Haemostasis and beyond: The expanding role of desmopressin in intensive care

Abstract

Desmopressin (1-deamino-8-D-arginine vasopressin, DDAVP) is a synthetic analogue of arginine vasopressin, the body’s natural antidiuretic hormone. It acts selectively on V2 receptors, promoting renal water reabsorption and stimulating the release of von Willebrand factor (vWF) and factor VIII, while exerting minimal vasoconstrictive effects through V1 receptors. Developed in the late 1960s and introduced clinically in the early 1970s for the management of central diabetes insipidus, desmopressin was engineered to provide a longer duration of action and reduced cardiovascular side effects compared to native vasopressin. Its haemostatic potential was later recognized when it was observed to enhance endogenous levels of vWF and factor VIII, leading to its incorporation into the treatment of mild haemophilia A and von Willebrand disease (vWD). This unique combination of antidiuretic and prohemostatic properties has broadened its therapeutic role across various clinical settings. In critical care, desmopressin has emerged as a potentially valuable agent in managing complex scenarios such as uremic platelet dysfunction, trauma-associated coagulopathy, intracranial hemorrhage, vWD, and central diabetes insipidus. However, despite its mechanistic appeal and broad pharmacologic utility, the full scope of desmopressin’s applications in the intensive care unit (ICU) remains underrecognized. This review aims to provide a comprehensive examination of desmopressin’s pharmacological characteristics, evidence-based indications in critically ill patients, therapeutic efficacy, safety profile, and practical considerations for dosing in the ICU setting.

Keywords: Antidiuretic hormone; Critical care; Desmopressin; Intensive care unit; Platelet dysfunction

Core Tip: In recent years, desmopressin has emerged as a potentially valuable agent in managing complex scenarios such as uremic platelet dysfunction, trauma-associated coagulopathy, intracranial hemorrhage, von Willebrand disease, and central diabetes insipidus. These conditions may be particularly challenging to manage, especially in critically ill patients. Emerging evidence suggests that desmopressin use may improve surrogate outcomes such as bleeding time and transfusion reduction. However, its impact on long-term clinical outcomes remains under investigation. The primary safety concern is hyponatremia due to water retention, which necessitates proactive fluid restriction and electrolyte monitoring. Thrombotic risk is low but warrants caution in high-risk patients. Despite its increasing application in intensive care units, desmopressin use remains largely empirical in many of these off-label contexts. This is because there is no universally accepted guidance on optimal dosing strategies, timing of administration, or patient selection.