From the Guidelines
Diabetes insipidus (DI) should be diagnosed and treated based on its type, with central DI typically managed with desmopressin (DDAVP) and nephrogenic DI treated with thiazide diuretics, a low-salt diet, and NSAIDs in some cases, as recommended by the latest expert consensus statement 1.
Diagnosis and Treatment Overview
The diagnosis of DI involves distinguishing between central and nephrogenic forms, which is crucial for guiding treatment. Central DI is characterized by insufficient production of antidiuretic hormone (ADH) by the pituitary gland, while nephrogenic DI results from the kidneys' inability to respond properly to ADH.
Treatment Approaches
- For Central Diabetes Insipidus: Desmopressin (DDAVP) is the primary medication, available in various forms including 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.
- For Nephrogenic Diabetes Insipidus: Thiazide diuretics like hydrochlorothiazide (25-50 mg daily) may be prescribed, often alongside a low-salt diet and NSAIDs like indomethacin in certain cases 1.
Management Recommendations
Key recommendations for managing DI, especially in children, include:
- Free access to fluid for all children with nephrogenic DI (level X, strong) 1.
- Normal-for-age milk intake instead of water in infants to ensure adequate caloric intake (level B, moderate) 1.
- Considering tube feeding in infants and children with repeated episodes of vomiting, dehydration, and/or failure to thrive (level B, moderate) 1.
- Dietetic counseling to monitor dietary salt and protein intake, reducing renal osmotic load without compromising growth (level B, moderate) 1.
- Starting treatment with a thiazide and prostaglandin synthesis inhibitors in symptomatic infants and children (level B, moderate) 1.
- Adding amiloride to thiazide in patients with thiazide-induced hypokalemia (level B, moderate) 1.
Monitoring and Follow-Up
Regular monitoring of urine osmolality, urine output, weight gain, and growth is essential to evaluate treatment efficacy (level D, strong) 1. Ongoing drug treatment should balance apparent efficacy with the concern for side effects (level B, strong) 1. A multidisciplinary team approach, including a nephrologist, dietitian, psychologist, social worker, and urologist, is recommended for patient care (level X, strong) 1.
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. Response should be estimated by two parameters: adequate duration of sleep and adequate, not excessive, water turnover. Laboratory tests for monitoring the patient include urine volume and osmolality In some cases, plasma osmolality may be required.
The diagnosis of Diabetes Insipidus (DI) involves assessing urine volume and osmolality, as well as plasma osmolality in some cases. The treatment for central (cranial) DI is desmopressin acetate injection, with a usual dosage range of 0.5 mL (2 mcg) to 1 mL (4 mcg) daily, administered intravenously or subcutaneously, usually in two divided doses 2. Key considerations for treatment include:
- Monitoring urine volume and osmolality
- Adjusting dosage based on response
- Restricting fluid intake to prevent hyponatremia and water intoxication 2
- Using caution in patients with conditions associated with fluid and electrolyte imbalance, such as cystic fibrosis, heart failure, and renal disorders 2
From the Research
Diagnosis of Diabetes Insipidus (DI)
- Diabetes insipidus is a disorder characterized by a high hypotonic urinary output of more than 50ml per kg body weight per 24 hours, with associated polydipsia of more than 3 liters a day 3
- The diagnosis of DI must be distinguished from primary polydipsia and other causes of hypotonic polyuria 4
- The gold standard for diagnosis is a water deprivation test followed by desmopressin administration 4
- A new surrogate marker of ADH called copeptin may simplify and improve the accuracy in diagnosing DI in the future 4
- Functional tests such as water deprivation or stimulation of copeptin by hyperosmolarity can be proposed to distinguish between different etiologies 5
Treatment of Diabetes Insipidus (DI)
- Treatment of central DI consists of fluid management and drug therapy with the synthetic AVP analogue Desmopressin (DDAVP) 3
- Patients with DI require adequate access to water, and there are nuances on treatment approaches depending on whether a patient is diagnosed with central or nephrogenic DI 4
- The treatment of diabetes insipidus depends on the underlying etiology, and in the case of a central etiology, is based on the administration of desmopressin 5
- Oral dDAVP has replaced nasal dDAVP as a more reliable mode of treatment for chronic central diabetes insipidus 6
- Hyponatraemia is a common side effect of dDAVP treatment, and should be avoided by allowing a regular break from dDAVP to allow a resultant aquaresis 6
- Treatment of nephrogenic diabetes insipidus involves removing the underlying cause, if possible, reducing solute load or therapy with a diuretic agent 7