IV Desmopressin Availability
Yes, intravenous (IV) desmopressin is available and FDA-approved for clinical use. The FDA-approved formulation is desmopressin acetate injection 4 mcg/mL, which can be administered intravenously, subcutaneously, or by direct IV injection depending on the indication 1.
FDA-Approved Formulations and Routes
IV desmopressin has been available since 1981 and is indicated for multiple clinical conditions 1, 2:
- Hemophilia A and von Willebrand Disease (Type I): Administered as IV infusion at 0.3 mcg/kg diluted in sterile saline over 15-30 minutes 1
- Diabetes Insipidus: Can be given by direct IV injection or subcutaneously at 0.5-1 mL (2-4 mcg) daily in divided doses 1
- Bleeding disorders: The standard hemostatic dose is 0.3 mcg/kg IV infused over 15-30 minutes 1
Clinical Applications in Critical Care
Multiple clinical guidelines recommend IV desmopressin for specific hemostatic indications 3:
- Antiplatelet reversal: The Neurocritical Care Society recommends desmopressin 0.4 mcg/kg IV × 1 for patients with intracranial hemorrhage on antiplatelet agents, with platelet transfusion added if neurosurgical intervention is required 3
- Uremic platelet dysfunction: The American Society of Nephrology recommends 0.3 mcg/kg IV as first-line treatment, with hemostatic effects beginning within 1 hour and lasting 6-8 hours 4
- Von Willebrand disease: For bleeding patients with types 1 and 2A, desmopressin is recommended first-line before specific VWF/FVIII concentrates 3
Administration Guidelines
For hemostatic purposes, the standard protocol is 1:
- Dose: 0.3 mcg/kg body weight
- Dilution: In 50 mL sterile saline for adults and children >10 kg; 10 mL for children ≤10 kg
- Infusion time: 15-30 minutes
- Timing: Administer 30 minutes before scheduled procedures
- Monitoring: Blood pressure and pulse during infusion
Important Safety Considerations
Fluid restriction is mandatory to prevent water intoxication and hyponatremia 5, 1:
- Limit evening fluid intake to ≤200 mL (6 ounces) 5
- Monitor serum sodium levels, particularly with repeated dosing 4
- The risk of hyponatremia is substantial, with rates of 146 per 1,000 person-years reported in population studies 6
Tachyphylaxis occurs after 3-5 doses due to depletion of endothelial VWF stores, limiting repeated administration to intervals >48 hours 3, 7, 1.
Common Pitfalls
- Thromboembolic risk: Desmopressin can cause thromboembolic events in at-risk patients and should be used with caution in elderly populations 3, 5
- Renal impairment: Avoid in severe renal impairment (CrCl <30 mL/min) as desmopressin is substantially excreted by the kidney 5, 1
- Limited efficacy in specific conditions: Does not effectively reverse ticagrelor or prasugrel, and may be ineffective in COVID-19 patients on ECMO due to depleted endothelial stores 5
- Vasodilator effects: Can cause arterial hypotension, reactive tachycardia, and facial flushing 5