Bedside Snapshot

Use It For
Central diabetes insipidus (head trauma, pituitary surgery, donor management); hemophilia A or von Willebrand type 1 bleeding or surgery; off-label uremic or antiplatelet bleeding (see Indications)
Adult Dose
  • Diabetes insipidus: starting dose 2–4 mcg/day IV or SC, divided; titrate
  • Hemophilia A or vWD: 0.3 mcg/kg IV over 15–30 min (max 20 mcg)
  • Off-label sodium re-lowering: 1–3 mcg IV or SC every 8–12 h, expert-directed
Pediatric Dose
Hemophilia or vWD from 3 months: 0.3 mcg/kg IV (max 20 mcg). Diabetes insipidus not established under 12 years: specialist use only
Onset / Duration
IV: factor VIII rise within 30 min / effect about 8–12 h. Plasma half-life 2.8 h
Do Not Give / Hold If
Hyponatremia or SIADH; creatinine clearance below 50 mL/min; loop diuretic or systemic or inhaled steroid; polydipsia; heart failure; uncontrolled hypertension
Watch For
Hyponatremia (headache, nausea, confusion, seizure): check sodium; anaphylaxis, including fatal IV reports; thrombosis in type 2B vWD; blood pressure change
Reversal / Rescue
No specific antidote: stop the drug, check serum sodium and treat hyponatremia per protocol. Fluid restriction until sodium is stable
Must Remember
It holds water in: check sodium before each dose and restrict fluids from 1 hour before to 8 hours after (boxed warning)

Indications

ED / ICU / Transport

  • Central diabetes insipidus: Replacing antidiuretic hormone is the job here. It also treats temporary polyuria and polydipsia after head trauma or pituitary-region surgery (label). Not for nephrogenic diabetes insipidus
  • Hemophilia A (factor VIII activity above 5%, no factor VIII antibodies): Two jobs. Hemostasis for surgery, and bleeding from hemarthrosis, intramuscular hematoma or mucosal bleeding (label)
  • von Willebrand disease type 1 (mild to moderate; factor VIII above 5%): Same surgical and bleeding uses as hemophilia A (label). Not for severe type 1, or for an abnormal factor VIII molecular form
  • Brain-dead organ donor: Treats central diabetes insipidus during donor management. This is ICU practice, not a labelled use

Other Uses

  • Uremic bleeding (off-label): Bleeding time gets shorter in uremia, but the response is variable and protocol-dependent. Patients with uremia usually meet the label contraindication (CrCl below 50 mL/min; in severe impairment the half-life is up to 8.7 h and AUC 3.6-fold higher). Specialist direction only, with close sodium monitoring
  • Antiplatelet-associated intracerebral hemorrhage (off-label): The evidence is thin, and it does not support routine use (see Clinical Pearls). The label advises against use where raised intracranial pressure is a risk (label 5.5). That risk may apply in ICH
  • Re-lowering an overcorrected serum sodium (off-label, expert-directed): The label contraindicates it in hyponatremia. Expert direction only, with close sodium monitoring

Dosing & Administration

Doses vary by protocol; follow local protocols and medical direction.

Available Forms

  • Injection, 4 mcg/mL: 1 mL single-dose ampule, or 10 mL multiple-dose vial (40 mcg/10 mL) with chlorobutanol 5 mg/mL. Store refrigerated at 2–8 °C (36–46 °F)
  • Nasal spray and tablets: Outpatient forms with their own dosing. Not used for acute IV or SC care. Moving from nasal spray to injection starts at one-tenth of the daily nasal dose (label)
Hyponatremia risk: Every route carries the boxed warning. Before the first dose, and before each resumed course, confirm serum sodium is normal. Then restrict free water.

