From the Guidelines
Desmopressin (DDAVP) can cause hyponatremia by increasing water reabsorption in the kidneys without sodium retention, leading to dilutional hyponatremia, and management strategies include immediate discontinuation of the medication and fluid restriction to 1-1.5 L/day for mild to moderate cases. This synthetic analog of vasopressin binds to V2 receptors in the collecting ducts, increasing water permeability and promoting water retention while urine becomes more concentrated 1. The risk of hyponatremia is higher when desmopressin is combined with excessive fluid intake, and polydipsia is a contraindication to desmopressin treatment 1.
Key Management Strategies
- Immediate discontinuation of desmopressin when serum sodium drops below 130 mEq/L or if symptoms develop
- Fluid restriction to 1-1.5 L/day for mild to moderate cases
- For severe symptomatic hyponatremia (sodium <120 mEq/L with neurological symptoms), 3% hypertonic saline may be administered at 1-2 mL/kg/hr with careful monitoring to avoid rapid correction
- Sodium correction should not exceed 8-10 mEq/L in 24 hours to prevent osmotic demyelination syndrome
- Regular monitoring of serum sodium levels (every 2-4 hours initially in severe cases) is essential
- When restarting DDAVP after an episode, use lower doses with careful titration, administer at bedtime to minimize daytime fluid intake effects, and implement routine sodium monitoring 1.
Patient Education
- Patients should be educated about recognizing early symptoms of hyponatremia such as headache, nausea, confusion
- Importance of appropriate fluid intake while on this medication, with a general recommendation of an evening intake of 200 ml (6 ounces) or less and then no drinking until morning 1.
From the FDA Drug Label
Desmopressin acetate can cause hyponatremia. Severe hyponatremia can be life-threatening if it is not promptly diagnosed and treated, leading to seizures, coma, respiratory arrest, or death [see Boxed Warning]. Prior to starting or resuming desmopressin acetate, ensure that the serum sodium concentration is normal Limit fluid intake to a minimum from 1 hour before administration until 8 hours after administration. Monitor the serum sodium concentration within 1 week and approximately 1 month of initiating desmopressin acetate, and periodically thereafter
Desmopressin causes hyponatremia by increasing water reabsorption in the kidneys, leading to an excess of water in the body and a dilution of sodium levels in the blood. Management strategies for hyponatremia caused by desmopressin include:
- Discontinuing desmopressin acetate temporarily or permanently
- Restricting fluid intake to a minimum from 1 hour before administration until 8 hours after administration
- Monitoring serum sodium levels within 1 week and approximately 1 month of initiating desmopressin acetate, and periodically thereafter
- Treating hyponatremia depending on the clinical circumstances, including the duration and severity of the hyponatremia 2 2
From the Research
Desmopressin and Hyponatremia
- Desmopressin (DDAVP) is a synthetic vasopressin receptor agonist that can lead to renal water retention, resulting in iatrogenic hyponatremia if fluid intake is not restricted 3.
- The use of desmopressin has been associated with hyponatremia in several cases, including a 29-year-old woman with primary nocturnal enuresis who developed severe hyponatremia after starting intranasal desmopressin therapy 4.
Mechanism of Hyponatremia
- Desmopressin-induced hyponatremia is mainly due to the syndrome of inappropriate antidiuresis (SIAD), which can be grouped into syndrome of inappropriate antidiuretic hormone secretion (SIADH) and nephrogenic syndrome of inappropriate antidiuresis (NSIAD) 5.
- Desmopressin binds to the vasopressin V2 receptor (V2R), leading to water reabsorption in the kidneys and resulting in hyponatremia 5.
Management Strategies
- In the management of desmopressin-associated hyponatremia with neurologic symptoms, the drug should not be withheld despite the presence of hyponatremia, and intravenous hypertonic saline solution should be administered concurrently 3.
- Desmopressin can be used to minimize water excretion during the correction of hyponatremia, and clinicians should monitor closely to avoid free-water diuresis 3.
- A proactive strategy of desmopressin administration with hypertonic saline may be effective in preventing rapid sodium correction in severe hyponatremia 6.
- Discontinuation of desmopressin and concurrent use of hypertonic saline can be an effective treatment strategy in patients with desmopressin-induced hyponatremia 7.