What is the treatment for Diabetes Insipidus?

Treatment of Diabetes Insipidus

The treatment of diabetes insipidus depends fundamentally on whether it is central (vasopressin deficiency) or nephrogenic (renal resistance to vasopressin), with desmopressin being the definitive treatment for central diabetes insipidus and combination therapy with thiazide diuretics plus NSAIDs for nephrogenic diabetes insipidus. 1, 2

Central Diabetes Insipidus Treatment

Desmopressin is the treatment of choice for central diabetes insipidus and can be administered via multiple routes (oral, intranasal, subcutaneous, or intravenous). 1, 3, 2

Dosing and Administration

• For treatment-naïve patients, start with 2-4 mcg daily administered as one or two divided doses by subcutaneous or intravenous injection, adjusting morning and evening doses separately for adequate diurnal rhythm 2
• Oral desmopressin has replaced nasal formulations as the more reliable mode of treatment for chronic central diabetes insipidus 4
• When switching from intranasal desmopressin, use 1/10th the daily maintenance intranasal dose administered subcutaneously or intravenously as one or two divided doses 2

Critical Safety Monitoring

• Ensure serum sodium is normal before starting or resuming desmopressin 2
• Measure serum sodium within 7 days and approximately 1 month after initiating therapy, then periodically during treatment 2
• Monitor more frequently in patients ≥65 years and those at increased risk of hyponatremia 2
• Hyponatremia occurs in approximately one in four patients and should be avoided by allowing regular breaks from desmopressin to permit aquaresis 4
• Initiate fluid restriction during treatment with desmopressin 2

Important Contraindications

• Desmopressin is contraindicated in patients at increased risk of severe hyponatremia, including those with excessive fluid intake, illnesses causing fluid/electrolyte imbalances, and those using loop diuretics or systemic/inhaled glucocorticoids 2

Nephrogenic Diabetes Insipidus Treatment

Desmopressin is ineffective and not indicated for nephrogenic diabetes insipidus. 2

Pharmacological Management

• For symptomatic infants and children with nephrogenic diabetes insipidus, start combination therapy with thiazide diuretics and prostaglandin synthesis inhibitors (NSAIDs) 1, 5
• Thiazide diuretics can reduce diuresis by up to 50% in the short term when combined with a low-salt diet 5
• Add amiloride to thiazide in patients who develop hypokalemia 5
• Prostaglandin synthesis inhibitors are contraindicated during pregnancy and should be considered for discontinuation once patients reach adulthood or achieve complete continence 5

Dietary Modifications

• Implement a low-salt diet (≤6 g/day) and protein restriction (<1 g/kg/day) with dietetic counseling to reduce renal osmotic load and minimize urine volume 1, 5
• For infants with nephrogenic diabetes insipidus, provide normal-for-age milk intake (instead of water) to ensure adequate caloric intake 5
• Consider tube feeding in infants and children with repeated episodes of vomiting, dehydration, and/or failure to thrive 5

Universal Management Principles for All Types

Fluid Management

• All patients with diabetes insipidus must have free access to fluid to prevent dehydration, hypernatremia, growth failure, and constipation 1, 5, 3
• Patients capable of self-regulating should determine fluid intake based on thirst sensation rather than prescribed amounts 1, 5
• For patients who cannot self-regulate (infants, cognitively impaired), offer water frequently beyond regular intake with close monitoring of weight, fluid balance, and biochemistry 5, 3
• When fasting is required (>4 hours), administer intravenous 5% dextrose in water at maintenance rate with close monitoring 5

Monitoring Requirements

• Regularly assess height and weight, especially in children 5
• Monitor basic plasma biochemistry (Na, K, Cl, HCO₃, creatinine, osmolality) and urine osmolality 5
• Perform kidney ultrasound at least once every 2 years to monitor for urinary tract dilatation and/or bladder dysfunction caused by polyuria 5
• Evaluate treatment efficacy via urine osmolality, urine output, weight gain, and growth 5

Emergency Preparedness

• Each patient with diabetes insipidus should have an emergency plan, including a letter explaining their diagnosis with advice regarding intravenous fluid management 5
• For emergency rehydration, use intravenous water and dextrose or glucose (e.g., 5% dextrose) 5
• Maintain close observation of clinical status, including neurological condition, fluid balance, body weight, and serum electrolytes 5

Common Pitfalls to Avoid

• Never restrict fluid access in diabetes insipidus patients—this can lead to life-threatening hypernatremia, particularly during hospitalization when access to water may be inadvertently limited 4
• Do not use desmopressin for nephrogenic diabetes insipidus, as it is completely ineffective 2
• Be aware that tachyphylaxis (lessening of response) with repeated desmopressin administration given more frequently than every 48 hours may occur; the initial response is reproducible if administered every 2-3 days 2
• Hypernatremia, though less common than hyponatremia, typically occurs during hospitalization when access to water is restricted 4