What is the recommended dose of desmopressin?

Desmopressin Dosing Recommendations

Hemostatic Indications (Bleeding Disorders)

For patients with von Willebrand disease, hemophilia A, or platelet dysfunction from antiplatelet drugs, administer 0.3 μg/kg (maximum 20 μg) diluted in 50 mL saline infused intravenously over 15-30 minutes. 1, 2

Standard Hemostatic Dosing Protocol

• Intravenous administration: 0.3 μg/kg actual body weight (maximum 20 μg) diluted in sterile 0.9% sodium chloride and infused over 15-30 minutes 1, 2
• Dilution volumes: Use 10 mL diluent for patients ≤10 kg; use 50 mL diluent for patients >10 kg 2
• Timing for procedures: Administer 30 minutes prior to surgical procedures 2
• Repeat dosing: May repeat after 8-12 hours and once daily thereafter based on clinical condition and factor levels 2

Important Hemostatic Considerations

• Tachyphylaxis warning: Repeated administration more frequently than every 48 hours may result in diminished response; initial response is reproducible if given every 2-3 days 2
• Patient selection: Verify factor VIII levels >5% before treatment in hemophilia A patients; exclude factor VIII autoantibodies 2
• Monitoring requirements: Monitor blood pressure and pulse during infusion; assess factor VIII coagulant activity, bleeding time, and von Willebrand factor levels 2
• Limited efficacy: Desmopressin does not effectively reverse ticagrelor or prasugrel effects 1

Special Population: ECMO Patients

• Not recommended for COVID-19 ARDS patients on ECMO: A prospective study of 27 COVID-19 patients on VV-ECMO showed desmopressin 0.3 μg/kg did not significantly increase VWF levels, likely due to depleted endothelial stores 3
• Mechanism limitation: High shear stress in ECMO circuits may cause proteolysis of released VWF by ADAMTS-13, limiting efficacy 3

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Diabetes Insipidus

For treatment-naïve patients with central diabetes insipidus, initiate 2-4 μg daily administered subcutaneously or intravenously as one or two divided doses, without dilution. 2

Diabetes Insipidus Dosing Details

• Starting dose: 2-4 μg daily by subcutaneous or intravenous injection, divided into one or two doses 2
• Route-specific instruction: Do not dilute desmopressin for diabetes insipidus patients 2
• Dose adjustment: Separately adjust morning and evening doses for adequate diurnal rhythm of water turnover 2
• Conversion from intranasal: Use 1/10th the daily maintenance intranasal dose when switching to injectable formulation 2

Age-Related Dosing Patterns

• Adult dose requirements: Median daily oral dose of 200 μg in acquired diabetes insipidus versus 600 μg in congenital cases 4
• Age correlation: Younger patients require higher doses; age is the primary predictor of sublingual desmopressin dose requirements 5
• Pediatric dosing: Median oral dose of 9.5 μg/kg/day (range 4.2-17.0) with median frequency of 2.5 times daily 6

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Nocturnal Enuresis

For nocturnal enuresis, prescribe oral tablets 0.2-0.4 mg taken at least 1 hour before sleep, or oral melt tablets 120-240 μg taken 30-60 minutes before bedtime. 1, 7

Enuresis Dosing Specifics

• Oral tablets: 0.2-0.4 mg taken at least 1 hour before sleep 1
• Oral melt tablets: 120-240 μg taken 30-60 minutes before bedtime 1
• Dose titration strategy: Start with 0.2 mg and increase only if needed; most patients (86.2%) achieve response at 0.2 mg dose 8
• Weight-independent: Dose is not influenced by body weight or age 1

Critical Safety Measures for Enuresis

• Fluid restriction mandatory: Limit evening fluid intake to ≤200 mL (6 ounces) with no drinking until morning 1, 7
• Contraindication: Polydipsia is an absolute contraindication to desmopressin treatment 1, 7
• Nasal spray warning: Oral formulations are strongly preferred over nasal spray due to higher risk of water intoxication, hyponatremia, and convulsions with nasal administration 7
• Drug holidays: Implement regular short drug holidays when using daily to reassess ongoing need 1, 7

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Universal Safety Precautions

All patients receiving desmopressin require strict fluid restriction and serum sodium monitoring to prevent life-threatening hyponatremia. 1, 2

Monitoring Requirements

• Pre-treatment assessment: Ensure normal serum sodium before initiating or resuming therapy 2
• Ongoing monitoring: Monitor serum sodium regularly, especially with repeated doses 2
• High-risk populations: Exercise particular caution in elderly patients who have increased risk of hyponatremia and convulsions 9

Contraindications and Cautions

• Renal impairment: Avoid in dialysis patients and those with severe renal impairment (CrCl <30 mL/min) 1
• Cardiovascular effects: Can cause thromboembolic events, systemic vasodilation, arterial hypotension, reactive tachycardia, and facial flushing 1
• Not for isolated liver disease: Unless concomitant end-stage renal disease is present 1