Pharm

Desmopressin

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Desmopressin, dDAVP, Synthetic Hormone Arginine Vasopressin, Synthetic Vasopressin, Noctiva

  • Indications
  1. Diabetes Insipidus
  2. Control of Hemophilia A related bleeding
  3. Primary Nocturnal Enuresis
  4. Nocturia (non-medication options are preferred)
  5. Von Willebrand's Disease
    1. Type I (and in Type 2N) cases prior to surgery and in cases of Trauma
    2. Other VWD forms (Type 2, Type 3 and pseudo-VWF) will not respond to DDAVP
      1. May have paradoxical lowering of VWF
  • Contraindications
  1. Impaired Renal Function
  2. Congestive Heart Failure
  • Mechanism
  1. Synthetic ADH replacement Hormone (anologue of Vasopressin)
  2. Potent antidiuretic
  3. No Vasopressor activity
  4. Urine Volume decreases by resorbing water at distal renal tubules
  5. Increases release of Von Willebrand FactorProtein (stored in Weibel-Palade bodies)
  • Pharmacokinetics
  1. Duration of action: 12 hours
  1. General
    1. If effective, may continue for 3-6 months
    2. Maintain dose for 4-6 weeks and then slowly taper off over 6 months
      1. Discontinue slowly (e.g. 10 mcg/month)
      2. Reduces risk of relapse
    3. Consider in combination with Bed-Wetting Alarm or Oxybutynin
  2. Desmopressin Intranasal (standard, high dose)
    1. Not recommended due to risk of Hyponatremia (from Water Intoxication)
    2. Initial: 5 mcg spray each nostril qhs
    3. Increase as needed up to 20 mcg each nostril qhs
  3. Desmopressin Intranasal (Noctiva, low dose)
    1. Each spray delivers 0.83 to 1.66 mcg
    2. Marketed for Nocturia in adults (but other non-medication approaches are preferred)
    3. Expensive: $425/month in 2018
  4. Desmopressin Oral
    1. Initial: 0.2 mg PO qhs
    2. Use lowest effective dose
    3. Increase as needed to 0.6 mg at bedtime
  1. Nasal Spray: 10-40 mcg daily (or divided 2-3 times per day)
    1. Intranasal 5 mcg equivalent to 0.1 mg oral
  2. Oral Tablet: 0.05 to 1.2 mg orally daily (or divided 2-3 times daily)
  3. Subcutaneous or IV: 2-4 mcg/day IV/SC divided twice daily
  1. IV: 0.3 mcg/kg IV over 15 to 30 minutes
  2. Intranasal concentrated dDAVP (Stimate)
    1. Weight <50kg: 150 mcg intranasally (1 spray in SINGLE nostril)
    2. Weight >50kg: 300 mcg intranasally (1 spray EACH nostril)
  3. Pharmacokinetics specific to VWF release
    1. Onset of action within 30-60 minutes with duration of 6-12 hours
    2. Do not repeat more often than every 24 to 48 hours due to Hyponatremia risk (as well as tachyphylaxis)
  • Adverse Effects
  1. Nasal irritation or Epistaxis with nasal spray
  2. Behavior changes
    1. Aggressive behavior
    2. Nightmares
  3. Nocturia
    1. Administer at night to reduce Nocturia
  4. Severe Hyponatremia (Water Intoxication)
  5. Seizures (with high dose Desmopressin nasal sprays)
  • Labs
  1. Serum Sodium
    1. Obtain baseline, at 7 days, 30 days and periodically (esp. after dose changes)
  1. Most effective in over age 8-9 years (60-70% respond)
  2. Also more effective if only a few wet nights and normal Bladder capacity
  3. High relapse rate (>80%); Reduced if slowly tapered - see doing above
  • Disadvantages
  1. Expensive
  2. Severe Hyponatremia risk
  1. Diuretics
  2. Corticosteroids (inhaled or systemic)
  3. Selective Serotonin Reuptake Inhibitors (SSRI)
  4. Chronic NSAIDs
  • References
  1. Deloughery and Orman in Majoewsky (2013) EM:Rap 13(9): 1-4
  2. Tullus (1999) Acta Paediatr 88:1274-8 [PubMed]
  3. Kruse (2001) BJU Int 88:572-6 [PubMed]
  4. Robson (2007) J Urol 178: 24-30 [PubMed]