Adult Dosing

IndicationDose & RouteRepeat / MaxNotes
Central diabetes insipidus (starting dose)
2–4 mcg/day IV or SC, as one or two divided doses
Label gives no stated maximum; titrate to sleep and water turnover
Do not dilute for diabetes insipidus (label). Adjust morning and evening doses separately. Watch serum sodium
Central diabetes insipidus in donor management (ICU practice)
Initial IV dose of 1–4 mcg, repeated as needed
Repeat until urine volume and serum sodium are controlled; no fixed max in source
Intermittent desmopressin or continuous IV vasopressin, chosen by vasopressor need (ICU donor review)
Hemophilia A or von Willebrand disease type 1
0.3 mcg/kg actual body weight IV over 15–30 min, diluted (Preparation)
Repeat after 8–12 h, then once daily if needed; max 20 mcg per dose
Give 30 min before a procedure if used for surgery. Tachyphylaxis (lessening response) can occur with doses given more often than every 48 h; the response is reproducible with doses 2–3 days apart (label 2.2)
Uremic or antiplatelet-associated bleeding (off-label)
Per hematology or neurocritical-care protocol
No fixed max in this reference
Effect is uncertain (see Clinical Pearls). Label 5.5: not recommended where raised intracranial pressure is a risk. Check sodium after each dose
Overcorrected sodium, re-lowering (off-label, expert-directed)
1–3 mcg IV or SC; ESE 2014 suggests 2 mcg IV
Not more often than every 8–12 h (NDT 2024: 1–3 mcg); every 8 h at most (2014 ESE guideline)
Caution: label contraindication in hyponatremia. Pair with the electrolyte-free water plan on the D5W page. Serum sodium every 1–2 h

Dosing weight: Hemophilia and von Willebrand doses run on actual body weight (label). Central diabetes insipidus dosing is fixed and not weight-based.

Pediatric Dosing

IndicationDose (per kg) & RouteMax Single / Max TotalNotes
Hemophilia A or von Willebrand disease type 1, age 3 months and older
0.3 mcg/kg IV over 15–30 min
20 mcg single; no cumulative max stated (label)
Same rules as adults: factor VIII above 5%, no antibodies, sodium and aPTT checked first. Fluid restriction needed
Central diabetes insipidus, age 12 years and older
Adult diabetes insipidus dosing (2–4 mcg/day IV or SC)
No fixed max: titrate to effect
Label establishes safety and effectiveness from age 12
Central diabetes insipidus, under 12 years
Not established in children
—
Specialist use only, with fluid restriction
Under 3 months (bleeding indications)
Not established in infants
—
Label: safety and effectiveness not established below 3 months
Not established in children: Diabetes insipidus under 12 years and bleeding use under 3 months are not established (FDA label). Pair specialist or hematology direction with weight-based dosing checks.

Preparation & Administration

  • Dilution (hemophilia and von Willebrand only): add the dose to 0.9% sodium chloride: 10 mL if the patient weighs 10 kg or less, 50 mL if more than 10 kg. Do not dilute for diabetes insipidus (label)
  • Push rate: infuse the diluted dose slowly over 15–30 min. Do not give as a bolus
  • Monitoring during infusion: blood pressure and pulse (label). Hypotension with reflex tachycardia can happen, and so can hypertension
  • Line: IV or SC, per indication. Pick the line that the protocol and dilution allow. The label has no extravasation data
  • Fluid restriction: limit fluid intake from 1 hour before to 8 hours after each dose (label)
  • Light and storage: refrigerate unopened ampules and vials at 2–8 °C. Dilute immediately before use and follow pharmacy stability data
Dosing Notes:
  • Doses vary by protocol; follow local protocols and medical direction.
  • The label dose runs per kg of actual body weight. For bleeding use, it stops at 20 mcg.
  • Check serum sodium before starting or resuming, within 1 week and about 1 month after starting, then periodically (label). That is the schedule for stable outpatients. ICU and donor diabetes insipidus need protocol-set checks, more frequent (see Monitoring).
  • Re-lowering sodium is off-label. It does not replace the hypertonic saline plan on the hypertonic saline page.

Contraindications & Precautions

Contraindications

  • Hypersensitivity to desmopressin or any component. IV use has come with reports of fatal anaphylaxis (label)
  • Moderate to severe renal impairment: creatinine clearance below 50 mL/min (Cockcroft-Gault)
  • Hyponatremia or a history of hyponatremia; known or suspected SIADH; polydipsia (label)
  • Concomitant loop diuretics or systemic or inhaled glucocorticoids (label)
  • Illness causing fluid or electrolyte imbalance, such as gastroenteritis, salt-wasting nephropathy or systemic infection (label)
  • Heart failure or uncontrolled hypertension (fluid retention, label)

Precautions

  • Raised intracranial pressure or urinary retention: not recommended. Fluid retention can make both worse (label 5.5)
  • Type 2B von Willebrand disease: platelets can clump, the count can drop, and thrombosis is possible (label 5.3)
  • Heart disease: watch blood pressure during the infusion. Hypotension with compensatory tachycardia can occur, and so can hypertension (label 5.2)
  • Other vasoconstrictors: the desmopressin dose may need to be lower (label 7.2)

