From the Guidelines
The management of Diabetes Insipidus (DI) should prioritize creating an emergency plan for each patient, including a letter explaining their diagnosis and advice on intravenous fluid management, as well as recommending the use of a medical alert bracelet or card. This approach is supported by the most recent and highest quality study available, which emphasizes the importance of preparedness and clear communication in managing DI, particularly for patients with nephrogenic diabetes insipidus (NDI) 1.
When considering the treatment of central diabetes insipidus, desmopressin (DDAVP) is a key medication, available in various forms such as nasal spray, oral tablets, or sublingual melt tablets. The dosage can vary from 10-40 mcg daily for the nasal spray, 0.1-0.8 mg daily for oral tablets, to 60-240 mcg daily for sublingual melt tablets. For nephrogenic diabetes insipidus, thiazide diuretics like hydrochlorothiazide are often used, sometimes in combination with amiloride or indomethacin.
Key aspects of management include:
- Maintaining adequate fluid intake based on thirst
- Monitoring urine output
- Restricting sodium intake to less than 3 grams daily to reduce urine output
- Regular monitoring of electrolytes, especially sodium levels, to prevent hypernatremia or hyponatremia
The rationale behind these treatments is to either replace the missing antidiuretic hormone (vasopressin) with desmopressin in central DI or to utilize thiazides in NDI, which paradoxically reduce urine output by enhancing sodium and water reabsorption in the proximal tubule. This approach is crucial for managing DI effectively and improving the patient's quality of life, as highlighted by the international expert consensus statement on the diagnosis and management of congenital nephrogenic diabetes insipidus 1.
From the FDA Drug Label
- 1 Central Diabetes Insipidus Desmopressin Acetate Injection 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 management of Central Diabetes Insipidus (DI) includes antidiuretic replacement therapy with desmopressin acetate injection.
- Key considerations:
- Assess serum sodium, urine volume, and osmolality prior to treatment
- Intermittently monitor serum sodium, urine volume, and osmolality or plasma osmolality during treatment
- Restrict free water intake and monitor for hyponatremia
- Ensure serum sodium is normal prior to initiating or resuming treatment with desmopressin acetate injection 2
From the Research
Management of Diabetes Insipidus (DI)
The management of DI involves different approaches depending on the type of DI.
- For central DI, treatment consists of fluid management and drug therapy with the synthetic AVP analogue Desmopressin (DDAVP) 3, 4.
- DDAVP is used as nasal or oral preparation in most cases, with oral DDAVP being a more reliable mode of treatment for chronic central DI 4.
- The major complication of DDAVP therapy is water intoxication and hyponatremia, which can be reduced by careful dose titration and close monitoring of serum osmolality 5, 3.
- Treatment of nephrogenic DI involves removing the underlying cause, if possible, reducing solute load or therapy with a diuretic agent 6.
- Patients with DI require adequate access to water, and treatment approaches depend on whether a patient is diagnosed with central or nephrogenic DI 7.
Treatment Considerations
- Hyponatraemia is a common side effect of DDAVP treatment, occurring in one in four patients, and should be avoided by allowing a regular break from DDAVP to allow a resultant aquaresis 4.
- Hypernatraemia is less common, and typically occurs during hospitalization, when access to water is restricted, and in cases of adipsic DI 4.
- Management of adipsic DI can be challenging, and requires initial inpatient assessment to establish dose of DDAVP, daily fluid prescription, and eunatraemic weight which can guide day-to-day fluid targets in the long-term 4.