What is desmopressin used for?

Desmopressin Clinical Indications

Desmopressin is used for three primary indications: central diabetes insipidus (as antidiuretic replacement therapy), nocturnal enuresis (bedwetting in children), and hemostatic management in mild hemophilia A and von Willebrand disease type 1. 1

Central Diabetes Insipidus

• Desmopressin is the treatment of choice for central (cranial) diabetes insipidus, serving as antidiuretic replacement therapy by stimulating V2 receptors to increase water reabsorption in the kidney and reduce urine production 1, 2
• The standard dose is 2-4 mcg daily administered as one or two divided doses by subcutaneous or intravenous injection 1
• It is also effective for managing temporary polyuria and polydipsia following head trauma or pituitary surgery 1
• Desmopressin is completely ineffective and contraindicated for nephrogenic diabetes insipidus 1

Nocturnal Enuresis (Bedwetting)

• Desmopressin is evidence-based first-line therapy for monosymptomatic nocturnal enuresis, with approximately 30% of children achieving complete dryness and 40% showing partial response 3
• Oral tablets (0.2-0.4 mg) should be taken at least 1 hour before sleep, while oral melt formulations (120-240 μg) should be taken 30-60 minutes before bedtime 3, 4
• The dose is not influenced by body weight or age, and physicians may start with the higher dose and taper down based on response 3, 4
• Desmopressin is most efficient in children with nocturnal polyuria (nocturnal urine production >130% of expected bladder capacity) and normal bladder function (maximum voided volume >70% of expected bladder capacity) 3
• The anti-enuretic effect is immediate, and families can choose between daily medication or administration before important nights only 3
• Regular short drug holidays are essential when using daily desmopressin to assess whether medication is still needed 3, 4

Hemostatic Indications

Hemophilia A

• Desmopressin is indicated for patients with mild hemophilia A who have factor VIII coagulant activity levels greater than 5% to maintain hemostasis during surgical procedures or reduce bleeding from spontaneous/traumatic injuries 1
• The standard hemostatic dose is 0.3 mcg/kg (maximum 20 mcg) diluted in 50 mL saline and infused over 30 minutes 4, 5, 1
• Desmopressin increases plasma factor VIII levels by 300-400% from baseline, with maximal effect at 90 minutes to 2 hours and duration of 8-12 hours 1

von Willebrand Disease

• Desmopressin is the treatment of choice for mild to moderate type 1 von Willebrand disease with factor VIII levels greater than 5% 1, 2
• It increases both von Willebrand factor and factor VIII levels, promoting platelet adhesion 1, 6
• Desmopressin is contraindicated in type 2B von Willebrand disease due to risk of thrombosis from platelet aggregation 5, 1
• For type 2B VWD, human-derived medium-purity FVIII concentrates complexed to von Willebrand factor (such as Humate-P) are the preferred treatment 7
• Desmopressin is not indicated for severe type 1 von Willebrand disease or when there is evidence of abnormal molecular forms of factor VIII antigen 1

Other Hemostatic Uses

• Desmopressin may be considered for patients with platelet-inhibiting drug effects or refractory microvascular bleeding, though evidence is limited with newer antiplatelet agents like ticagrelor and prasugrel 4, 5
• It has been used for uremic bleeding and drug-induced bleeding complications 8, 6
• Desmopressin is not recommended for routine use in bleeding trauma patients 4, 5

Critical Safety Considerations

Hyponatremia Risk (Boxed Warning)

• Desmopressin can cause life-threatening hyponatremia due to water retention 1
• Evening fluid intake must be restricted to 200 mL (6 ounces) or less with no drinking until morning 3, 4
• Serum sodium must be normal before starting therapy and should be measured within 1 week, at 1 month, and periodically during treatment 1
• More frequent monitoring is required in patients ≥65 years old and those at increased risk 1
• Polydipsia is an absolute contraindication to desmopressin treatment 3, 1

Contraindications

• Moderate to severe renal impairment (creatinine clearance <50 mL/min) 1
• Hyponatremia or history of hyponatremia 1
• Syndrome of inappropriate antidiuretic hormone (SIADH) secretion 1
• Concomitant use with loop diuretics or systemic/inhaled glucocorticoids 1
• During illnesses causing fluid or electrolyte imbalance 1
• Heart failure or uncontrolled hypertension 1

Special Populations

• Use with extreme caution in infants and children under 18 months due to increased risk of water intoxication and electrolyte imbalance, especially with parenteral fluid administration 8
• Elderly patients require careful fluid restriction and more frequent monitoring due to decreased renal function 1
• Intranasal formulations carry higher risk of hyponatremia and have had the enuresis indication removed in many countries; oral formulations are strongly preferred 3, 9

Other Adverse Effects

• Desmopressin can cause systemic vasodilation leading to hypotension, reactive tachycardia, and facial flushing 4, 5
• Rare thromboembolic events have been reported, requiring caution in at-risk patients 4, 5
• Fluid retention can worsen conditions susceptible to volume status changes 1