Hold / Reassess If

  • Serum sodium is below normal or falling: hold and treat the hyponatremia per protocol. Do not start or resume until sodium is normal (label)
  • Headache, nausea, confusion, drowsiness or seizure: check serum sodium now. Each one is an early sign of water intoxication (label)
  • Large weight gain, edema or dilute polyuria with no fluid balance: reassess fluid intake and sodium before the next dose
  • Hypotension, hypertension or reflex tachycardia during infusion: stop the infusion and reassess
FDA Boxed Warning: DDAVP can cause hyponatremia. When it is severe, it can be life-threatening, with seizures, coma, respiratory arrest or death. Do not use it in patients at increased risk, such as those with excessive fluid intake, illness causing fluid or electrolyte imbalance, or those using loop diuretics or systemic or inhaled glucocorticoids. Make sure serum sodium is normal before you start or resume. Measure it within 1 week and about 1 month after starting, and more often in patients 65 and older.
Off-label sodium re-lowering: The label contraindicates desmopressin in hyponatremia. Re-lowering is an expert decision only. Track urine output, and check sodium every 1–2 h.

Adverse Effects & Toxicity

Common

  • Abdominal cramps, nausea and headache (post-marketing; frequency not stated in the label)
  • Facial flushing, burning pain, erythema and swelling at the injection site or in the face
  • Fluid retention and hyponatremia (boxed warning): check sodium. Hold or stop the drug if sodium is low or falling. The label says the drug may need to stop, for a while or for good (label 5.1)
  • Tachycardia, hypotension or hypertension during infusion

Serious / Life-Threatening

EffectRecognitionManagement
Severe hyponatremia
Headache, nausea, confusion, drowsiness, seizures, coma, respiratory arrest
Stop desmopressin; check sodium now; treat per protocol (see the hypertonic saline page); reassess before any restart
Anaphylaxis
Urticaria, bronchospasm, hypotension; fatal reports with IV use
Stop the infusion; treat anaphylaxis per protocol; do not restart. Permanent discontinuation after serious reaction (label)
Thrombosis in type 2B von Willebrand disease
New thrombosis, falling platelet count
Avoid use in type 2B; hematology direction for any suspected thrombotic event
Hypertension or hypotension
Blood pressure change or reflex tachycardia during infusion
Slow or stop the infusion; treat per protocol

Overdose & Toxicity Management

  • Signs: headache, abdominal cramps, nausea, facial flushing, confusion, drowsiness, difficulty passing urine, rapid weight gain from fluid retention (label)
  • Immediate management: reduce the dose, lengthen the interval or stop the drug. Check serum sodium. Treat hyponatremia per protocol (label)
  • Antidote: no specific antidote. The label lists no reversal agent for desmopressin
  • Removal: the label does not describe it. Supportive care and sodium control only

Monitoring
ParameterWhen / How OftenTarget / Act If
Clinical: mental status and seizure
Continuous in ICU; each check during transport
New confusion, headache, drowsiness or seizure: check sodium now and hold the drug (act if sodium is low or falling)
Clinical: blood pressure and pulse
Before, during and after each IV dose (label)
Hypotension, hypertension or reflex tachycardia: slow or stop the infusion
Clinical: urine output and fluid balance
Hourly during diabetes insipidus or re-lowering; daily weights
Sudden large dilute urine: the dose is too low; large weight gain or edema: the dose is too high (reassess fluids)
Laboratory: serum sodium
Before the first dose, within 1 week and about 1 month, then periodically; more often at 65 and older
Below normal or falling: hold and treat. Re-lowering: every 1–2 h until the rise is controlled
Laboratory: serum sodium in ICU or donor diabetes insipidus
Protocol-set and more often than the outpatient schedule (the label schedule is for stable outpatient therapy); pair with hourly urine output
Sodium low or falling: hold and treat per protocol. Large dilute urine output: reassess the dose
Laboratory: urine and plasma osmolality
Intermittently during diabetes insipidus treatment (label)
Osmolality rising with dilute urine: consider a dose increase; falling sodium with high urine output: reassess
Laboratory: aPTT and factor VIII
Before treatment and to confirm response in hemophilia or von Willebrand disease (label)
Factor VIII or von Willebrand factor below the hematology target: escalate per hematology

