What is the treatment for gastrointestinal (GI) bleeding in a patient with impaired renal function undergoing dialysis using Desmopressin (DDAVP)?

From the Guidelines

DDAVP (desmopressin) is a recommended treatment option for gastrointestinal bleeding in dialysis patients, with a typical dose of 0.3 μg/kg intravenously, as it stimulates the release of von Willebrand factor and improves platelet adhesion and clot formation, as supported by the most recent guidelines 1. The use of desmopressin in dialysis patients with gastrointestinal bleeding is based on its ability to increase the release of von Willebrand factor and factor VIII from endothelial stores, which helps improve platelet adhesion and clot formation. This mechanism is particularly beneficial in uremic patients who often have platelet dysfunction. Some key points to consider when using DDAVP in dialysis patients include:

• Timing the administration just after dialysis to prevent premature clearance of the medication
• Monitoring for side effects such as hyponatremia, fluid retention, hypotension, and facial flushing
• Carefully assessing the risk of fluid overload and monitoring blood pressure during administration
• Using DDAVP cautiously in patients with coronary artery disease due to potential vasoconstrictive effects While DDAVP can provide temporary hemostasis, the underlying cause of bleeding should still be identified and definitively treated. The most recent guidelines suggest that desmopressin may lead to a small reduction in blood loss and volume of RBCs transfused in patients undergoing cardiac surgery, although the certainty of the evidence is low 1. In patients on antiplatelet drugs who experience intracranial haemorrhage, a multicentre trial demonstrated feasibility and safety of desmopressin administration, but confirmatory data are needed 1. Overall, the use of DDAVP in dialysis patients with gastrointestinal bleeding should be based on the individual patient's clinical response and underlying medical conditions, and should be guided by the most recent and highest quality evidence available 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment of GI Bleed in Dialysis Patients with DDAVP

• DDAVP (desmopressin) is a synthetic analogue of the antidiuretic hormone L-arginine vasopressin that can raise circulating levels of factor VIII and von Willebrand factor, making it a potential treatment for uremic bleeding syndrome 2.
• A study published in 2004 found that DDAVP administration shortened bleeding time and increased factor VIII and VWF levels in hemodialysis patients, indicating its potential use in patients with serious bleeding 3.
• Another study published in 2007 reviewed the treatment options for uremic bleeding syndrome, including DDAVP, and found that it can be used to prevent or treat bleeding in patients with uremic bleeding syndrome 4.
• The management of uremic bleeding may include dialysis, red-blood-cell transfusions, cryoprecipitate, desmopressin, and conjugated estrogens, with DDAVP being a useful option for short-term treatment 5.
• However, the frequency of tachyphylaxis with DDAVP is high, limiting its usefulness for major bleeds, and conjugated estrogens may provide a more sustained hemostatic effect 6.

Mechanism of Action of DDAVP

• DDAVP increases the release of von Willebrand factor from storage sites, which helps to improve platelet adhesion and aggregation, reducing the risk of bleeding 2.
• DDAVP also increases the levels of factor VIII, which is essential for the coagulation cascade 3.
• The increase in VWF and factor VIII levels after DDAVP administration can help to shorten bleeding time and reduce the risk of bleeding in patients with uremic bleeding syndrome 3.

Clinical Use of DDAVP

• DDAVP can be used to treat uremic bleeding syndrome, including gastrointestinal bleeding, in patients with chronic renal failure 3, 4.
• DDAVP can also be used to prevent bleeding in patients with uremic bleeding syndrome who are undergoing surgical procedures or other invasive procedures 2.
• However, the use of DDAVP should be carefully considered, taking into account the risk of tachyphylaxis and the potential for conjugated estrogens to provide a more sustained hemostatic effect 6.