From the Guidelines
The primary treatment for diabetes insipidus, specifically nephrogenic diabetes insipidus, involves a combination of free access to fluid, normal-for-age milk intake in infants, and consideration of thiazide and prostaglandin synthesis inhibitors in symptomatic cases, as recommended by the latest expert consensus statement 1.
Treatment Approach
The treatment approach for diabetes insipidus, particularly for nephrogenic diabetes insipidus (NDI), has been outlined in a recent international expert consensus statement published in Nature Reviews Nephrology 1. This statement provides guidance on the management of NDI, emphasizing the importance of:
- Free access to fluid for all children with NDI
- Normal-for-age milk intake in infants to ensure adequate caloric intake
- Considering tube feeding in infants and children with repeated episodes of vomiting and dehydration and/or failure to thrive
- Dietetic counseling to monitor dietary salt and protein intake, reducing renal osmotic load without compromising growth
Medication
In symptomatic infants and children, the consensus recommends starting treatment with a thiazide and prostaglandin synthesis inhibitors 1. Additionally, for patients who develop hypokalaemia induced by thiazides, adding amiloride to thiazide is suggested 1.
Monitoring and Follow-Up
Treatment efficacy should be evaluated through urine osmolality, urine output, weight gain, and growth 1. Ongoing drug treatment should balance apparent efficacy with concerns over the development of side effects 1. Regular follow-up, including kidney ultrasound at least every 2 years to monitor for urinary tract dilatation and/or bladder dysfunction caused by polyuria, is also recommended 1.
Multidisciplinary Care
The management of NDI should be undertaken by a multidisciplinary team that includes a (paediatric) nephrologist, dietitian, psychologist, social worker, and urologist 1, ensuring comprehensive care that addresses the complex needs of patients with this condition.
From the FDA Drug Label
Diabetes Insipidus: 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 primary treatment for central (cranial) diabetes insipidus is desmopressin acetate injection. The dosage range for adults is typically between 0.5 mL (2 mcg) to 1 mL (4 mcg) daily, administered in two divided doses.
- Key points:
- Desmopressin acetate injection is used for antidiuretic replacement therapy.
- It is effective for central (cranial) diabetes insipidus.
- The usual dosage range is 0.5 mL (2 mcg) to 1 mL (4 mcg) daily.
- Administration is typically intravenous or subcutaneous, in two divided doses. 2
From the Research
Primary Treatment for Diabetes Insipidus
The primary treatment for diabetes insipidus, particularly central diabetes insipidus, is based on the administration of desmopressin, a synthetic analogue of antidiuretic hormone (ADH) or arginine-vasopressin (AVP) 3, 4, 5, 6, 7.
Desmopressin Administration
Desmopressin can be administered through various routes, including:
- Subcutaneously to infants or patients with postoperative or posttraumatic brain injury 5
- Intranasally 5, 6
- Orally, with a lyophilisate form that melts under the tongue providing better bioavailability than the previously used tablet form 5, 6
Considerations for Treatment
The treatment aims to replace the deficient hormone and improve patient symptoms, but it may not always result in an optimal quality of life 4. Patient education is crucial to avoid the risk of water intoxication and hyponatremia, which are major complications of desmopressin therapy 3, 5, 6. The dose of desmopressin needs to be carefully titrated, and serum osmolality should be closely monitored, especially when used with other medications affecting water balance 3.
Management Challenges
Management of central diabetes insipidus remains a challenge, particularly in adipsic patients and in young children during intercurrent illness, regardless of the desmopressin formulation 6. A multidisciplinary team is generally recommended for the management and monitoring of central diabetes insipidus 7.