Interactions & Compatibility

Clinically Significant Interactions

Drug / ClassEffectWhat To Do
Loop diuretics (furosemide, bumetanide)
Additive hyponatremia; contraindicated by label
Avoid. Use a different plan with the prescriber
Systemic or inhaled glucocorticoids (for example hydrocortisone)
Additive hyponatremia; contraindicated by label
Avoid. Check sodium before any steroid start if desmopressin is planned
Vasopressin or other vasoconstrictors
Additive pressor effect; label may require a lower desmopressin dose
Monitor blood pressure closely; reduce the desmopressin dose per protocol. See vasopressin
Drugs that add to hyponatremia risk: tricyclic antidepressants, SSRIs, chlorpromazine, opiate analgesics, thiazides, NSAIDs, carbamazepine, lamotrigine, sulfonylureas, oxybutynin
Water intoxication with hyponatremia (label 7.1)
Check sodium more often when these drugs are started or their doses increased

IV Compatibility

  • Preferred diluent: 0.9% sodium chloride for the hemophilia and von Willebrand dose (label)
  • Diabetes insipidus doses: not diluted (label)
  • Y-site compatibility: not described in the label. The label does not require a dedicated line

Check it against an institutional compatibility resource.

Special Populations
  • Pediatrics: established for hemophilia A and von Willebrand disease from age 3 months, and for diabetes insipidus from age 12. Keep fluids restricted to head off hyponatremia and water intoxication (label 8.4). See the Pediatric Dosing table.
  • Neonates: bleeding use is not established below 3 months. Specialist direction only.
  • Pregnancy: published experience spanning decades shows no drug-associated major birth defect or miscarriage risk. Placental transfer is poor in vitro. Animal studies show no adverse outcomes at high multiples of the human dose (label 8.1). At delivery, women with hemophilia or von Willebrand disease may bleed, and the newborn may be at risk of bleeding.
  • Lactation: desmopressin transfers poorly into breast milk, in negligible amounts. The label has no information on effects on the breastfed child or on milk production (label 8.2).
  • Older Adults: begin low in the dosing range. Watch renal function and sodium more often at 65 and older (label 8.5).
  • Renal Impairment: below a creatinine clearance of 50 mL/min, it is contraindicated. Half-life climbs from 2.8 h to 4 h (mild), 6.6 h (moderate) and 8.7 h (severe). AUC runs 1.5-, 2.4- and 3.6-fold higher (label 12.3).
  • Hepatic Impairment: the label establishes no specific adjustment. CYP450 enzymes do not metabolize desmopressin.
  • Obesity / Dosing Weight: bleeding doses run on actual body weight, with a 20 mcg cap (label). Diabetes insipidus doses are fixed, not weight-based.

Field & Transport Considerations
  • Scope: not typically carried by EMS. Transport crews get it for patients who are already on it. Varies by state and agency protocol.
  • Storage & Stability: refrigerate at 2–8 °C (36–46 °F). Don't leave it at room temperature in the transport bag for long. Follow pharmacy beyond-use dating.
  • Carried Concentration: Both the 1 mL ampule (4 mcg) and the 10 mL vial (40 mcg) hold 4 mcg/mL. Check the container volume before you calculate the dose.
  • Infusions in Transport: bleeding doses run over 15–30 min through a dedicated IV, or with the line flushed before and after. Watch blood pressure and pulse. Keep the fluid restriction going.
  • Altitude / Environment: the label has no specific data.
  • Handoff Essentials: say when and how much desmopressin was last given. Give the latest serum sodium, when it was drawn, and when the next draw is due. Report fluid intake and urine output since the dose, and any new headache, confusion or seizure.

Clinical Pearls
Polyuria pattern: big volumes of dilute urine with a rising sodium point to central diabetes insipidus. Desmopressin treats that. In SIADH, where sodium is already low, it is the wrong drug.
Water loading trap: desmopressin plus free-water intake or IV dextrose leads to hyponatremia. Restrict fluids from 1 hour before to 8 hours after each dose. Check sodium before the next one.
Desmopressin vs vasopressin:
  • Desmopressin: V₂-selective. Antidiuretic, with little pressor effect. Raises factor VIII (label).
  • Vasopressin: V₁ vasoconstriction and V₂ antidiuresis. Used for shock (see the vasopressin page).
  • Look-alike: these two are commonly mixed up. Read the drug name and concentration on every order.
Exam discriminator: the labelled bleeding group is a hemophilia A or von Willebrand patient with factor VIII above 5% and no inhibitor. Hemophilia B, severe type 1 von Willebrand disease, type 2B and type 3 are not indicated, or are risky with desmopressin (label).
Donor DI: in brain-dead donors, pick between intermittent desmopressin and continuous IV vasopressin for central diabetes insipidus, based on vasopressor need. Sodium and urine output set the next dose (ICU donor review).
Antiplatelet bleeding is not proven: the DASH trial (2023) was a feasibility study of one 20 mcg IV dose. It was not designed to show benefit. A 2021 meta-analysis of three retrospective studies found a non-significant reduction in hematoma expansion and worse neurologic outcome (mRS 4 or higher). The meta-analysis does not support routine use. The 2022 AHA/ASA spontaneous ICH guideline (Greenberg et al., Stroke 2022) is the society statement for ICH management. Check its wording on antiplatelet-associated ICH before use.

