What are the indications and doses for desmopressin (DDAVP)?

Desmopressin (DDAVP) Indications and Dosing Guidelines

Desmopressin is indicated for central diabetes insipidus, nocturnal enuresis, von Willebrand disease (Type I), hemophilia A, and patients on platelet-inhibiting drugs with bleeding, with specific dosing regimens for each condition.

Central Diabetes Insipidus

Indications:

• Antidiuretic replacement therapy in central (cranial) diabetes insipidus
• Management of temporary polyuria and polydipsia following head trauma or pituitary surgery
• Not effective for nephrogenic diabetes insipidus 1

Dosing:

• Parenteral (IV/SC): 2-4 mcg daily, administered as one or two divided doses 1
• Oral tablets: 0.2-0.4 mg daily 2
• Oral melt formulation: 120-240 mcg daily 2
• Timing for oral tablets: at least 1 hour before sleep
• Timing for oral melt: 30-60 minutes before bedtime 2

Nocturnal Enuresis

Indications:

• Monosymptomatic enuresis in children 3
• Most effective in children with nocturnal polyuria and normal bladder function

Dosing:

• Oral tablets: 0.2-0.4 mg at bedtime
• Oral melt: 120-240 mcg at bedtime
• Timing: Tablets 1 hour before sleep; oral melt 30-60 minutes before bedtime 3

Hemophilia A

Indications:

• Patients with factor VIII coagulant activity levels >5% 1, 4
• Maintain hemostasis during surgical procedures
• Reduce bleeding with spontaneous or traumatic injuries
• Not indicated for factor VIII levels ≤5% or for patients with factor VIII antibodies 4

Dosing:

• IV infusion: 0.3 mcg/kg (maximum 20 mcg) 1
• Administer 30 minutes prior to scheduled procedures 4

Von Willebrand Disease (Type I)

Indications:

• Mild to moderate Type I disease with factor VIII levels >5% 1, 4
• Maintain hemostasis during surgical procedures
• Manage episodes of spontaneous or trauma-induced bleeding
• Not indicated for severe Type I disease or abnormal molecular forms of factor VIII antigen 1, 4

Dosing:

• IV infusion: 0.3 mcg/kg (maximum 20 mcg) 1
• Administer 30 minutes prior to scheduled procedures 4

Patients on Platelet-Inhibiting Drugs

Indications:

• Patients taking aspirin or clopidogrel with bleeding or requiring surgery 3
• Patients with intracerebral hemorrhage on antiplatelet therapy 3

Dosing:

• IV/SC: 0.3 mcg/kg diluted in 50 ml saline and infused over 30 minutes 3

Important Safety Considerations

Hyponatremia Risk:

• Limit evening fluid intake to 200 ml (6 ounces) or less with no drinking until morning 3, 2
• Monitor serum sodium within 1 week and approximately 1 month after starting therapy, then periodically 1
• More frequent monitoring in patients ≥65 years and those at increased risk of hyponatremia 1

Contraindications:

• Moderate to severe renal impairment (creatinine clearance <50 mL/min)
• Hyponatremia or history of hyponatremia
• Known or suspected SIADH
• Polydipsia
• Concomitant use with loop diuretics or systemic/inhaled glucocorticoids
• Illnesses causing fluid or electrolyte imbalance
• Heart failure or uncontrolled hypertension 1

Special Populations:

• Consider temporarily suspending desmopressin during intercurrent illness to prevent water intoxication 2
• Wide inter-individual variation in dose requirements and dosing intervals in children 5

Formulation Selection and Conversion

• Oral formulations generally have fewer episodes of hypo/hypernatremia than nasal formulations 5
• When switching from nasal to oral formulation, a median dose conversion factor of approximately 20:1 may be used (though individual variation exists) 5

Desmopressin has been used safely for over 50 years, with the primary risk being hyponatremia that can be mitigated through proper dosing, fluid restriction, and monitoring 6.