From the FDA Drug Label
Desmopressin acetate injection 4 mcg/mL is indicated as antidiuretic replacement therapy in the management of central (cranial) diabetes insipidus and for the management of the temporary polyuria and polydipsia following head trauma or surgery in the pituitary region. The usual dosage range in adults is 0.5 mL (2 mcg) to 1 mL (4 mcg) daily, administered intravenously or subcutaneously, usually in two divided doses.
The management protocol for central diabetes insipidus in a neurocritical care Intensive Care Unit (ICU) involves the use of desmopressin acetate injection. The dosage should be determined for each patient and adjusted according to the pattern of response, with the goal of achieving adequate duration of sleep and adequate, not excessive, water turnover.
- The usual dosage range is 0.5 mL (2 mcg) to 1 mL (4 mcg) daily, administered intravenously or subcutaneously, usually in two divided doses.
- Fluid restriction should be observed.
- The patient's response should be estimated by two parameters: adequate duration of sleep and adequate, not excessive, water turnover.
- For patients who have been controlled on intranasal desmopressin acetate and who must be switched to the injection form, the comparable antidiuretic dose of the injection is about one-tenth the intranasal dose 1.
From the Research
The management of central diabetes insipidus (CDI) in a neurocritical care ICU should prioritize fluid replacement and desmopressin administration, with careful monitoring to prevent complications such as osmotic demyelination syndrome, as supported by the most recent study 2. The initial treatment involves replacing ongoing fluid losses with hypotonic fluids (0.45% saline or 5% dextrose in water) to correct hypernatremia and maintain euvolemia.
- Desmopressin (DDAVP) is the primary pharmacologic treatment, typically started at 1-2 mcg IV every 8-12 hours or 10-20 mcg intranasally twice daily, with dose adjustments based on urine output, serum sodium, and urine osmolality.
- In the ICU setting, IV administration is preferred for more predictable absorption.
- Careful monitoring is essential, including:
- Hourly urine output
- Fluid balance every 4-6 hours
- Serum sodium levels every 4-6 hours initially, then less frequently once stabilized
- Target sodium correction should not exceed 8-10 mEq/L per 24 hours to prevent osmotic demyelination syndrome.
- Underlying causes of CDI should be addressed simultaneously.
- The triphasic response following neurosurgery or traumatic brain injury requires vigilance, as initial polyuria (phase 1) may be followed by transient inappropriate antidiuretic hormone secretion (phase 2) before returning to permanent CDI (phase 3), as noted in studies 3, 4. This pattern necessitates frequent reassessment and adjustment of fluid and desmopressin therapy to prevent dangerous fluctuations in serum sodium levels, and the use of desmopressin orally disintegrating tablet may be considered for its ease of administration and efficacy, as shown in study 5. Additionally, the phenomenon of transient diabetes insipidus after discontinuation of vasopressin in neurological intensive care unit patients should be recognized, and routine administration of desmopressin may be useful in controlling sodium levels until the condition resolves, as reported in study 6.