Desmopressin for Uremic Bleeding
Administer desmopressin 0.3 μg/kg intravenously diluted in 50 mL saline infused over 15-30 minutes for uremic bleeding, with hemostatic effects beginning within 1 hour and lasting 6-8 hours. 1
Dosing Protocol
The standard dose is 0.3 μg/kg IV, diluted in 50 mL saline, infused over 15-30 minutes. 1, 2 This can also be administered subcutaneously at the same dose, though IV is preferred for acute bleeding. 1 The intranasal route is not recommended for acute uremic bleeding management. 3
Mechanism and Timing
Desmopressin enhances platelet function in uremia by increasing plasma levels of factor VIII and von Willebrand factor, which promotes platelet adhesion to the vessel wall. 1, 3 The hemostatic effect is detectable within 1 hour after infusion and reaches maximum effect between 5-7 days with repeated dosing, lasting 6-8 hours after a single dose. 1, 4
Critical Safety Measures
Fluid restriction is mandatory to prevent water intoxication and hyponatremia, particularly in elderly uremic patients. 1, 2 Limit evening fluid intake to 200 mL (6 ounces) or less when using desmopressin. 2 Monitor serum sodium levels closely, as desmopressin's antidiuretic effect can cause severe hyponatremia and seizures, especially in patients receiving parenteral fluids. 1, 5
Desmopressin can cause thromboembolic events and requires caution in at-risk patients. 2 Additional side effects include systemic vasodilation leading to arterial hypotension, reactive tachycardia, and facial flushing. 6, 5
Special Considerations for Uremic Patients on Antiplatelet Agents
Desmopressin is particularly effective in uremic patients taking antiplatelet drugs such as aspirin. 7 A prospective study demonstrated that desmopressin significantly shortened collagen/epinephrine-closure time from 252.7 seconds to 144.6 seconds in uremic patients on aspirin before invasive procedures, with minimal to mild bleeding and no severe events. 7
However, desmopressin does not effectively reverse ticagrelor or prasugrel effects and should not be relied upon for these newer P2Y12 inhibitors. 6, 1, 2
Alternative Therapies When Longer Duration Needed
If a longer duration of action is required beyond the 6-8 hour window of desmopressin, conjugated estrogens are an adequate alternative. 4, 8 Estrogens shorten bleeding time with effects detectable after 6 hours, reaching maximum between days 5-7, and lasting up to 14 days. 4
Monitoring Response
Platelet function testing with PFA-100 or whole blood aggregometry may help identify patients who would benefit from desmopressin therapy and confirm adequate response. 2 Response can also be measured by shortening of bleeding time and partial thromboplastin time, indicating a rise in Factor VIII or von Willebrand factor. 5
Common Pitfalls to Avoid
- Do not use in dialysis patients with severe fluid overload without careful monitoring, as the antidiuretic effect can worsen volume status. 2
- Avoid in patients with polydipsia, as this is a contraindication due to increased risk of water intoxication. 2
- Do not exceed 0.3 μg/kg dosing and ensure infusion lasts at least 20-30 minutes to minimize side effects. 5
- Use with extreme caution in infants and children under 18 months due to increased risk of water intoxication and electrolyte imbalance. 5