Desmopressin - Intensive Care & Coordination Monitoring Unit

Liverpool Health Service Drug Administration Protocol First Issued February 2002
Intensive Care Unit
Policy Statement
desmopressin (DDAVP, Minirin, Octostim)
All care provided within the Liverpool Health Service will be in accordance with infection control
guidelines, manual handling guidelines and minimisation and management of aggression
guidelines.
Medications are to be prescribed and signed by a medical officer unless required during an
emergency.
Medications are to be given at the time prescribed and are to be signed by the administering
registered nurse.
Parenteral medication prescriptions and the drug are to be checked with a second registered
nurse prior to administration.
Infection Control guidelines are to be followed.
All drugs administered during an emergency (under the direction of a medical officer) are to be
documented during the event, then prescribed and signed following the event. Exceptions to this
Policy are found in ‘Emergency Drug Dose Guidelines’ – Policy 1.e.
Adverse drug reactions are to be documented and reported to a medical officer.
Medication errors are to be reported using the hospital Drug Incident Report form.
Guidelines are for adult patients unless otherwise stated.
Formal diagnosis of DI will be made based upon serum and urine osmolality (not upon
large diuresis) prior to administration of vasopressin.
Not for use in Type II von Willebrand’s Disease.
• Intravenous fluid administration must be reviewed to avoid overhydration.
Actions
Desmopressin is a posterior pituitary hormone, known as ADH: antidiuretic hormone.
The drug is a synthetically manufactured form of the natural hormone ‘arginine vasopressin’ with
major differences being a three to five-fold increase in antidiuretic activity and an almost absent
pressor effect.
Desmopressin acts in the renal tubule to increase water reabsorption.
High doses of desmopressin produce marked, sustained increases in Factor VIII coagulant
activity (VIII:C) and increases in von Willebrand factor (vWF). There is release of plasminogen
activator.
There is slight stimulation of uterine activity in non-pregnant women at doses of 15 – 20
micrograms intranasally.
At doses to treat bleeding, desmopressin has a vasodilatory effect, causing minor decreases in
systolic and diastolic BP.
When given IV, IM or SC the majority of the drug is available, whereas intranasally only 10% is
available. Thus IV, IM, SC doses are one tenth of the intranasal route.
There is varied duration of effect, ranging outside 8 – 20 hours of effect.
Indications
Pituitary diabetes insipidus (not Nephrogenic).
Post hypophysectomy (pituitary surgery) temporary or permanent injury.
The treatment of ADH sensitive cranial diabetes insipidus, including treatment of
posthypophysectomy polydipsia and polyuria.
Diagnostic test to establish renal concentrating capacity.
Mild and moderate haemophilia A and von Willebrand's disease.
To increase factor VIII levels in patients undergoing dental or minor surgery.
Bleeding in patients with platelet dysfunction.
Treatment of excessive bleeding in patients with congenital or acquired clinical conditions
associated with platelet dysfunction, which is characterized by a prolonged bleeding time.
Patients undergoing cardiac surgery with cardiopulmonary bypass for prosthetic valve
replacement or aortocoronary bypass grafting, especially when it is complicated by platelet
function defects sufficient to prolong bleeding time despite relatively normal platelet cover.
Reviewed: September 2004 Authors: M. Edgtton-Winn Page 1 of 1
Review Date: September 2005

Liverpool Health Service Drug Administration Protocol First Issued February 2002
Intensive Care Unit
Contraindications
Type IIB von Willebrand's disease.
Habitual and psychogenic polydipsia.
Cardiac insufficiency and other conditions requiring treatment with diuretic agents.
Hypersensitivity to the preservative.
Desmopressin is ineffective for the treatment of nephrogenic diabetes insipidus.
Precautions
Overhydration, especially with children, the elderly, when used with concurrent fluid replacement.
Patients with a history of cardiac failure and when used to test renal concentrating ability.
Excessive water intake or chronic use of desmopressin can produce hyponatraemia with
associated effects.
When desmopressin is used for diagnostic purposes, the fluid intake must be limited and not
exceed 0.5 litres from one hour before until eight hours after administration.
Desmopressin should not be administered to dehydrated or overhydrated patients until water
balance has been adequately restored.
In haemophilia, where high doses are given, extreme care must be paid to the water balance.
Fluid intake should be restricted as much as possible and the patient should be weighed
regularly.
Not for intransal administration if rhinorrhoea or local infection exists.
Use with caution in patients with cystic fibrosis because of impaired water handling and increased
risk of hyponatraemia.
Use with caution in patients at risk of increased intracranial pressure secondary to fluid retention.
Significant Interactions
Tricyclic antidepressants, chlorpromazine and carbamazepine may cause an additive antidiuretic
effect and increase the risk of water retention.
Indomethacin may augment the magnitude but not the duration of the response to desmopressin.
Glibenclamide inhibits the antidiuretic effect of desmopressin.
Clofibrate has potentiated and prolonged the effects of desmopressin.
Adverse Effects
Tachycardia, fall in diastolic blood pressure by 10 to 20% with large IV doses.
Hypertension.
Headache, nausea, mild abdominal cramp, vomiting.
Nasal congestion, facial flushing, vulval pain.
Water intoxication from overhydration, hyponatraemia.
Presentation
Intranasal solution, 100 micrograms/mL, 2.5mL dropper bottle plus rhinyle (Minirin).
Injection, 4 micrograms/mL in 1mL ampoule (DDAVP).
Injection, 15 micrograms/mL in 1mL ampoule (Octostim) for intravenous use only.
Reviewed: September 2004 Authors: M. Edgtton-Winn Page 2 of 2
Review Date: September 2005

