Desmopressin

General information

Desmopressin ( N -deamino-8- d -arginine vasopressin, dDAVP) is a longer acting analogue of vasopressin. It has very little vasoactive effect but is antidiuretic by an action on vasopressin V ₂ receptors in the renal tubule and is used to treat central diabetes insipidus and nocturnal enuresis.

At higher doses desmopressin also has significant hematological effects and can significantly boost concentrations of factor VIII and von Willebrand factor (VWF) in the blood. Desmopressin is therefore a valuable agent for the treatment of mild and moderate hemophilia A (congenital or acquired) and type 1 von Willebrand disease, in which the VWF protein structure is normal but the plasma concentration is reduced [ ]. By contrast with conventional coagulation factor concentrates, desmopressin is cheap and is free from the risk of transmission of viral infections, which have proved such a problem in the past. It is also very useful in the treatment of carriers of hemophilia A, many of whom have significant reductions in the baseline concentration of factor VIII. By contrast, desmopressin has no effect on the concentration of factor IX, and is thus of no value in hemophilia B (Christmas disease). It is also of little value in type 2 (abnormal VWF structure) von Willebrand’s disease, which accounts for about 15–20% of all cases. The administration of desmopressin to patients with type 2B von Willebrand’s disease can be hazardous, as it is likely to cause thrombocytopenia [ ]. The use of desmopressin in bleeding disorders has been reviewed [ ]. Tachyphylaxis develops if desmopressin is used for prolonged periods to control bleeding disorders, because desmopressin causes release of stored factor VIII and von Willebrand factor, after which it takes time for them to accumulate again.

Intravenous injection is the most common route although subcutaneous injection may also be used. A concentrated nasal spray formulation has been proved to be efficient for home treatment of patients with bleeding episodes or even minor surgical procedures and has also been used prophylacticly [ ]. The nasal spray used to treat diabetes insipidus (Desmospray) is too dilute for use in disorders of hemostasis. Similarly, desmopressin in tablet form (Desmotabs) is intended for treatment of nocturnal enuresis in children and is of no use in the treatment of hemostatic disorders.

Desmopressin also shortens the prolonged skin bleeding time in patients with renal insufficiency [ , ], hepatic cirrhosis [ , ], and congenital or acquired defects of platelet function [ ], including aspirin-induced platelet dysfunction [ ].

Desmopressin reduces blood loss in patients without bleeding disorders during surgical procedures, including cardiac surgery [ , ]. However, similar benefits have also been observed with other agents, including aprotinin, tranexamic acid, and aminocaproic acid. Meta-analyses have confirmed the efficacy of these agents and have shown that aprotinin is the most effective of these agents in reducing blood loss, while desmopressin was the least effective [ , ].

Children with nocturnal enuresis treated with desmopressin have fewer wet nights per week, but this effect does not persist after therapy is stopped. A meta-analysis showed an overall rate of 7.1 adverse events per 100 children [ ]. These were almost all local nasal reactions, including nasal irritation and epistaxis.

In an open trial of high-dose desmopressin 1.5 mg intranasally to control bleeding in 278 patients with congenital bleeding disorders, headache occurred in 3.6% and flushing in 3.2% of patients [ ]. Dizziness and nausea were reported in 1–1.5% and edema in 0.3% of patients.

Drug studies

Organs and systems