When this happens, your muscles and nerves cannot function as usual, and the patient gets some symptoms.

      Most of the time, the symptoms of this condition are mild.  However, they can sometimes be vague. A patient might get one or more symptoms involving the GI, muscles, kidneys, nerves and the heart. Here are some of the most common symptoms
      • Some patients experience tiredness, weakness or even cramping in their legs or arm muscles. These cramping might be severe sometimes, causing the patient not to be unable to move their legs or arms.
      • Numbness or tingling is also common.
      • Vomiting and a lot of nausea might also be present.
      • Bloating and abdominal cramping.
      • Constipation.
      • Some patients complain about palpitations.
      • Feeling thirsty all the time and passing large amounts of urine.
      • Due to low blood pressure, some patients experience fainting.
      • Changes in psychological behavior in the patient. Some might get depression, delirium, psychosis, confusion or even hallucinations.[1,5]


      How is low potassium diagnosed? (with ECG (EKG) changes)


      It is very easy to measure your potassium levels during your normal routine blood tests. Hypokalemia is considered a potential complication when an individual is taking some medications. Patients who suffer from high blood pressure are mostly given some diuretics like hydrochlorothiazide or Lasix. This means that they have a high risk of getting hypokalemia, so their potassium levels should be monitored closely.

      If you have a patient who is ill, it is important to be extremely careful if they are vomiting or have diarrhea. These might lead to dehydration and weakness, common symptoms of hypokalemia. These patients should have their electrolyte levels monitored just to be sure that the potassium levels are good or whether they need to be replaced. 


      Difference between Normal ECG and Hypokalemia
       
      There are some EKG or ECG changes that are mostly associated with hypokalemia. Sometimes, the diagnosis of hypokalemia is done by getting the U waves in the EKG tracing. When the condition is serious, there can be severe disturbances in the heart rhythm. [1,6,8]

       Prominent U waves in Hypokalemia ECG 

      Also check Hyperkalemia ECG
         

      Treatment and Management of low potassium


      Patients who have serum potassium levels of above 3.0 mEq/liter have nothing to worry about.  These levels are not considered to be dangerous, and they can be given potassium replacements by mouth.

      However, patients with potassium levels that are lower than 3.0mEq/liter might require some intravenous replacement, depending on their current medical condition and symptoms.  Most of the time, the decision is patient –specific, and it depends on the diagnosis, the patient’s ability to tolerate fluid and the medication by mouth and the circumstances of the illnesses. 

      If the low potassium levels are short term or caused by self -limited diseases such as vomiting, diarrhea or gastroenteritis, the patients does not have to worry about medications. This is because the potassium levels can restore on their own.  If the hypokalemia is severe, or may be the doctor predicts that the potassium losses will be on going, potassium supplementation or replacement is very important.

      For individuals who get hypokalemia due to the use of diuretics, the doctor might recommend a small amount of oral potassium. This is due to the fact that the loss will continue as long as the diuretic is being used. The oral potassium supplementation is presented in liquid or in pill form. The dosages of these supplements are measured using mEg. The common dosage is 10-20mEq daily.

      Patients suffering from hypokalemia can also consume foods that are high in potassium.  This is always the first option given by the doctor to replace potassium, especially if the condition is not serious. Oranges, bananas, apricots and tomatoes are some of the food that are considered to be high in potassium content. 

      Potassium is extracted through the kidneys, and most of the time, the doctor will order blood tests that will monitor the patients kidney function. This way, it will be easier to monitor and predict the potassium levels from getting too high.

      If a patient will be getting their potassium supplements intravenously, the doctor should give it slowly. Potassium is very irritating to the veins, and it should only be given at a maximum rate of 10mEq.  Infusing potassium too fast in the veins can easily cause heart irritations and gradually promote potentially dangerous rhythms like ventricular tachycardia.[5,9]

       

      A Special Situation: Periodic Paralysis

      Although very rare, sometimes the potassium levels in the body moves from the blood stream in to the cells of the body. When this happens, the serum potassium levels drops to 1.0 mEq/liter or sometimes lower. This can be very serious to the patient. The muscles become very week to a point where the patient cannot move their body and become paralyzed.  The most affected parts are the legs and arms.  The breathing and swallowing muscles are also affected sometimes. 