Liverpool Health Service Drug Administration Protocol First Issued February 2002
Intensive Care Unit
Administration Guidelines
ADH sensitive cranial diabetes insipidus:
Adults.
Intranasally 5 to 20 micrograms twice daily, adjusted for adequate sleep patterns.
IV, IM or SC slow injection, undiluted using a diabetic syringe. Administer 0.5 – 1.0 microgram which
may require bd or tds dosage.
Dosage is controlled by measurement of serum and urine osmolality.
A single daily dose may be used if tolerated and provides control of the diabetes insipidus.
Paediatric.
Intranasally 1.25 to 10 micrograms twice daily.
IV, IM or SC up to 200 nanograms twice daily as a slow, injection using a diabetic syringe.
A single daily dose may be used if tolerated and provides control of the diabetes insipidus.
Notes:
Intranasal administration:
⇒ Load the dose from the dropper bottle into the plastic catheter following manufacturer's
instructions.
⇒ The patient places one end of the catheter into the mouth, and the other end into a nostril, and
the contents of the catheter are blown into the nasal cavity. The dose is not inhaled!
Parenteral administration:
⇒ When using doses less than 4 micrograms the dose should be drawn up from the ampoule as a
fraction of a ml using a diabetic syringe without dilution or use of infusion.
Diagnostic test of renal concentrating capacity:
Intranasal. Adults. Single dose of up to 40 micrograms. Children. Single dose of up to 20 micrograms.
Intramuscular. Adults. Single dose of up to 4 micrograms.
Mild/moderate haemophilia A and von Willebrand's disease. Parenteral administration only.
VIII:C assays should be undertaken regularly during treatment. When surgery or dental extractions
are to be undertaken, tranexamic acid should be given intravenously (tranexamic acid 10 mg/kg)
unless contraindicated, then 25 mg/kg orally three to four times daily until healing is complete.
Within 1/2 hour before surgery desmopressin 0.4 microgram/kg diluted to 10 to 100 ml in normal
saline is given as a slow intravenous infusion over 15 to 20 minutes before and 20 minutes after the
infusion.
VIII:C assays and in the case of von Willebrand's disease determination of VIIIR:Ag and bleeding
time should also be carried out.
If a sufficient response was obtained with the initial dose of desmopressin, further doses may be
given at 12 hourly intervals so long as cover is required.
VIII:C levels must be monitored regularly since some patients have shown a diminishing response to
successive infusions.
If a sufficient level has not been reached to cover the intended surgical procedure, a supplementary
dose of factor VIII concentrate should be given to make up the deficit.
Treatment of bleeding in patients with inherited and acquired platelet function defects:
Desmopressin is given at a dose of 0.3 microgram/kg diluted to 50 mL sterile 0.9% normal saline as
a slow intravenous infusion over 30 minutes.
Further doses may be given at 12 hourly intervals as long as cover is required.
In some patients a 12 hourly injection for three to four days may result in clinically significant fluid
retention.
General surgery (except cardiac surgery): Half an hour prior to surgery, desmopressin is given as a
slow intravenous infusion over 30 minutes.
Cardiac surgery: Desmopressin is administered in patients with a prolonged bleeding time when
bypass has been completed and immediately after protamine has been given to neutralize the effect of
heparin or at any time thereafter.
Nonsurgical use: In patients with epistaxis, menorrhagia or other bleeding episodes, desmopressin is
given as a slow intravenous infusion over 30 minutes. Red blood cell transfusion is of value in improving
haemostasis in uraemic patients.
Reviewed: September 2004 Authors: M. Edgtton-Winn Page 3 of 3
Review Date: September 2005

Liverpool Health Service Drug Administration Protocol First Issued February 2002
Intensive Care Unit
Clinical Considerations
• Observe for signs of water intoxication, report immediately.
• Maintain strict fluid balance.
• Monitor electrolytes frequently.
• Monitor urinalysis, including specific gravity:
⇒ SG < 1.005 may indicate need for further investigations as to the cause of dilute urine.
⇒ Rule out spurious causes such as large IV / oral / enteral administration of fluids.
⇒ Rule out drugs which cause diuresis e.g. mannitol or frusemide.
• If SG is < 1.005 and there is a history of cranial injury/surgery; ensure that there is confirmation of
DI with both serum and urine osmolality results prior to the administration of desmopressin.
• Monitor serum and urine osmolality.
• Serum osmolality normal value: 266 – 300 mosm/kg
• Urine osmolality: 300 – 1400 mosm/kg.
References
Carlton, J.B. 1997. The handbook of parenteral drug administration. (4 th . Ed.). William’s Printers. Shepparton
MIMS Online. CIAP: NSW Health Department. 1 August-31 October 2001. http://www.mims.hcn.net.au/
Policy Author(s): M. Edgtton-Winn, ICU – CNC.
Policy Reviewers: ICU Director, ICU – CNC.
Reviewed: September 2004 Authors: M. Edgtton-Winn Page 4 of 4
Review Date: September 2005