Names and pronunciation
(des-moe-press′in) DDAVP, Nocdurna , Octostim , Stimate
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Drug reference
(des-moe-press′in) DDAVP, Nocdurna , Octostim , Stimate
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Func. class.: Pituitary hormone
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Chem. class.: Synthetic antidiuretic hormone
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ACTION: Promotes reabsorption of water by action on renal tubular epithe- lium; causes smooth muscle constric- tion, increase in plasma factor VIII levels, which increases platelet aggregation, thereby resulting in vasopressor effect; similar to vasopressin
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USES: Hemophilia A, von Willebrand’s disease type 1, nonnephrogenic diabetes insipidus, symptoms of polyuria/polydip- sia caused by pituitary dysfunction, noc- turnal enuresis, nocturia
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Unlabeled uses: Uremic bleeding
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CONTRAINDICATIONS: Hyper- sensitivity, nephrogenic diabetes insipi- dus, severe renal disease, loop diuretics or systemic/inhaled glucocorticosteroids (nocturia)
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Black Box Warning: Hyponatremia Precautions: Pregnancy, breastfeeding, coronary artery disease, hypertension, cys- tic fibrosis, thrombus, electrolyte imbal- ances, male infertility Black Box Warning: Increase: hypona- tremia—loop diuretics, inhaled gluco- corticosteroids, do not use together in nocturia Increase: pressor effect—pressor prod- ucts, monitor Decrease: antidiuretic action—lithium, alcohol, demeclocycline, heparin, large doses of EPINEPHrine Black Box Warning: Hyponatremia: assess for conditions that can cause hy- ponatremia (fluid/electrolyte imbalances, loop diuretics/inhaled glucocorticoster- oids, severe diarrhea, infections); monitor sodium levels baseline, 7 days, 30 days after start of treatment (nocturia) • Diabetes insipidus: urine volume/osmo- lality and plasma osmolality; monitor for dry skin, poor turgor, thirst (dehydration) • Hemophilia/von Willebrand’s disease: factor VIII coagulant activity, bleeding time prior to using for hemostasis; assess for bleeding, frank and occult D • Pregnancy/breastfeeding: no well- controlled studies; use only if benefit outweighs fetal risk; use caution in breastfeeding, excretion is unknown • Beers: avoid for treatment of nocturia or nocturnal polyuria; high risk of hypo- natremia
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SIDE EFFECTS CNS: Drowsiness, headache, lethargy, flushing, seizures CV: Increased B/P, palpitations, tachycardia EENT: Nasal irritation, congestion, rhinitis GI: Nausea, heartburn, cramps GU: Vulval pain META: Hyponatremia, hyponatremia- induced seizures SYST: Anaphylaxis (IV)
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INTERACTIONS Increase: adverse reactions—carBAMaze pine, chlorproPAMIDE, clofibrate, SSRIs, lamotrigine
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DOSAGE AND ROUTES • PO is 10-20× greater effect than nasal • Child: Evening dose is 2× higher than daytime to provide sufficient antidiuresis during the night Primary nocturnal enuresis • Adult/child ≥6 yr: PO 20 mcg at bed- time, max 0.6 mg at bedtime; INTRANA- SAL 0.2 mL at bedtime, half in each nostril Diabetes insipidus • Adult: INTRANASAL 10-40 mcg in divided doses (1-4 sprays with pump); PO Initially 0.05 mg bid, adjust based on diurnal pattern of response; usual range (0.1-1.2 mg)/day in 2-3 divided doses IV/SUBCUT 2-4 mcg/day or SUBCUT in 2 divided doses • Child 3 mo to 12 yr: INTRANASAL 5- 30 mcg/day in divided doses Hemophilia/von Willebrand’s disease • Adult/child >3 mo: IV 0.3 mcg/kg in 0.9% NaCl over 15-30 min; may repeat if needed • Adult/child >11 mo: NASAL SPRAY 300 mcg (1 spray in each nostril); give 2 hr prior to surgery Antihemorrhagic • Adult/child >3 mo: IV/SUBCUT 0.2- 0.4 mcg/kg/dose • Adult/child <50 kg: INTRANASAL 1 spray in 1 nostril • Adult/child >50 kg: INTRANASAL 1 spray in each nostril Nocturia • Adult 50-64 yr: INTRANASAL 1 spray in 1 nostril 30 min before going to bed (not at increased risk for hyponatre- mia); women SL 27.7 mcg 1 hr prior to bedtime with no water; men 55.3 mcg 1 hr prior to bedtime with no water Uremic bleeding (unlabeled) • Adult: SUBCUT/IV 0.3-0.4 mcg/kg as a single injection
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Available forms: Injection 4 mcg/mL, tablets 0.1, 0.2 mg; nasal spray pump (DDAVP) 10 mcg/spray (0.1 mg/mL); nasal spray (Stimate) 1.5 mg/mL (150 mcg/dose); tablets (SL) 27.7, 55.3 mcg