      Periodic paralysis is said to be hereditary and sometimes, it might be precipitated by excessive exercising, consuming high carbohydrate or too salty meals, or even occur without any cause.  People who get periodic paralysis can be treated easy. They should be given potassium replacement intravenously. The recovery is expected to take place within the first 24 hours. [3,5]


      Prevention of low potassium

      The human body is able to maintain its potassium levels in the normal ranges as long as an individual takes foods that are rich in potassium.  When an individual gets any short time illnesses that can make the body to loose potassium levels, the body can easily compensate the loss. If the doctor says that the loss of the potassium is ongoing, it is crucial for a patient and the health care provider to anticipate this loss, and urgently consider the routine potassium replacement that will work effectively. Leaving the condition untreated can lead to serious problems. [4,6]


      References
      1. Diseases & Conditions - Medscape Reference [Internet]. Emedicine.medscape.com. 2016 [cited 2 May 2016]. Available from: http://emedicine.medscape.com
      2. Mayo Clinic [Internet]. Mayoclinic.org. 2016 [cited 2 May 2016]. Available from: http://www.mayoclinic.org
      3. National Library of Medicine - National Institutes of Health [Internet]. Nlm.nih.gov. 2016 [cited 2 May 2016]. Available from: https://www.nlm.nih.gov
      4. Marjorie Lazoff M, Cadogan M, Morgenstern J, Long N, Long N, Lynch D et al. LITFL: Life in the Fast Lane Medical Blog [Internet]. LITFL: Life in the Fast Lane Medical Blog. 2016 [cited 2 May 2016]. Available from: http://lifeinthefastlane.com
      5. The MSD Manuals - Trusted Medical Information [Internet]. Msdmanuals.com. 2016 [cited 2 May 2016]. Available from: http://www.msdmanuals.com
      6. [Internet]. 2016 [cited 2 May 2016]. Available from: http://Electrolyte Disorders
      7. The MSD Manuals - Trusted Medical Information [Internet]. Msdmanuals.com. 2016 [cited 2 May 2016]. Available from: http://www.msdmanuals.com
      8. Medical Information & Trusted Health Advice: Healthline [Internet]. Healthline.com. 2016 [cited 2 May 2016]. Available from: http://www.healthline.com
      9. [Internet]. Emedicinehealth.com. 2016 [cited 2 May 2016]. Available from: http://www.emedicinehealth.com
      10. [Internet]. 2016 [cited 2 May 2016]. Available from: http://healthy living az list
      Read More »

      Hyponatremia - Causes, Pathophysiology, Algorithm, Correction, Treatment

      Facts about Hyponatremia : Definition

      This is a condition characterized by lower-than-normal levels of sodium in the blood. The normal serum sodium concentration in the body is between 135 and 145mEq/L. If the sodium serum levels go below 135mEq/L, you are considered to be suffering from hyponatremia. The condition is said to be severe if the serum levels go below 125mEq/L. The body uses sodium as an electrolyte to regulate water in and around the cells of the tissues. [1, 2, 3,5,8,9, 10, 13,]

      Pathophysiology 

      • The sodium concentration in the serum is regulated by secretion of the ADH (antidiuretic hormone), variations of the renal handling of filtered sodium, and the renin-angiotensin-aldosterone system.
      • If the serum osmolality increases over the normal range of 280-300mOsm/kg, there is the stimulation of hypothalamic osmoreceptors that cause an increase in thirst and circulate the ADH.
      • The ADH increase the reabsorption of the water from urine that results in low volume urine with high osmolality but returns the serum osmolality to normal.
      • Aldosterone is also released to curb hypovolemia through renin-angiotensin-aldosterone feedback system. The hormone causes the sodium absorption in the kidney’s renal tubule.
      • The sodium retention causes the retention of water that in turn corrects the hypovolemic problem. The kidney is able to balance the sodium-independent of these two hormones.
      • In a hypovolemic, state such as dehydration or hemorrhage increases the absorption of sodium in the proximal tubule of the kidney.
      • When the vascular volume is increased, tubular sodium reabsorption is suppressed and helps to restore the normal vascular volume. Thus, the sodium balance disorders can be traced to aldosterone, renal sodium transport, ADH, or disturbance water or thirst acquisition.
      • Hyponatremia is said to be physiologically significant when there is the indication of extracellular hyposmolality and the tendency of free water shifting from vascular space to the intracellular space.
      • The body tolerates cellular edema to a greater extent by not at the bony calvarium. Thus, hyponatremia clinical manifestations are primarily on cerebral edema. The rate at which the condition develops is critical to its treatment. [4,6,10, 11]

      Hypovolemic Vs Hypervolemic hyponatremia  

      A condition is considered hypovolemic hyponatremia if there is a decrease in total body water with the decrease in the total amounts of the body sodium.

