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

Table 1 Desmopressin administration routes, dosing, onset, and half-life

Route	Typical dose	Time to peak effect	Half-life (healthy)	Half-life (renal impairment)	Clinical notes
Intravenous	0.3 µg/kg over 20-30 min	30-60 minutes	2-4 hours	8-10 hours	Preferred in ICU for bleeding control and acute DI
Subcutaneous	0.3 µg/kg	60-90 minutes	2-4 hours	Approximately 8 hours	Practical alternative when IV access is unavailable
Intranasal	150-300 µg (1-2 sprays)	60-90 minutes	Approximately 3 hours	Extended	Often used for chronic bleeding disorders or enuresis
Sublingual melt	120 µg (paediatric use)	60-90 minutes	Approximately 3 hours	Extended	Suitable for children or outpatient settings

ICU: Intensive care unit; DI: Diabetes insipidus; IV: Intravenous.

Table 2 Desmopressin use in renal and hepatic dysfunction

Clinical setting	eGFR	Recommended dose	Dosing interval	Key considerations
Mild-Moderate renal impairment	eGFR 30-60 mL/min	0.15-0.2 µg/kg IV or SC	Every 24-48 hours	Monitor serum sodium every 6-12 hours; avoid free water intake
Severe renal impairment	eGFR < 30 mL/min	Avoid for antidiuresis	—	High risk of hyponatremia and water intoxication
End stage renal disease/hemodialysis (for bleeding only)	On dialysis	0.3 µg/kg IV over 20-30 minutes	Single dose only; no repeat within 48-72 hours	Administer post-dialysis; enforce strict fluid restriction (≤ 1 L/day); monitor sodium every 6-8 hours
Hepatic dysfunction (e.g., Cirrhosis)	All stages	0.3 µg/kg IV over 20-30 minutes	Single dose only	Use for variceal bleeding or pre-procedure; monitor for thrombosis; avoid repeat dosing

eGFR: Estimated glomerular filtration rate; IV: Intravenous; SC: Subcutaneous.

Table 3 Dosing and monitoring of desmopressin in intensive care unit indications

Clinical Indication	Desmopressin dose and route	Frequency/duration	Monitoring/notes
Uremic bleeding (end-stage renal disease)	0.3 µg/kg IV (approximately 20-30 µg)	Single dose; may repeat in 24 hours with caution	Check bleeding time or PFA-100 if available; effect begins in approximately 1 hour, lasts 6-8 hours. Implement fluid restriction for 12-24 hours post-dose
Antiplatelet-associated intracerebral hemorrhage	0.4 µg/kg IV (max approximately 30 µg)	One-time dose at presentation	Administer promptly upon confirmation of hemorrhage. Monitor blood pressure during infusion (risk of hypotension). Reassess hematoma size on imaging. No routine repeat dosing
Trauma-induced coagulopathy (suspected platelet dysfunction/vWD)	0.3 µg/kg IV	Single dose early during resuscitation	Indicated for patients on antiplatelet agents or with known vWD. Incorporate into massive transfusion protocols. Monitor bleeding parameters (e.g., TEG/ROTEM). Not for empirical use
Inherited von Willebrand disease (type 1 and select type 2)	0.3 µg/kg IV/SC or 300 µg intranasal (150 µg/nostril)	Single dose; repeat in 12-24 hours if needed (max 2-3 doses)	Verify normal serum sodium before administration. Trial dose recommended to confirm responsiveness. Ineffective in Type 3 vWD—use vWF concentrate instead. Monitor vWF: FVIII levels if possible
Qualitative platelet dysfunction (e.g., CPB, liver disease)	0.3 µg/kg IV	One-time dose as needed for diffuse bleeding	Use in microvascular bleeding when platelet count is adequate but function impaired. Observe bleeding control (e.g., chest drain output). Consider adjunctive use of TXA
Central diabetes insipidus	1-2 µg IV/SC (fixed dose)	q8-12h; titrate based on clinical response	Monitor urine output hourly, urine specific gravity, and serum sodium every 4-6 hours. Adjust dose to maintain balanced output and stable sodium. Reduce or pause if sodium drops rapidly. Transition to oral/intranasal forms when stable

All doses should be adjusted in renal impairment carefully - desmopressin clearance is reduced, prolonging effect. IV: Intravenous; SC: Subcutaneous; IN: Intranasal; PRN: As needed; TXA: Tranexamic acid; UOP: Urine output; ROTEM: Rotational Thromboelastometry; TEG: Thromboelastography; vWF: Von Willebrand factor; vWD: Von Willebrand disease.

Table 4 Summary of desmopressin use in primary hematologic disorders

Bleeding disorder	Indication	Utility
Mild congenital haemophilia A	Surgery, acute bleeding	Strong evidence; test dose recommended
Acquired haemophilia A	Minor bleeding, low inhibitor titres	Conditional use if FVIII > 5 IU/dL and inhibitor < 5 BU
Haemophilia B	Any bleeding	Not effective
Factor XI deficiency	Surgical prophylaxis, minor bleeding	Limited evidence; consider if response documented
Type 1 vWD	Surgical prophylaxis, mucosal bleeding	First-line agent; strong response in approximately 80% of patients
Type 2A vWD	Minor bleeding	Variable benefit; not preferred
Type 2B vWD	Any bleeding	Contraindicated - risk of thrombocytopenia
Type 2M/2N vWD	Minor bleeding	Limited or case-level evidence
Type 3 vWD	Any bleeding	Not effective – no vWF stores to mobilize

BU: Bethesda unit; vWD: Von Willebrand disease.

Table 5 Key effects of desmopressin on sodium

Effect	How it happens	Clinical impact
Lowers sodium levels (hyponatremia risk)	Retains water, diluting sodium	Risk of dilutional hyponatremia if fluid intake is not controlled
Stabilizes sodium correction in SIADH	Slows rapid sodium rise by promoting water retention	Prevents osmotic demyelination syndrome
Does not directly alter sodium excretion	Primarily affects water balance, not sodium transport	Sodium levels change due to dilution effects