desmopressin

BEERS REMS

PO:
SC: IV:
Central diabetes insipidus caused by a deficiency of vasopressin.
IV: Bleeding in certain types of hemophilia and von Willebrand’s disease.
Nocturia due to nocturnal polyuria in patients who awaken ≥2 times per night to void (Nocdurna only)
PO:
Primary nocturnal enuresis.

Action ⬆ ⬇

An analogue of naturally occurring vasopressin (antidiuretic hormone). Primary action is enhanced reabsorption of water in the kidneys.

Therapeutic effects:

Prevention of nocturnal enuresis.
Reduction in number of episodes of nocturia.
Maintenance of appropriate body water content in diabetes insipidus.
Control of bleeding in certain types of hemophilia or von Willebrand’s disease.

Pharmacokinetics ⬆ ⬇

Absorption: <1% absorbed following oral or SL administration; nasal solution 10–20% absorbed; nasal spray 3–4% absorbed.

Distribution: Distribution not fully known.

Metabolism/Excretion: Primarily excreted in urine.

Half-Life: PO: 1.5–2.5 hr; SL: 2.8 hr; IV: 75 min (↑ in renal impairment); Intranasal: 1.8–3.5 hr.

Time/Action Profile ⬆ ⬇

(PO, intranasal = antidiuretic effect; IV = effect on factor VIII activity)

ROUTE	ONSET	PEAK	DURATION
PO	1 hr	4–7 hr	unknown
SL	unknown	unknown	unknown
Intranasal	1 hr	1–5 hr	8–20 hr
IV	within min	15–30 min	3 hr‡

‡4–24 hr in mild hemophilia A.

Contraind./Precautions ⬆ ⬇

Contraindicated in:

Hypersensitivity;
Hypersensitivity to chlorobutanol;
Patients with severe type I, type IIB, or platelet-type (pseudo) von Willebrand’s disease, hemophilia A with factor VIII levels <5%, or hemophilia B;
Renal impairment (CCr <50 mL/min);
Current or a history of hyponatremia;
Polydipsia (Nocdurna only);
Concurrent use with loop diuretics or systemic/inhaled glucocorticoids (Nocdurna only);
Known or suspected syndrome of inappropriate antidiuretic hormone secretion (Nocdurna only);
Conditions that can lead to electrolyte or fluid imbalances, including gastroenteritis, salt-wasting nephropathies, or infection (Nocdurna only);
HF (New York Heart Association class II-IV) (Nocdurna only);
Uncontrolled hypertension (Nocdurna only);
OB: Nocdurna not recommended for treatment of nocturia in pregnancy.

Use Cautiously in:

Angina pectoris;
Hypertension;
Patients at risk for hyponatremia;
Patients at risk for ↑ intracranial hypertension (Nocdurna only);
Urinary retention (Nocdurna only);
Women (↑ risk of hyponatremia; require ↓ dose) (Nocdurna only);
Patients who require use of other intranasal medications
Pedi: Safety and effectiveness not established in children (Nocdurna only);
Geri: Appears on Beers list. risk of hyponatremia in older adults. Avoid use for treatment of nocturia or nocturnal polyuria in older adults.

Adv. Reactions/Side Effects ⬆ ⬇

CV: edema, hypertension, hypotension, tachycardia (large IV doses only)

Derm: flushing

EENT:

intranasal

epistaxis, nasal congestion, nasal discomfort, rhinitis, sneezing

F and E: HYPONATREMIA

GI: dry mouth, mild abdominal cramps, nausea

GU: vulval pain

Local: phlebitis at IV site

MS: back pain

Neuro: dizziness, drowsiness, headache, listlessness, SEIZURES

Resp: dyspnea

Interactions ⬆ ⬇

Drug-drug:

Loop diuretics, systemic glucocorticoids, or inhaled glucocorticoids↑ risk of severe hyponatremia; concurrent use with Nocdurna contraindicated
Carbamazepine, chlorpromazine, lamotrigine, NSAIDs, opioids, SSRIs, sulfonylureas, TCAs, or thiazide diuretics may ↑ risk of fluid retention and hyponatremia.
Demeclocycline, lithium, or norepinephrine may diminish the antidiuretic response to desmopressin.
Large doses may enhance the effects of vasopressors.

Route/Dosage ⬆ ⬇

Primary Nocturnal Enuresis

PO (Adults and Children ≥6 yr): 0.2 mg at bedtime; may be titrated up to 0.6 mg at bedtime to achieve desired response.
(Adults and Children ): 120 mcg 1 hr before bedtime; may be titrated up to 360 mcg at bedtime to achieve desired response.

Diabetes Insipidus

PO (Adults and Children ): 0.05 mg twice daily; adjusted as needed (usual range: 0.1–1.2 mg/day for adults or 0.1–0.8 mg/day for children in 2–3 divided doses).
(Adults and Children ): 60 mcg 3 times daily; adjusted as needed (usual range: 120–720 mcg/day in 2–3 divided doses).
(Adults and Children ≥12 yr): DDAVP: 5–40 mcg (0.0.05–0.4 mL) in 1–3 divided doses.
(Children 3 mo–12 yr): DDAVP: 5–30 mcg (0.05–0.3 mL) in 1–2 divided doses.
SC IV (Adults and Children ≥12 yr): 2–4 mcg/day in 2 divided doses.
SC IV (Children <12 yr): 0.1–1 mcg/day in 1–2 divided doses.

