What are the indications for DDAVP (desmopressin)?

Indications for DDAVP (Desmopressin)

DDAVP (desmopressin) is primarily indicated for central cranial diabetes insipidus, nocturnal enuresis, mild hemophilia A, and von Willebrand disease. These indications are supported by high-quality evidence and clinical guidelines.

Primary Indications

1. Central Cranial Diabetes Insipidus

• First-line therapy for management of central diabetes insipidus 1
• Indicated for temporary polyuria and polydipsia following head trauma or surgery in the pituitary region 1
• Produces 8-20 hours of antidiuresis in patients with complete central diabetes insipidus 2
• Available in both intranasal and parenteral formulations when the nasal route is compromised (nasal congestion, discharge, atrophy of nasal mucosa, impaired consciousness) 1

2. Nocturnal Enuresis

• Evidence-based therapy (grade Ia evidence) for monosymptomatic nocturnal enuresis 3
• Most effective in children with:
  • Nocturnal polyuria (urine production >130% of expected bladder capacity)
  • Normal bladder reservoir function (maximum voided volume >70% of expected capacity) 3
  • Children in whom alarm therapy has failed or unlikely to comply with alarm therapy 3
• Response rates: approximately 30% full responders, 40% partial responders 3
• Dosing:
  • Oral tablets: 0.2-0.4 mg taken 1 hour before bedtime
  • Oral melt formulation: 120-240 μg taken 30-60 minutes before bedtime 3

3. Bleeding Disorders

• Treatment of mild type I von Willebrand disease 3
• Treatment of mild hemophilia A with Factor VIII levels ≥5% of normal 3
• Works by promoting the release of von Willebrand factor and Factor VIII from the endothelium 4, 5
• Allows for minor surgery in patients with these conditions 4
• Response should be tested individually as efficacy varies between patients 5

4. Uremic Bleeding

• May benefit patients with renal dysfunction experiencing uremia-associated platelet dysfunction 3
• Used alongside cryoprecipitate and optimization of renal status 3

Administration Routes and Dosing

• Intranasal: First-line for diabetes insipidus (10-40 μg nightly) 3
• Oral tablets: Preferred for enuresis (0.2-0.4 mg) 3
• Oral melt formulation: Alternative for enuresis (120-240 μg) 3
• Parenteral: For situations where intranasal route is compromised 1, 6
  • Subcutaneous dosing: 0.5-4 μg shows dose-response relationship 6

Safety Considerations

Water Intoxication Risk

• Primary safety concern is water intoxication with hyponatremia and seizures if combined with excessive fluid intake 3
• Higher risk with nasal spray formulation 3
• Recommendations to prevent:
  • Limit evening fluid intake to 200 ml (6 ounces) or less
  • No drinking until morning 3
  • Polydipsia is a contraindication to desmopressin treatment 3
  • Monitor electrolytes during intercurrent illnesses 3

Other Side Effects

• Generally well-tolerated with few side effects 3, 2
• Uncommon side effects: headache, abdominal discomfort, nasal congestion, nausea 3

Practical Considerations

• For enuresis treatment:

  • Regular drug holidays to assess continued need 3
  • Can be used daily or only before important nights 3
  • Anti-enuretic effect is seen immediately 3
  • May be combined with anticholinergics in therapy-resistant cases 3

• For diabetes insipidus:

  • Monitor response through urine volume and osmolality 1
  • Some patients may show decreased responsiveness or shortened duration of effect over time (usually >6 months) 1

Limitations and Caveats

• Not effective for nephrogenic diabetes insipidus 1
• Curative potential for enuresis is low 3
• Relapse rates after discontinuation in enuresis can be as high as 80% 3, 7
• Nasal spray is no longer recommended for enuresis in many countries due to safety concerns 3
• Response varies significantly between individuals, particularly in bleeding disorders 5

When considering DDAVP, clinicians should carefully evaluate the specific indication, select the appropriate formulation, and implement safety measures to prevent water intoxication, especially in children and patients with polydipsia.