Otsuka is pushing tolvaptan (Scamsca™) hard. We are getting detailed a lot, and I hear that the cardiologists are also getting an earful. Honestly, the data looks a little thin to me. The drug is the most reliable method for tackling persistent SIADH. But that’s rare. In my experience, usual care fixes almost every case of hyponatremia within a day or two. There are a minority of cases that don’t respond quickly. These episodes of persistent hyponatremia worry me. Unfortunately, tolvaptan doesn’t feel like a good option for these patients. We know from the SALT studies that a week after you stop the drug the sodium equals the control group and the drug costs $300 per day (average wholesale price (PDF), retail price). I find it hard to prescribe a $9,000 per month drug for chronic therapy. I’ll stick with salt tablets, furosemide and water restriction.