Hemophilia A/von Willebrand's Disease

IV (Adults and Children >3 mo): 0.3 mcg/kg, repeated as needed.

Nocturia

(Adults ): Women: 27.7 mcg 1 hr before bedtime; Men: 55.3 mcg 1 hr before bedtime.

Availability ⬆ ⬇

(Generic available)

Tablets: 0.1 mg; 0.2 mg
Sublingual tablet (Nocdurna): 27.7 mcg; 55.3 mcg; 60 mcg; 120 mcg
Nasal spray: 10 mcg/spray in 5-mL bottle (contains 50 sprays)
Solution for injection: 4 mcg/mL; 15 mcg/mL

Assessment ⬆ ⬇

Restrict free water intake and monitor for hyponatremia.
Nocturnal Enuresis: Monitor frequency of enuresis during therapy. Use cautiously in patients at risk for water intoxication with hyponatremia.
Do not use intranasal form for nocturnal enuresis.
Nocturia: Assess for possible causes of nocturia (adults who awaken at least 2 times per night to void), including excessive fluid intake before bedtime, and address other treatable causes of nocturia.
Diabetes Insipidus: Monitor serum sodium, urine and plasma osmolality and urine volume frequently. Assess patient for symptoms of dehydration (excessive thirst, dry skin and mucous membranes, tachycardia, poor skin turgor). Weigh patient daily and assess for edema.
Hemophilia: Monitor plasma factor VIII coagulant, factor VIII antigen, and ristocetin cofactor. May also assess activated partial thromboplastin time (aPTT) for hemophilia A and skin bleeding time for von Willebrand’s disease. Assess patient for signs of bleeding.
- Monitor BP and pulse during IV infusion.
- Monitor intake and output and adjust fluid intake (especially in children and elderly) to avoid overhydration in patients receiving desmopressin for hemophilia.

Lab Test Considerations:

Begin Nocdurna with a normal serum sodium level. Determine that serum sodium concentration is normal before starting or resuming Nocdurna, within 1 wk, 1 mo after starting, and periodically during therapy. Patients ≥65 yrs and older and patients at ↑ risk of hyponatremia may require more frequent monitoring. May need to hold or discontinue therapy if hyponatremia occurs.
- Nocdurna: Obtain a 24-hr urine collection to confirm diagnosis of nocturnal polyuria before starting therapy.

Toxicity and Overdose:

Signs and symptoms of water intoxication include confusion, drowsiness, headache, weight gain, difficulty urinating, seizures, and coma.
- Treatment of overdose includes decreasing dose and, if symptoms are severe, administration of furosemide.

Implementation ⬆ ⬇

Do not confuse desmopressin with vasopressin.
IV desmopressin has 10 times the antidiuretic effect of intranasal desmopressin.
PO: Begin oral doses 12 hr after last intranasal dose. Monitor response closely.
Administer 1 hr before bedtime. Place tablet under tongue until dissolved completely. Nocdurna: Limit fluid intake for at least 1 hr before until 8 hrs after administration. Use without fluid reduction may lead to fluid retention and hyponatremia.
Diabetes Insipidus: Parenteral dose for antidiuretic effect is administered IV push or SUBQ.
Hemophilia: Parenteral dose for control of bleeding is administered via IV infusion. If used preoperatively, administer 30 min prior to procedure.
If intranasal dose is used preoperatively, administer 2 hr before procedure.

IV Administration:

(for diabetes insipidus).
Diluent: Administer undiluted.Concentration: 4 mcg/mL.
Intermittent Infusion: Diluent: Dilute each dose in 50 mL of 0.9% NaCl for adults and children >10 kg and in 10 mL in children weighing 10 kg. Inspect solution; do not administer solutions that are cloudy, discolored, or contain particulate matter.Concentration: Maximum 0.5 mcg/mL.
Rate: Infuse slowly over 15–30 min.

Patient/Family Teaching ⬆ ⬇

Diabetes Insipidus:

If nasal spray is used, prime pump prior to first use by pressing down 4 times. Caution patient that nasal spray should not be used beyond the labeled number of sprays; subsequent sprays may not deliver accurate dose. Do not attempt to transfer remaining solution to another bottle.
Instruct patient to take missed doses as soon as remembered but not if it is almost time for the next dose. Do not double doses.
Advise patient that rhinitis or upper respiratory infection may decrease effectiveness of this therapy. If increased urine output occurs, patient should contact health care professional for dose adjustment.
Patients with diabetes insipidus should carry identification at all times describing disease process and medication regimen.

Explain purpose of desmopressin to patient.
Advise patient to notify health care professional if bleeding is not controlled or if headache, dyspnea, heartburn, nausea, abdominal cramps, vulval pain, or severe nasal congestion or irritation occurs.
- Caution patient to avoid concurrent use of alcohol with this medication.
- Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications.
Rep: Advise females of reproductive potential to notify health care professional if pregnancy is planned or suspected or if breastfeeding.
Nocturia: Instruct patient to place tablet under tongue 1 hr before bedtime and empty bladder immediately before bedtime.
- Advise patient to limit fluid intake before bedtime and to avoid caffeine and alcohol before bedtime.
- Advise patient to notify health care professional immediately if signs and symptoms of hyponatremia (headache, feeling restless, drowsiness, muscle cramps, nausea or vomiting, fatigue, dizziness, change in mental condition [hallucinations, confusion, decreased awareness or alertness]) occur.
- Instruct patient to notify health care professional if fever, infection, or diarrhea occurs. May need to hold medication.

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