What is the recommended treatment for central diabetes insipidus using vasopressin (antidiuretic hormone)?

Management of Central Diabetes Insipidus with Vasopressin

Desmopressin (DDAVP) is the first-line treatment for central diabetes insipidus, with dosage individualized according to the patient's diurnal pattern of response. 1, 2

Mechanism and Formulations

• Desmopressin is a synthetic analog of vasopressin (antidiuretic hormone) with selective antidiuretic activity
• Available formulations:
  • Intranasal spray (0.01% solution): Most commonly used
  • Sublingual lyophilisate (melt): Better bioavailability than tablets
  • Parenteral (subcutaneous/intravenous): For patients with nasal congestion or post-surgical cases

Dosing Guidelines

Intranasal Administration

• Adults: 0.1-0.4 mL daily (10-40 μg), either as a single dose or divided into 2-3 doses
  • Most adults require 0.2 mL (20 μg) daily in two divided doses 2
• Children (3 months-12 years): 0.05-0.3 mL daily (5-30 μg), as single or divided doses 2
• Approximately 25-33% of patients can be controlled with a single daily dose 2

Dose Titration

1. Start with a low dose and adjust based on:
   • Adequate duration of sleep
   • Adequate (not excessive) water turnover
   • Morning and evening doses should be separately adjusted for proper diurnal rhythm 2
2. Monitor urine volume and osmolality to assess response 2

Special Considerations

• Elderly patients: Use caution as renal function may be decreased; consider lower initial doses and monitor renal function 2
• Fluid management: Fluid restriction should be observed to prevent water intoxication 2
• Monitoring: Regular assessment of serum sodium levels to avoid hyponatremia 3
• Nasal issues: For patients with nasal congestion, blockage, discharge, or atrophic rhinitis, consider alternative routes (sublingual or parenteral) 2

Potential Adverse Effects

• The major complication of desmopressin therapy is water intoxication and hyponatremia 3
• Risk of hyponatremia can be reduced by:
  • Careful dose titration when initiating therapy
  • Close monitoring of serum osmolality when desmopressin is used with other medications affecting water balance 3
• Studies show approximately 30.7% of patients may experience sodium levels <136 mmol/L, with 9.3% experiencing levels <131 mmol/L 4

Important Clinical Pearls

• Desmopressin is ineffective for nephrogenic diabetes insipidus 1, 2
• Patients with central DI should have unrestricted access to water to prevent dehydration 1
• Avoid administration of hypotonic fluids (e.g., dextrose 5%) in patients with central DI to prevent rapid development of hyponatremia 1
• Recent research suggests patients with congenital central DI may require higher doses (median 600 μg oral equivalent) compared to acquired DI (median 200 μg oral equivalent) 4
• Patient education is crucial to avoid the risk of water intoxication and hyponatremia 5

Diagnostic Confirmation

Before initiating treatment, confirm diagnosis with:

• Water deprivation test with desmopressin challenge (gold standard)
• MRI of the sella with high-resolution pituitary protocols 1
• Laboratory findings consistent with central DI: urine osmolality <200 mOsm/kg, serum sodium >145 mmol/L, significant increase in urine osmolality after desmopressin administration 1