Desmopressin

• Tablets 100micrograms, 200micrograms (£79.33 = 90 x 100micrograms; £24.54 = 30 x 200micrograms)
• Oral lyophilisates sugar free 25micrograms, 50micrograms, 60micrograms, 120micrograms, 240micrograms (£30.34 = 30 x 120micrograms)
• Nasal spray 10micrograms/dose (£37.11 = 60 dose)
• Intranasal solution 100micrograms/ml
• Injection 4micrograms/ml

Indications and dose

• Diabetes insipidus treatment, adult:
  • Oral: 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
  • Intranasal: 10–40micrograms daily in 1–2 divided doses
• Diabetes insipidus treatment, child (12 to 17 years) (for younger children, refer to BNFc):
  • Oral: 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
  • Intranasal: Initially 10–20micrograms 1–2 times a day, adjusted according to response
• Primary nocturnal enuresis, adult (under 65 years) and child over 5 years:
  • Oral: 200micrograms at bedtime, only increased to 400micrograms 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
  • 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
• 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

Notes

1. May be initiated on recommendation of specialists, which in the case of nocturnal enuresis or nocturnal polyuria can include the Bladder and Bowel Care 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 CG111: 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 8hours 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 been forced 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 manufacturers 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 IV

• Injection 1mg vial

Notes

1. Terlipressin should be given to patients suspected of variceal haemorrhage prior to endoscopic diagnosis and after endoscopic treatment of acute oesophageal variceal haemorrhage.
2. In acute variceal bleeding, 2mg of terlipressin should be administered by intravenous bolus, followed by 1-2mg every 4-6 hours until bleeding is controlled, up to a maximum of 72 hours.
3. Refer also to NICE CG141: Acute Upper Gastrointestinal Bleeding for further guidance.
4. 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

Antidiuretic hormone antagonist

Demeclocycline

• See 5.1.3 Tetracyclines

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 commissioning policy)