      Hypervolemic hyponatremia occurs when there is an increase in total body sodium along with the increase in total body water.
      If the normal body sodium levels do not change with the increase in total body water, the condition is said to be euvolemic hyponatremia. [1, 2, 3,5,8,9]

      There are cases where water shifts from the intercellular to extracellularly environment and results in dilution of sodium. The total body water is not changed in this case.
      This condition occurs if one is suffering from hyperglycemia and is referred to as redistributive hyponatremia. [1, 2, 3, 5, 8, 9]

      Acute hyponatremia and chronic hyponatremia

      Acute hyponatremia is the case where sodium levels fall rapidly in less than 48 hours.
      The condition is more dangerous than hyponatremia that occurs over several day or weeks, commonly known as chronic hyponatremia. In the latter, the brain cells adjust to the condition, and there is minimal swelling. [1, 2, 3, 5, 8, 9]

      Signs and symptoms of hyponatremia

      • Vomiting
      • Short memory loss
      • Lethargy
      • Fatigue
      • Irritability
      • Loss of appetite
      • Nausea
      • Confusion and muscle weakness.
      • Some patients also complain muscle cramps, seizures, and decreased consciousness.
      • In severe cases, one may fall into a coma. 

      Neurological symptoms only occur when sodium levels get very low at quantities below 115mEq/L. At this level of sodium, water enters the brain causing the brain to swell.

      The condition later causes pressure in the skull, a condition called hyponatremic encephalopathy. If the condition is not checked at the point, there is squeezing of the brain across the structures of the skull. The physical symptoms of this condition are:

      • Confusion
      • Respiratory arrest
      • Non-cardiogenic fluid accumulation in lungs
      • Brain stem compression. 
      The condition is fatal if not treated at once.
      The severity of the symptoms is dependent on the severity of the sodium drop and show fast the condition happens. The body may tolerate gradual drop even to levels that are very low. As the body has a neurotic adaptation capability. However, the presence of neurological diseases, seizure disorders, and other non-neurological metabolic abnormalities influence the severity of the condition [1, 2, 3,5,8,9, 13]


      Causes of hyponatremia 

      Sodium in the body fluid is used to maintain electrolyte balance, blood pressure and for the working of muscles and nerves. If the level of sodium in the fluids outside the cells goes down, the fluids enter the cells causing the cells to swell. Here are the main causes of hyponatremia:

      • Diarrhea
      • The intake of diuretic medicines that increase the urine output
      • Burns that cover large areas of the body
      • Heart failure
      • Vomiting
      • Sweating
      • Vomiting
      • Heart failure
      • Kidney diseases
      • Liver cirrhosis
      • The Syndrome of Inappropriate antidiuretic hormone secretion (SIADH)
      • Hypothyroidism, a condition where there is underperformance of the pituitary glands
      • Deficiency of glucocorticoid, a steroid
      • Congenital adrenal hyperplasia that makes the adrenal glands unable to produce enough steroid 

      Hormones 

      • Exercise-associated hyponatremia from prolonged period of exercise while taking water alone
      • Certain medications such as Lasix for treating blood pressure and antidiuretics [1, 2, 3,5,8,9, 13]


      Workup : A clinical diagnosis chart used to determine the cause of hyponatremia

       

      Legionnaire’s disease workup

      Cases of pneumonia are caused by several pathogens that share similar laboratory findings. Hyponatremia that is secondary to SIADH is common in Legionnaires’ disease that that which is caused by pathogens. However, the condition is not specific to Legionnaires’ disease. [4, 5]


