6.5.2 Posterior pituitary hormones and antagonists

Desmopressin
  • Tablets 100 micrograms, 200 micrograms (£63.09 = 90 x 100 micrograms; £31.11 = 90 x 200 micrograms)
  • Oral lyophilisates, 25 micrograms, 50 micrograms, 60 micrograms, 120 micrograms, 240 micrograms (£91.02 = 90 x 120 micrograms)
  • Nasal spray 10 micrograms per metered spray, 150 micrograms per metered spray (£17.73 = 10 micrograms)
  • Injection 4 micrograms in 1ml, 15 micrograms in 1ml

Indications and dose

  • Diabetes insipidus treatment, adult:
    • Oral: Initially 100 micrograms 3 times a day; maintenance 100-200 micrograms 3 times a day; usual dose 0.2-1.2 mg daily
    • Sublingual (Under the tongue): Initially 60 micrograms 3 times a day, adjusted according to response; usual dose 40-240 micrograms 3 times a day
    • Intranasal: 10–40 micrograms daily in 1–2 divided doses
  • Diabetes insipidus treatment, child (12 to 17 years) (for younger children, refer to BNFc):
    • Oral: Initially 100 micrograms 2–3 times a day, adjusted according to response; usual dose 0.2–1.2 mg daily
    • Sublingual (Under the tongue): Initially 60 micrograms 3 times a day, adjusted according to response; usual dose 40–240 micrograms 3 times a day
    • Intranasal: Initially 10–20 micrograms 1–2 times a day, adjusted according to response
  • Primary nocturnal enuresis, adult (under 65 years) and child over 5 years:
    • Oral: 200 micrograms at bedtime, only increased to 400 micrograms if lower dose not effective; withdraw for at least 1 week for reassessment after 3 months.
    • Sublingual (Under the tongue): 120 micrograms at bedtime, only increased to 240 micrograms if lower dose not effective; withdraw for at least 1 week for reassessment after 3 months
  • Primary idiopathic nocturnal polyuria, adult:
    • Sublingual (Under the tongue): 25 micrograms in women and 50 micrograms in men once daily. Dose to be taken one hour before bedtime, administered without water

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. At the request of the MHRA, the indication for the treatment of primary nocturnal enuresis has been removed from all desmopressin nasal spray products. The tablets currently remain licensed for primary nocturnal enuresis.
  3. Please refer to NICE Guidance CG 111: Bedwetting in under 19s (October 2010) for advice on the assessment and management of children and young people with nocturnal enuresis.
  4. NHS Patient safety alert (February 2016): Risk of severe harm or death when desmopressin is omitted or delayed in patients with cranial diabetes insipidus
  5. In nocturia and nocturnal enuresis limit fluid intake to minimum from 1 hour before to 8 hours after administration
  6. In nocturia the BNF recommends that periodic blood pressure and weight checks are needed to monitor for fluid overload
  7. 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)
  8. 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.
  9. 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 SPCs); discontinue treatment if levels fall below the normal range (i.e.135 mmol/L). Review treatment if no therapeutic benefit after 3 months.
Terlipressin
  • Injection 1mg in 5ml
Vasopressin
  • Injection 20 units/ml

Notes

  1. Please refer to NICE Guidance (CG 141) 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

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)

 

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