Pharmacology

Mechanism of Action

  • V₂ receptors in the renal collecting duct pull water back in. Urine output drops and urine osmolality rises (label 12.1).
  • Vascular V₁ activity is minimal at antidiuretic doses. The pressor effect stays small (label 12.1).
  • Factor VIII and plasminogen activator release raises plasma factor VIII activity within 30 min. That shortens bleeding in hemophilia A and mild von Willebrand disease type 1 (label 12.2).

Pharmacokinetics

RouteOnsetPeakDuration
IV
Factor VIII rise within 30 min
Factor VIII peak 90 min to 2 h
Hemostatic effect about 8–12 h (factor VIII half-life)
SC
Not described in the label
Not described in the label
Not described in the label
  • Half-life: the geometric mean terminal half-life is 2.8 h with normal renal function (label 12.3).
  • Metabolism: human CYP450 enzymes do not metabolize it, and it does not inhibit CYP in vitro (label).
  • Active metabolites: the label describes none.
  • Elimination: about 52% comes out unchanged in urine within 24 h after 2 mcg IV (label).
  • Protein binding / Vd: the label does not describe either.

Names & Classification
Generic Name
Desmopressin acetate
Brand Names
DDAVP (Ferring; injection and tablets); Stimate (Ferring; nasal spray); Desmoda (Eton; oral solution, not an IV or SC product). Injection is generic from several manufacturers
Pharmacologic Class
Synthetic vasopressin analog; V₂-selective agonist
Therapeutic Class
Antidiuretic hormone replacement; hemostatic agent for hemophilia A and von Willebrand disease type 1
Controlled Substance
Not controlled
ISMP High-Alert
No
Look-Alike / Sound-Alike
vasopressin / DESMOpressin (see the vasopressin page)

Related

References
  1. Ferring Pharmaceuticals Inc. (2022). DDAVP (desmopressin acetate) injection, for intravenous or subcutaneous use: prescribing information with boxed warning for hyponatremia. DailyMed, U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=651f6fee-a2c7-431b-8d5d-58b156c72244
  2. Spasovski G, Vanholder R, Allolio B, Annane D, et al. (2014). Clinical practice guideline on diagnosis and treatment of hyponatraemia. European Journal of Endocrinology, 170(3), G1–G47. https://doi.org/10.1530/EJE-13-1020
  3. Spasovski G. (2024). Hyponatraemia-treatment standard 2024. Nephrology Dialysis Transplantation, 39(10), 1583–1592. https://doi.org/10.1093/ndt/gfae162
  4. Further reading: Connell NT, Flood VH, Brignardello-Petersen R, Abdul-Kadir R, et al. (2021). ASH ISTH NHF WFH 2021 guidelines on the management of von Willebrand disease. Blood Advances, 5(1), 301–325. https://doi.org/10.1182/bloodadvances.2020003264
  5. Meyfroidt G, Gunst J, Martin-Loeches I, Smith M, Robba C, Taccone FS. (2019). Management of the brain-dead donor in the ICU: general and specific therapy to improve transplantable organ quality. Intensive Care Medicine, 45(3), 343–353. https://doi.org/10.1007/s00134-019-05551-y
  6. Desborough MJR, Al-Shahi Salman R, Stanworth SJ, Havard D, Woodhouse LJ, Craig J, et al. (2023). Desmopressin for patients with spontaneous intracerebral haemorrhage taking antiplatelet drugs (DASH): a UK-based, phase 2, randomised, placebo-controlled, multicentre feasibility trial. The Lancet Neurology, 22(7), 557–567. https://doi.org/10.1016/S1474-4422(23)00157-6
  7. Loggini A, El Ammar F, Darzi AJ, Mansour A, Kramer CL, Goldenberg FD. (2021). Effect of desmopressin on hematoma expansion in antiplatelet-associated intracerebral hemorrhage: a systematic review and meta-analysis. Journal of Clinical Neuroscience, 86, 116–121. https://doi.org/10.1016/j.jocn.2021.01.017
  8. Greenberg SM, et al. (2022). 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage: a guideline from the American Heart Association/American Stroke Association. Stroke, 53. https://doi.org/10.1161/STR.0000000000000407

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