      Diagnosis 

      Hyponatremia is also classified according to effective osmolality. It can be said to be: 
      • Hypotonic hyponatremia
      • Hypertonic hyponatremia
      • Isotonic hyponatremia.
      During the diagnosis, the patients undergo three tests that when combined with physical examination and history, the doctor is able to establish the etiological mechanism as urinary sodium concentration, urine osmolality, serum osmolality. [1, 2, 5, 6, 9, 13]

      Urine osmolality 

      This osmolality test is used to differentiate primary polydipsia from free-water excretion. Osmolality that is greater than 100mOsm/kg shows that the kidneys are unable to dilute the urine. . [1,2,5,6,9,13]


      Serum osmolality 

      Serum osmolality is used for differentiating between pseudo hyponatremias and true hyponatremia. The earlier is secondary to hyperproteinemia or hyperlipidemia or could be hypertonic hyponatremia that is linked to elevated mannitol, glucose, and glycine maltose or sucrose. Symptoms do not appear until the plasma levels drop below 120 mmol per L . [1,2,5,6,9]

      The urinary sodium concentration

      This test is used to differentiate between the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and hyponatremia that is secondary to hypovolemia. The condition is considered SIADH hyponatremia when the urine sodium is greater than 20-40mEq/L. The typical measurements of urine sodium for hypovolemia patients are usually less than 25mEq/L. However, an SIADH patient taking low sodium will have the values falling below 25mEq/L.  . [1,2,5,6,9,11,13]

      Hyponatremia treatment 

      • The treatment of the hyponatremia condition is dependent on the underlying cause. Such a condition should be treated first to correct the condition.
      • Treatment starts with the examination of the condition to determine if one has euvolemic, hypervolemic or hypovolemic condition
      • If the patient is suffering from hypovolemia, the condition is corrected by an intravenous administration of normal salt in a saline solution.
      • Euvolemic hyponatremia is treated by restriction of fluid and abolishment of the stimuli that causes the secretion of the antidiuretic hormone such as nausea.
      • Any drug that the patient is taking that could be causing SADH is also discontinued.
      • Hypervolemic hyponatremia is treated by treating the disease that could be causing the condition. In most cases, the cause is usually liver or heart failure. If this is not resolved, the patient receives the same treatment as that of the euvolemic hypervolemic hyponatremia condition. 
      There is a risk of the patient developing severe neurological disorder called Central Pontine Myolysis that breaks down the sheaths covering parts of the nerve cells if hyponatremia is corrected rapidly. As a precautionary measure the salt level in blood, or called sodium serum, should not rise beyond 0.33mmol/l/h during the application of the saline solution. [1,2,4,5,6,8,9,13]

      Hyponatremia correction calculator

       Hyponatremia calculator is used for calculating the amount and the intensity of the saline solution that is needed to correct the serum hyponatremia. The formula for calculation of the infusateRate is; 

      Infusate Rate = (1000 * Serum Na Change Per Hr * ((Water Fract * Weight) + 1)) / (IVNa + IVK - SerumNa) 

      Serum Na Change Per Liter = (IVNa + IVK - SerumNa) / ((Water Fract * Weight) + 1) [12]

      ICD-9-CM Diagnosis Code 276.1 

      ICD-9-CM Diagnosis Code 276.1 is a billable medical code used to indicate that hyposmolality and hyponatremia were diagnosed for reimbursements. However, the code can only be used for claims for services rendered before October 1, 2015. For claims after the date, the code ICD-10-CM code is used. [7]


