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(DESS-moe-PRESS-in ASS-uh-TATE)
DDAVP, Stimate, Octostim, Rhinyle Nasal Solution
Class: Posterior pituitary hormone

 Action Has antidiuretic effect that decreases urinary volume and increases urine osmolality.

 Indications Control of primary nocturnal enuresis; control of central cranial diabetes insipidus; maintenance of hemostasis in patients with hemophilia A and type I von Willebrand disease during surgery and postoperatively. Unlabeled use(s): Treatment of chronic autonomic failure.

 Contraindications Standard considerations.

 Route/Dosage

Primary Nocturnal Enuresis

ADULTS & CHILDREN ³ 6 YR: Intranasal 20 mcg (0.2 mL) at bedtime.

Central Cranial Diabetes Insipidus

ADULTS & CHILDREN ³ 12 YR: Intranasal 0.1 to 0.4 qd. IV/SC 0.5 to 1 mL qd in 2 divided doses. PO 0.05 mg bid adjusted for adequate diurnal rhythm (range 0.1 to 1.2 mg/day divided). CHILDREN 3 MONTHS to 12 YR: Intranasal 0.05 to 0.3 mL qd, either as a single dose or 2 divided doses. PO Begin dosing with 0.05 mg. Careful fluid intake restrictions in children is required to prevent hyponatremia and water intoxification.

Hemophilia A, Type I von Willebrand Disease

ADULTS & CHILDREN: IV Administer 0.3 mcg/kg diluted in sterile physiologic saline infused slowly over 15 to 30 min. In patients weighing > 10 kg, use 50 mL diluent; in children weighing £ 10 kg, use 10 mL. Intranasal Administer by nasal insufflation, 1 spray per nostril, to provide a total dose of 300 mcg. In patients weighing < 50 kg, 150 mcg administered as a single spray provided the expected effect on Factor VIII coagulant activity, Factor VIII ristocetin cofactor activity, and skin bleeding time.

 Interactions

Carbamazepine; chlorpropamide: May potentiate antidiuretic effects of desmopressin.

 Lab Test Interferences None well documented.

 Adverse Reactions

CV: Slight elevation in blood pressure, facial flushing (intranasal); chest pain, palpitations, tachycardia, edema (Stimate). CNS: Headache (intranasal); somnolence, dizziness, insomnia, agitation (Stimate). DERM: Local erythema, swelling, pain (injection). EENT: Rhinitis, nosebleed, sore throat (intranasal); itchy or light-sensitive eyes (Stimate). GI: Nausea, mild abdominal cramps (intranasal); dyspepsia, vomiting (Stimate). GU: Vulval pain (intranasal); balanitis (Stimate). HEPA Elevated liver function test (injection). RESP: Cough, upper respiratory infection (intranasal). OTHER: Chills, warm feeling, pain (Stimate).

 Precautions

Pregnancy: Category B. Lactation: Undetermined. Children: Infants and children require careful fluid intake restriction to prevent possible hyponatremia and water intoxication. Safety and efficacy of intranasal form have not been established in children < 11 mo. Safety and efficacy of parenteral form for control of diabetes insipidus have not been established for children < 12 yr. Elderly: Elderly patients should ingest only enough fluid to satisfy thirst; water intoxication and hyponatremia are possible. Special risk patients: Use drug with caution in patients with coronary artery insufficiency or hypertensive cardiovascular disease. Use with caution in patients with conditions associated with fluid and electrolyte imbalance (eg, cystic fibrosis). These patients are prone to hyponatremia. Use with caution in patients predisposed to thrombus formation. Rare thrombotic events have occurred in these patients. Decrease in plasma osmolality: An extreme decrease in plasma osmolality occurs rarely and may result in seizures and coma. Hypersensitivity: Rare severe allergic reactions have been reported. Anaphylaxis has occurred with IV administration.

PATIENT CARE CONSIDERATIONS

 Administration/Storage

  • For intranasal administration, ensure that nasal passages are intact, clean, and free of obstruction before administration of drug. Calibrated plastic tube is provided in nasal tube delivery system. Draw solution up into this tube and insert into nostril. Place opposite end of tube in mouth and blow into tube to deliver medication.
  • Cranial surgery, changes in nasal mucosa, and nasal packing can compromise intranasal delivery. In this situation, parenteral therapy should be considered.
  • If used preoperatively, administer injection 30 min prior to procedure; administer intranasally 2 hr before.
  • The nasal spray pump only delivers doses of 10 mcg (DDAVP) or 150 mcg (Stimate). If doses other than these are required, consider nasal tube delivery or injection.
  • The Stimate pump must be primed prior to the first use. To prime pump, press down 4 times. Discard the bottle after 25 doses because the amount delivered thereafter per spray may be substantially < 150 mcg.
  • Refrigerate nasal solution. Nasal solution will maintain stability for £ 3 wk when stored at room temperature.
  • Refrigerate injectable solution at 2° to 8°C (36° to 46°F).

 Assessment/Interventions

  • Obtain patient history, including drug history and any known allergies.
  • Obtain baseline and ongoing measurements of both urine and plasma osmolality when treating patient with diabetes insipidus.
  • Monitor BP and pulse during infusion.
  • Check coagulation status prior to treating patients with hemophilia A and type I von Willebrand disease. Coagulation testing may include Factor VIII coagulant activity, Factor VIII antigen, ristocetin cofactor, activated PTT, and skin bleeding time.
  • Monitor I&O closely and accurately when drug is administered to very young and elderly patients. Fluid restriction in infants, children, and elderly is required to prevent possible hyponatremia and water intoxication.
  • Continually assess patient for signs of fluid intoxication including lungs, extremities (edema), weight, or jugular venous distention.
  • Check for nasal mucosa changes (eg, edema, discharge, congestion, scarring), transphenoidal hypophysectomy, and nasal packing because they may compromise intranasal delivery; consider IV method.
  • Occasional change in response to IV desmopressin occurs with time, usually > 6 mo.
OVERDOSAGE: SIGNS & SYMPTOMS
  Headache, abdominal cramps, nausea, facial flushing

 Patient/Family Education

  • Instruct patient on proper intranasal administration techniques and have patient or family demonstrate ability to perform.
  • Remind patient receiving drug intranasally to frequently inspect nasal passages.
  • Explain that it is important to reduce fluid intake when therapy is initiated to decrease chance of water intoxication.
  • Instruct patient to report the following symptoms to health care provider: headache, shortness of breath, heartburn, nausea, abdominal cramps, or vulvar pain.
  • Inform patients that DDAVP nasal spray accurately delivers 25 or 50 doses. Discard any solution remaining after the 25 or 50 doses because the amount delivered thereafter may be substantially less than prescribed.

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