Beer Potomania Syndrome

What is beer potomania?

Beer potomania is a potentially life-threatening condition in which drinking massive amounts of beer in combination with eating no or little food results in a drop in blood sodium levels and osmolality ^[1,2].

Osmolality refers to the concentration of osmotically active solutes, which contributes to the movement of water among the fluid compartments in the body. Low blood osmolality results in water retention in the kidneys and subsequently in low blood sodium levels (dilutional hyponatremia).

Factors that contribute to hyponatremia in beer potomania ^[8]:

• High intake of water (>5 L or 14 cans [12 oz] of beer/day)
• Low intake of sodium
• Low intake of protein

The condition typically occurs in chronic alcoholics ^[2].

The term potomania means craving for alcohol. It originates from the Latin pot = drink and mania = unreasonable enthusiasm ^[6,12].  The synonym for beer potomania is beer drinker’s hyponatremia.

Mechanism

To produce 1 L of maximally dilute urine, the kidneys require 50 to 60 mOsm of solutes (mainly sodium and urea, which is a breakdown product of protein from food) ^[8]. Normally, when you consume sufficient amount of solutes from fluids and foods (600-900 mOsm/day in average), your kidneys can excrete up to about 20 liters of water per day ^[4]. When you drink only beer, which is low in sodium (~40 mg/L) ^[7,10] and protein, and eating no or only a little food and therefore consume only, for example, 250 mOsm solutes per day, your kidneys will be able to excrete only about 5 liters of water per day ^[3,11]. All the additional water you consume with beer will stay in your body and cause a drop of blood sodium and osmolality or specifically euvolemic hypotonic hyponatremia. This can result in the movement of water from the blood into the tissues, including the brain and cause brain swelling (cerebral edema).

Symptoms

Symptoms of beer potomania are similar to water intoxication and other conditions with hyponatremia and can include ^[1,9]:

• Early symptoms: dizziness, impaired gait, fatigue, muscle weakness, decreased appetite, nausea or vomiting, headache
• Late symptoms: confusion, tremor, swelling of the feet or hands, abdominal pain, muscle cramps, decreased or no urination, seizures, coma or death

Diagnosis

Blood tests ^[5]:

• Sodium: low (<12o mEq/L) (severe hyponatremia)
• Potassium: normal or low (<3.5 mEq/L) (hypokalemia)
• Blood urea nitrogen (BUN): low (<7 mg/L or <2.5 mmol/L)
• Osmolality: low (<275 mOsm/kg)

Urine tests ^[2,5,8]:

• Sodium: usually low (<40 mEq/L/24 h)
• Osmolality: low (<300 mOsm/kg)
• Specific gravity: low (<1.010)

Differential Diagnosis

Other common causes of hyponatremia in a chronic alcoholic ^[5]:

• Liver cirrhosis
• Congestive heart failure
• Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
• Hypovolemia
• Pseudohyponatremia secondary to alcohol-induced severe hypertriglyceridemia
• Cerebral salt-wasting syndrome

Two other behaviors, similar to beer potomania, which can also result in hyponatremia are compulsive water drinking (psychogenic polydipsia) and “tea and toast” diet ^[3].

Treatment

A person who has drunk a massive amount of beer and consumed no or little food over several days and is confused or has other symptoms of hyponatremia needs to be treated in the hospital, preferably in the intense care. 

The goal of the treatment is to slowly (in the course of few days) increase the blood sodium levels toward the normal levels. Treatment may include ^[2,8]:

• Total food and fluid restriction for 24 hours
• If symptoms are present: isotonic saline (0.9% NaCl)
• D5W (5% dextrose in water)
• Treatment guidelines

• References

  1. Hilden T et al, 1975, Electrolyte disturbances in beer drinkers. A specific “hypo-osmolality syndrome”.  PubMed
  2. Harrow AS, 1989, Beer potomania syndrome in an alcoholic  PubMed
  3. Beer potomania  Renal Fellow Network
  4. Beer potomania syndrome (Hyponatremia)  Medicalopedia
  5. Unterseher K, 2014, Hyponatremia: Beer Potomania  Clinical Reviews
  6. poto-, pot-  WordInfo
  7. Sodium content of beverages  USDA.gov
  8. Sanghvi SR et al, 2007, Beer Potomania: An Unusual Cause of Hyponatremia at High Risk of Complications From Rapid Correction  Tufts University
  9. McGraw M, 2012, Beer potomania: Drink in this atypical cause of hyponatremia  Lippincott Nursing Center
  10. What is the sodium content of beer by brand?  Reference.com
  11. Kujubu DA, 2015, Beer Potomania—An Unusual Cause of Hyponatremia  PubMed Central
  12. Definition of mania  Merriam-Webster