      References
      1. Merck Manuals Professional Edition. Hyponatremia - Endocrine and Metabolic Disorders [Internet]. 2015 [cited 22 December 2015]. Available from: http://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/electrolyte-disorders/hyponatremia#sec12-ch156-ch156d-714
      2. Melissa Conrad Stöppler M. Hyponatremia: Get the Facts on Symptoms and Treatment [Internet]. MedicineNet. 2015 [cited 24 December 2015]. Available from: http://www.medicinenet.com/hyponatremia/article.htm
      3. Goh K. Management of Hyponatremia - American Family Physician [Internet]. Aafp.org. 2015 [cited 24 December 2015]. Available from: http://www.aafp.org/afp/2004/0515/p2387.html
      4. Emedicine.medscape.com. Legionnaires Disease Workup: Approach Considerations, Histologic Findings, Laboratory Studies [Internet]. 2015 [cited 24 December 2015]. Available from: http://emedicine.medscape.com/article/220163-workup
      5. Updated by: David C. Dugdale a. Hyponatremia: MedlinePlus Medical Encyclopedia [Internet]. Nlm.nih.gov. 2015 [cited 24 December 2015]. Available from: https://www.nlm.nih.gov/medlineplus/ency/article/000394.htm
      6. Haralampos J. Milionis M. The hyponatremic patient: a systematic approach to laboratory diagnosis. CMAJ: Canadian Medical Association Journal [Internet]. 2002 [cited 24 December 2015];166(8):1056. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC100882/
      7. Icd9data.com. 2012 ICD-9-CM Diagnosis Code 276.1 : Hyposmolality and/or hyponatremia [Internet]. 2015 [cited 24 December 2015]. Available from: http://www.icd9data.com/2012/Volume1/240-279/270-279/276/276.1.htm
      8. Mayoclinic.org. Hyponatremia Symptoms - Mayo Clinic [Internet]. 2015 [cited 24 December 2015]. Available from: http://www.mayoclinic.org/diseases-conditions/hyponatremia/basics/symptoms/con-20031445
      9. Healthline. Low Blood Sodium (Hyponatremia) [Internet]. 2015 [cited 24 December 2015]. Available from: http://www.healthline.com/health/hyponatremia
      10. Moritz M, Ayus J. The pathophysiology and treatment of hyponatraemic encephalopathy: an update. Nephrology Dialysis Transplantation. 2003;18(12):2486-2491.
      11. Encyclopedia Britannica. syndrome of inappropriate antidiuretic hormone (SIADH) | pathology [Internet]. 2014 [cited 24 December 2015]. Available from: http://www.britannica.com/science/syndrome-of-inappropriate-antidiuretic-hormone
      12. Reference.medscape.com. Hyponatremia Correction Infusate Rate [Internet]. 2015 [cited 24 December 2015]. Available from: http://reference.medscape.com/calculator/hyponatremia-correction-infusate-rate
      13. Updated by: David C. Dugdale a. Hyponatremia: MedlinePlus Medical Encyclopedia [Internet]. Nlm.nih.gov. 2015 [cited 24 December 2015]. Available from: https://www.nlm.nih.gov/medlineplus/ency/article/000394.htm
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      Paresthesia (Tingling and Numbness) - Causes and Treatment

      Definition

      Meaning : Paresthesia (pronunciation: \ˌpar-əs-ˈthē-zhə\; ICD-10: R20.2; ICD-9-CM: 782.0, 355.1) generally refers to abnormal sensations except pain (vs. dysesthesia). This covers a wide variety of sensations like tingling (pins and needles), itching, pricking, shooting, aching, burning, searing, twisting, or electrical, among others. Most common of these symptoms is the tingling sensation. It is primarily felt on the extremities (hands, feet, arms, and legs) [1, 2, 3].

       

      Causes

      Causes of Transient Paresthesia

      This is the temporary type of paresthesia and is very common because we sometimes tend to position ourselves in a wrong way, like resting your head on your bent forearm over a table or by simply crossing your legs. The following are the other common causes of transient paresthesia [2, 4, 5]:

      • Whiplash injury or injury to the soft tissue of the neck can cause paresthesia of upper extremities after a vehicular accident.
      • Disturbance in sodium ion occurs in hyperventilation syndrome, producing abnormal discharges in the afferent nerves.
      • During panic attacks, an individual may experience paresthesia of the mouth, hands, and feet. Add hyperventilation syndrome to that and it gets worse.
      • After a transient ischemic attack (TIA) or stroke, excess potassium goes out of the cell causing hyperactive muscle contraction, thus paresthesia.
      • Paresthesia during seizures is possible and with its treatment with vagus nerve stimulation, paresthesia is an adverse reaction, thus worsened.
      • Dehydration can also cause paresthesia because of electrolyte imbalance.
      • Insufficient blood supply due to acute arterial occlusion by thrombosis, embolism, or aneurysm can cause paresthesia.
      • Beta-alanine supplements have paresthesia as one of the side effects when the dose reaches 800 mg.


