Desmopressin

• Tablets 100micrograms, 200micrograms (£55.78 = 90 x 100micrograms; £19.32 = 30 x 200micrograms)
• Oral lyophilisates sugar free 25micrograms, 50micrograms, 60micrograms, 120micrograms, 240micrograms (£30.34 = 30 x 120micrograms)
• Oral solution sugar free 360micrograms/ml (£19.95 = 15ml)
• Nasal spray 10micrograms/dose (£34.01 = 60 dose)
• Solution for injection ampoules 4micrograms/1ml, 15micrograms/1ml

Indications and dose

• Diabetes insipidus treatment, adult:
  • Oral tablets: Initially 100micrograms 3 times a day; maintenance 100-200micrograms 3 times a day; usual dose 0.2-1.2mg daily
  • Sublingual (dissolve under the tongue): Initially 60micrograms 3 times a day, adjusted according to response; usual dose 40-240micrograms 3 times a day
  • Oral solution: Initially 90micrograms 3 times a day; maintenance 90-180micrograms 3 times a day; usual dose 180-1080micrograms daily
  • Intranasal: 10–40micrograms daily in 1–2 divided doses
• Diabetes insipidus treatment, child (12 to 17 years) (for younger children, refer to BNFc):
  • Oral tablets: Initially 100micrograms 2–3 times a day, adjusted according to response; usual dose 0.2–1.2mg daily
  • Sublingual (dissolve under the tongue): Initially 60micrograms 3 times a day, adjusted according to response; usual dose 40–240micrograms 3 times a day
  • Oral solution: Initially 90micrograms 3 times a day; maintenance 90-180micrograms 3 times a day; usual dose 180-1080micrograms daily.
  • Intranasal: Initially 10–20micrograms 1–2 times a day, adjusted according to response
• Primary nocturnal enuresis, patients aged 5 years to under 65 years:
  • Oral tablets: 200micrograms at bedtime, only increased to 400micrograms if lower dose not effective; withdraw for at least 1 week for reassessment after 3 months.
  • Sublingual (dissolve under the tongue): 120micrograms at bedtime, only increased to 240micrograms if lower dose not effective; withdraw for at least 1 week for reassessment after 3 months. Limit fluid intake from 1 hour before to 8 hours after administration.
  • Oral solution: 180micrograms at bedtime, only increased up to 360micrograms if lower dose not effective; withdraw for at least 1 week for reassessment after 3 months. If the desired clinical effect is not achieved after 4 weeks of dose titration, treatment should be discontinued. Limit fluid intake from 1 hour before to 8 hours after administration. (See also note 7).
• Primary idiopathic nocturnal polyuria, adult:
  • Sublingual (dissolve under the tongue): 25micrograms in women and 50micrograms in men once daily. Dose to be taken one hour before bedtime, administered without water. Review treatment if no therapeutic benefit after 3 months.

Notes

1. May be initiated on recommendation of specialists, which in the case of nocturnal enuresis or nocturnal polyuria can include Torbay and South Devon Continence Advisory Service and Livewell Southwest's Continence service
2. Please refer to NICE Guidance CG111: Bedwetting in under 19s (October 2010) for advice on the assessment and management of children and young people with nocturnal enuresis.
   
3. In nocturia the BNF recommends that periodic blood pressure and weight checks are needed to monitor for fluid overload
   
4. In the event of signs or symptoms of water retention and/or hyponatremia treatment should be interrupted and reassessed. When restarting treatment strict fluid restriction should be enforced and serum sodium levels monitored.
   
5. Elderly patients are at increased risk of hyponatraemia and renal impairment—manufacturer advises measure baseline serum sodium concentration, then monitor regularly during treatment (refer to individual manufacturer's SmPCs); discontinue treatment if levels fall below the normal range (i.e. 135mmol/L).
6. Hyponatraemic convulsions: patients being treated for primary nocturnal enuresis should be warned to avoid fluid overload (including during swimming) and to stop taking desmopressin during an episode of vomiting or diarrhoea (until fluid balance normal). The risk of hyponatraemic convulsions can also be minimised by keeping to the recommended starting doses and by avoiding concomitant use of drugs which increase secretion of vasopressin (e.g. tricyclic antidepressants).
7. Although desmopressin oral solution is licensed for primary nocturnal enuresis in adults aged 65 years and older, local specialists do not routinely recommend it in these patients due to risks of hyponatraemia.
8. NHS Patient safety alert (February 2016): Risk of severe harm or death when desmopressin is omitted or delayed in patients with cranial diabetes insipidus.
9. At the request of the MHRA, the indication for the treatment of primary nocturnal enuresis has been removed from all desmopressin nasal spray products.

Terlipressin

• Injection 1mg/5ml

Notes

1. MHRA Drug Safety Update (March 2023): Terlipressin: new recommendations to reduce risks of respiratory failure and septic shock in patients with type 1 hepatorenal syndrome

Vasopressin

• Injection 20units/ml

Notes

1. Please refer to NICE Guidance (CG141) Acute upper gastrointestinal bleeding: management (June 2012). This guideline aims to identify which diagnostic and therapeutic steps are useful in managing acute upper gastrointestinal bleeding.

Antidiuretic hormone antagonists

Demeclocycline

• See 5.1.3 Tetracyclines

Indications

• Demeclocycline can be used in the treatment of hyponatraemia resulting from inappropriate secretion of antidiuretic hormone, if fluid restriction alone does not restore sodium concentration or is not tolerable. Demeclocycline is thought to act by directly blocking the renal tubular effect of antidiuretic hormone.

Dose

• Initially 0.9–1.2g is given daily in divided doses, reduced to 600–900mg daily for maintenance.

Tolvaptan

• Tablets 15mg, 30mg, 60mg, 90mg

Notes

1. NICE TA358 Tolvaptan is recommended as an option for the treatment of autosomal dominant polycystic kidney disease in adults when specified criteria are met (October 2015)
2. Hyponatraemia secondary to SIADH in patients requiring cancer chemotherapy. Commissioned by NHS England (See NHS England Clinical Commissioning Policy)