From the Guidelines
Diabetes insipidus should be managed based on its type, with central diabetes insipidus treated with desmopressin (DDAVP) and nephrogenic diabetes insipidus treated with thiazide diuretics, a low-salt diet, and NSAIDs in some cases, as recommended by the most recent expert consensus statement 1.
Diagnosis and Management
Diabetes insipidus is a rare disorder characterized by excessive thirst and urination due to the body's inability to properly regulate water balance. It occurs in two main forms: central diabetes insipidus, caused by insufficient production of antidiuretic hormone (ADH) by the pituitary gland, and nephrogenic diabetes insipidus, where the kidneys don't respond properly to ADH.
- Central diabetes insipidus is typically treated with desmopressin (DDAVP), available as nasal spray (10-40 mcg daily in 1-3 doses), oral tablets (0.1-0.8 mg daily), or sublingual tablets (60-240 mcg daily) 1.
- Nephrogenic diabetes insipidus may be treated with thiazide diuretics like hydrochlorothiazide (25-50 mg daily) along with a low-salt diet and NSAIDs like indomethacin in some cases 1.
Importance of Genetic Testing
Genetic testing can provide an early and definite diagnosis of congenital nephrogenic diabetes insipidus, with important implications for clinical management and outcome, and can avoid unpleasant, challenging, and potentially harmful diagnostic procedures 1.
- A genetic diagnosis can help identify patients with partial insensitivity to AVP and inform recurrence risks and support patient decision-making regarding family planning.
- Genetic testing should be performed in a laboratory accredited for diagnostic genetic testing, using a massively parallel sequencing-based multigene panel that includes at least AQP2, AVPR2, and AVP 1.
Monitoring and Maintenance
Patients with diabetes insipidus should monitor fluid intake and output, maintain adequate hydration while avoiding overhydration, and be aware of symptoms of water imbalance such as headache, confusion, or lethargy 1.
- Proper diagnosis through water deprivation tests and measurement of blood and urine osmolality is essential for effective management.
- The condition differs from diabetes mellitus as it involves water regulation rather than blood glucose control, though both cause increased urination and thirst.
From the FDA Drug Label
2 DOSAGE AND ADMINISTRATION 2. 1 Pretreatment Testing and On-Treatment Monitoring Diabetes Insipidus Prior to treatment with desmopressin acetate injection, assess serum sodium, urine volume and osmolality.
2.2 Recommended Dosage Initiate fluid restriction during treatment with desmopressin acetate injection [see Warnings and Precautions (5.1), Use in Specific Populations (8.4,8. 5)]. Diabetes Insipidus Treatment naïve patients: The recommended starting daily dosage is 2 mcg to 4 mcg administered as one or two divided doses by subcutaneous or intravenous injection.
The recommended starting daily dosage of desmopressin for Diabetes Insipidus is 2 mcg to 4 mcg administered as one or two divided doses by subcutaneous or intravenous injection 2.
- Key points:
- Initiate fluid restriction during treatment with desmopressin acetate injection.
- Assess serum sodium, urine volume, and osmolality prior to treatment.
- Adjust dose based upon response to treatment estimated by adequate duration of sleep and adequate, not excessive, water turnover.
From the Research
Definition and Causes of Diabetes Insipidus
- Diabetes insipidus (DI) is a rare endocrine disease involving antidiuretic hormone (ADH) that encompasses both central and nephrogenic causes 3.
- Central diabetes insipidus (CDI) is associated with arginine vasopressin (AVP) deficiency, resulting in polyuria and polydipsia 4, 5.
- Nephrogenic diabetes insipidus results from resistance to AVP in the kidneys 3, 6.
- Other forms of DI include gestational diabetes insipidus and primary polydipsia 6.
Diagnosis of Diabetes Insipidus
- The gold standard for diagnosis is a water deprivation test followed by desmopressin administration 3.
- A detailed medical history, physical examination, and imaging studies are needed to detect the etiology of diabetes insipidus 6.
- Differentiation between the various forms of hypotonic polyuria can be done by the classical water deprivation test or the more recently developed hypertonic saline or arginine stimulation together with copeptin (or AVP) measurement 6.
Treatment of Diabetes Insipidus
- Desmopressin is recognized as the drug of choice for central diabetes insipidus due to its selective antidiuretic activity 7.
- Desmopressin is available for intranasal and parenteral administration, and its antidiuretic doses range from 10 to 40 micrograms intranasally and from 2 to 4 micrograms intravenously or subcutaneously 7.
- Desmopressin orally disintegrating tablet (ODT) is effective and well-tolerated in the treatment of CDI, with a mean daily dose ratio of intranasal desmopressin to desmopressin ODT of 1:24 4.
- Therapy with desmopressin in patients with transient and permanent CDI after resection of chiasmo-sellar region tumors is effective and safe in the early postoperative and long-term postoperative periods 5.