      Causes of Chronic Paresthesia

      Chronic paresthesia is the type of paresthesia that comes and goes and has been happening periodically, thus its other name intermittent paresthesia. Generally, the causes are neurologic diseases. Specific causes are listed below [2, 4, 5, 6]:

      Disorders of the Nervous System

      Central Nervous System
      1. Cerebrovascular accident (CVA) or stroke: Poststroke paresthesia, Lacunar infarction
      2. Epidural/Subdural hematoma or Subarachnoid hemorrhage
      3. Head trauma
      4. Brain tumor or metastasis: Cavernous angioma, Trigeminal sensory neuropathy, Syringomyelia
      5. Trigeminal trophic syndrome
      6. Encephalitis
      7. Meningitis
      8. Brain abscess
      9. Multiple sclerosis (MS)
      10. Transverse myelitis
      11. Lumbar spinal stenosis
      12. Pernicious anemia
      13. Lumbar puncture
      Peripheral Nervous System
      1. Peripheral neuropathy /Entrapment neuropathy
      2. Carpal tunnel syndrome (CTS)
      3. Thoracic outlet syndrome (TOS)
      4. Cubital tunnel syndrome
      5. Tarsal tunnel syndrome
      6. Lateral femoral cutaneous syndrome
      7. Peroneal palsy
      8. Neuralgia
      9. Chronic nerve compression
      10. Meralgia paresthetica
      11. Disc herniation
      12. Cervical spondylosis
      13. Sciatica
      14. Pressure palsy
      15. Piriformis syndrome
      16. Spinal canal stenosis
      17. Charcot-Marie-Tooth disease
      18. Amyloidosis
      19. Spondylolisthesis
      20. Spinal tumors
      Disorders of the Circulatory System
      1. Buerger’s disease or thromboangiitis obliterans
      2. Raynaud’s disease
      Metabolic Disorders
      1. Diabetic neuropathy
      2. Alcoholic neuropathy
      3. Electrolyte imbalance in potassium, sodium, calcium
      4. Hypothyroidism
      5. Hypoparathyroidism
      6. Insulinoma
      7. Uremia
      8. Hyperaldosteronism
      9. Porphyria
      10. Hypoestrogenemia
      Autoimmune Disorders
      1. Rheumatoid arthritis
      2. Systemic lupus erythematosus (SLE)
      3. Fibromyalgia
      4. Sjogren’s syndrome
      5. Polyarteritis nodosa
      6. Systemic sclerosis
      7. Autoimmune vasculitis
      Infections
      1. Herpes simplex virus (HSV)
      2. Herpes zoster virus causing shingles
      3. Human immunodeficiency virus (HIV)
      4. Guillain-Barre syndrome (GBS)
      5. Lyme disease
      6. Leprosy
      7. Rabies
      8. Neurosyphilis
      Other Causes of Paresthesia
      1. Trauma
      2. Acute idiopathic polyneuritis
      3. Chronic relapsing polyneuropathy
      4. Dental paresthesia
      5. Fabry disease
      6. Refsum syndrome
      7. Drug abuse especially opioids, pyridoxine
      8. HIV medications: Didanosine, Zalcitabine, Stavudine
      9. Heavy metal poisoning: Mercury, lead, arsenic
      10. Exposure to industrial toxins
      11. Carbon monoxide poisoning
      12. Nitrous oxide poisoning
      13. Snake bite
      14. Burns
      15. Frostbite
      16. Pink disease
      17. Tobacco smoking
      18. Ito syndrome
      19. Ciguatera (tropical fish) poisoning
      20. Paraneoplastic syndrome

      Pathophysiology



      Picture 1: The Nervous System and How it Works
      Image Source: people.eku.edu

      Sensations from different parts of the body are detected by receptors on the peripheral nerves. In the illustration above, we focus on the somatic nervous system under peripheral nervous system because it is type related to paresthesia.

      The afferent nerves deliver the information to the spinal cord into the brain (mainly to the sensory cortex) through the brainstem and trigeminal nerve. This is now interpreted by the brain and delivers response towards the effectors, in this case, the skeletal muscle, through the spinal cord and efferent nerves. Any disruption in this sensory pathway may cause paresthesia [2, 4, 7].