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Administer: PO route • Store at room temperature SL: Keep under tongue to dissolve; limit fluids at night 1 hr prior to 8 hr after use, avoid caffeine/alcohol before bed SUBCUT route • Rotate sites Nasal route • DDAVP and Stimate are not inter- changeable • Prime before first dose (press down 4 times), pump stays primed for 1 wk; to reprime, press down 1 time • Nocturia: do not shake bottle, prime by pumping 5 times into the air away from the face; if not used for >3 days, reprime with 2 actuations, have patient blow nose, tilt head back slightly, close nostril, inhale while pumping 1 time, wipe applicator and replace cap Direct IV route • Undiluted over 1 min for diabetes in- sipidus Intermittent IV INFUSION route • Diluted single dose/50 mL of 0.9% NaCl (adult and child >10 kg), single dose/10 mL in child <10 kg; give as IV infusion over 15-30 min; monitor B/P and pulse during infusion • Store in refrigerator
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Assess: • Pulse, B/P when giving IV or SUBCUT • Renal studies: BUN/creatinine, serum sodium, urine osmolality, I&O ratio, weight daily; check for edema in ex- tremities; if water retention severe, di- uretic may be prescribed • Water intoxication: lethargy, behav- ioral changes, disorientation, neuromus- cular excitability • Intranasal use: nausea, congestion, cramps, headache; usually decreased with decreased dose; for nasal mucosa changes: congestion, edema, discharge, scarring (nasal route) • For severe allergic reaction, including anaphylaxis (IV route); notify prescriber, discontinue use • Nocturnal enuresis: identify how often enuresis is occurring; avoid use in those prone to water intoxication or sodium depletion
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Evaluate: • Therapeutic response: absence of se- vere thirst, decreased urine output, de- creased osmolality
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CLINICAL CONSIDERATIONS
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Patient and caregiver information: • About the proper technique for nasal instillation: to insert tube into nostril to in- still product, clear nasal passage before use • To avoid OTC products (cough, hay fever) because these preparations may contain EPINEPHrine, decrease product response; not to use with alcohol be- cause adverse reactions may occur • To wear emergency ID specifying therapy • That if dose is missed, to take when remembered up to 1 hr prior to next dose; not to double dose; to avoid fluids from 1 hr to up to 8 hr after PO dose • To report upper respiratory infection, nasal congestion to prescriber • How to use SUBCUT, rotate sites See Appendix B
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PHARMACOKINETICS PO: Onset 1 hr, peak 4-7 hr INTRANASAL: Onset 1 hr; peak 1-4 hr; duration 8-20 hr IV: Onset 1 min, peak ½ hr, duration >3 hr Half-life 1.4-3.8 hr (eGFR >50 mL/ min/1.73m2) (PO)
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• Adult/child ≥6 yr: PO 20 mcg at bed- time, max 0.6 mg at bedtime; INTRANA- SAL 0.2 mL at bedtime, half in each nostril Diabetes insipidus
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• Adult: INTRANASAL 10-40 mcg in divided doses (1-4 sprays with pump); PO Initially 0.05 mg bid, adjust based on diurnal pattern of response; usual range (0.1-1.2 mg)/day in 2-3 divided doses IV/SUBCUT 2-4 mcg/day or SUBCUT in 2 divided doses
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• Adult/child >3 mo: IV 0.3 mcg/kg in 0.9% NaCl over 15-30 min; may repeat if needed
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• Adult/child >11 mo: NASAL SPRAY 300 mcg (1 spray in each nostril); give 2 hr prior to surgery Antihemorrhagic
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• Adult/child >3 mo: IV/SUBCUT 0.2- 0.4 mcg/kg/dose
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• Adult/child <50 kg: INTRANASAL 1 spray in 1 nostril
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• Adult/child >50 kg: INTRANASAL 1 spray in each nostril Nocturia
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• Adult 50-64 yr: INTRANASAL 1 spray in 1 nostril 30 min before going to bed (not at increased risk for hyponatre- mia); women SL 27.7 mcg 1 hr prior to bedtime with no water; men 55.3 mcg 1 hr prior to bedtime with no water Uremic bleeding (unlabeled)
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• Adult: SUBCUT/IV 0.3-0.4 mcg/kg as a single injection
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