Do you use tolvaptan for management of hyponatremia related to heart failure given the side effect profile and lack of mortality benefit seen in a previous trial?

In general, I have not found this to be helpful even though the trials showed a small benefit for sodium levels during the hospitalization only (none at longer-term follow-up). The trials did not show mortality benefit as stated in the question stem - nor did they show benefit for other meaningful outcomes such as heart failure hospitalizations or even body weight - and there was a signal towards worse creatinine in the tolvaptan group during hospitalization. The main reason, though, that I think that use of tolvaptan is limited during this setting is that it confuses the picture for the patient with respect to fluid restriction - risk of hypernatremia exists and access to free water should generally be liberalized, and this often counterac...