      Diagnosis

      Diagnosis of the underlying cause of paresthesia requires the patient’s detailed medical history, accurate physical and neurologic examination, and appropriate laboratory tests [8].
      Physical examination for paresthesia primarily consists of testing sensations for pain, touch, vibration, temperature and joint position.

      Stance and gait, which determine the presence of motor and cerebellar problems, are also included to correctly diagnose the cause of the paresthesia.

      The examination begins at the center of the problem and proceeds radially until the sensation is perceived as normal. The root and peripheral nerve territories define the distribution of the abnormality [3].



      Picture 2: Anterior Peripheral Nerves and Dermatomes
      The left (colored) side of this picture shows the dermatomes and on the right are the corresponding peripheral nerves.
      Image Source: www.mysijd.com


      Picture 3: Posterior Peripheral Nerves and Dermatomes
      The left (colored) side of this picture shows the dermatomes and on the right are the corresponding peripheral nerves.
      Image Source: mysijd.com



      Picture 4: Diagnosis of Common Nerve Root Lesions
      Image Source: McKnight JT & Adcock BB. 



      Picture 5: Diagnosis of Common Nerve Entrapment Syndrome
      Image Source: McKnight JT & Adcock BB.

      Laboratory tests indicated for the diagnosis of underlying cause of paresthesia may include the following [2, 9]:

      • Complete blood count (CBC)
      • Chemistry panel (Chem7)
      • Erythrocyte sedimentation rate (ESR)
      • Urinalysis
      • Thyroid stimulating hormone (TSH)
      • Radiograph of affected extremity
      • CT scan
      • MRI
      • Nerve conduction studies
      • Electromyogram (EMG)
      • Myelography
      • Vitamin B12
      • Serum folate
      • Antinuclear antibody (ANA)
      • Serology for syphilis (VDRL or RPR)
      • Nerve biopsy
      • Muscle biopsy
      • Serum immunoelectrophoresis


      Treatment


      Cure for paresthesia lies on the treatment of its underlying cause. For transient paresthesia, massage and exercise of the affected extremity frequently relieves this symptom. For chronic paresthesia, the following treatment may be helpful [5, 10]:

      • Acupuncture and massage with aromatic oils or capsaicin are useful in relieving paresthesia.
      • Anti-inflammatory drugs like ibuprofen or aspirin are used for mild paresthesia.
      • Low dose antidepressants such as amitriptyline are used to alter the patient’s perception for paresthesia.
      • For severe paresthesia, opioids may be used as prescribed by the physician.
      • Human nerve growth factor is controversial for restoring damaged nerves.
      • Vitamin supplements are used if the cause of paresthesia is nutrient deficiency.
      • Avoid exposure to underlying causes like alcohol and tobacco.

      References
      1. Merriam-Webster Dictionary. Available from: http://www.merriam-webster.com/dictionary/paresthesia
      2. McKnight JT & Adcock BB. Paresthesias: A Practical Diagnostic Approach. American Family Physician 1997 (Dec); 56 (9): 2253–2260
      3. Kasper DL, et. al. Harrison’s Principles of Internal Medicine 19th edition. McGraw-Hill Education. 2015.
      4. Alhoseini MS, Movaghar VR, Vaccaro AR. Underlying Causes of Paresthesia, Paresthesia, Dr. Luiz Eduardo Imbelloni (Ed). ISBN: 978-953-51-0085-0. InTech 2012. Available from: http://www.intechopen.com/books/paresthesia/underlying-causes-of-paresthesia
      5. Paresthesia: Causes, Symptoms, Diagnosis & Treatment. Available from: http://www.disabled-world.com/health/neurology/paresthesia.php
      6. Paresthesia Causes. Family Practice Notebook. Available from: http://www.fpnotebook.com/Neuro/Sensory/PrsthsCs.htm
      7. Neurons and the Nervous System Part 2. Available from: http://people.eku.edu/ritchisong/301notes2b.html
      8. NINDS Paresthesia Information Page. National Institute of Neurological Disorders and Stroke. Available from: http://www.ninds.nih.gov/disorders/paresthesia/paresthesia.htm
      9. Paresthesia. Family Practice Notebook. Available from: http://www.fpnotebook.com/neuro/Sensory/Prsths.htm
      10. Paresthesia. New Health Guide. Available from: http://www.newhealthguide.org/Paresthesia.html
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