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Medications for ADH disorders: Nursing Pharmacology

Notes

Notes

Robyn Hughes, MScBMC

MEDICATIONS FOR ADH DISORDERS
DRUG NAME
vasopressin (Vasostrict); desmopressin 
(DDAVP, Noctiva)
conivaptan (Vaprisol); tolvaptan (Jinarc, Samsca)
CLASS
Synthetic ADH; ADH analogue
Vasopressin receptor antagonists
MECHANISM OF ACTION
Promote water reabsorption at distal convoluted tubule and collecting duct
Promote water excretion in urine
INDICATIONS
Diabetes insipidus
SIADH
ROUTE(S) OF ADMINISTRATION
  • Vasopressin: SubQ, IM
  • Desmopressin: PO, NAS, IV, SubQ
  • Conivaptan: IV
  • Tolvaptan: PO
SIDE EFFECTS
  • Headache, lethargy
  • Flushing
  • Nausea, vomiting, heartburn, cramps
  • Vasopressin: urticaria, vertigo, chest pain, myocardial infarction
  • Desmopressin: seizures, hypertension, tachycardia, palpitations, anaphylactic reactions, water intoxication, hyponatremia (boxed warning)
  • Nausea, vomiting, constipation
  • Polyuria, dehydration
  • Conivaptan: headache, confusion, insomnia, increased thirst, injection site reactions, hypokalemia, hypomagnesemia, hyponatremia
  • Tolvaptan: dizziness, fever, hyperkalemia, hypernatremia, hyperglycemia, strokes, ventricular fibrillation, DIC, bleeding, pulmonary embolism, respiratory depression, rhabdomyolysis, hepatotoxicity, osmotic demyelination syndrome (boxed warning)
CONTRAINDICATIONS AND CAUTIONS
  • Severe renal disease
  • Coronary artery disease
  • Vasopressin: migraines, seizures, asthma
  • Desmopressin: nephrogenic diabetes insipidus, cystic fibrosis, hypertension, electrolyte imbalances
  • Hypovolemia
  • Pregnancy and breastfeeding
  • Conivaptan: orthostatic hypertension, heart failure, renal disease
  • Tolvaptan: anuria, autosomal dominant polycystic kidney disease, children and elderly clients, dehydration, hyperkalemia, malnutrition, alcoholism, hepatic disease
NURSING CONSIDERATIONS: MEDICATIONS FOR ADH DISORDERS
DRUG NAME
vasopressin (Vasostrict); desmopressin 
(DDAVP, Noctiva)
conivaptan (Vaprisol); tolvaptan (Jinarc, Samsca)
ASSESSMENT AND MONITORING
Assess
  • Vital signs
  • Weight
  • Hydration status
    • Dehydration
    • Enema, fluid overload
  • Signs of hypo- or hypernatremia

Laboratory test results
  • Serum osmolality
  • Urine osmolality
  • BUN
  • Creatinine
  • Sodium
  • Potassium
  • Hepatic function
  • Blood glucose

Monitor
  • Intake, output, weight, vital signs hydration status, serum osmolality, sodium, BUN, and creatinine
  • Side effects
  • Therapeutic response: fluid and electrolyte balance
CLIENT EDUCATION
Desmopressin
  • Purpose of medication: replace ADH; promote renal water reabsorption, increase urine output
  • Self-administration: nasal spray, rhinal tube
  • Monitor daily fluid intake, urine output
  • Report
    • Urine output not within normal limits
    • Nausea, abdominal cramps, nasal irritation
    • Symptoms of water intoxication and low sodium; e.g., headache, weakness, confusion
Tolvaptan
  • Purpose of medication: inhibit renal water reabsorption, increase urine output
  • Self-administration: with or without food
    • Avoid grapefruit, grapefruit juice
  • Monitor daily fluid intake, urine output; adhere to prescribed fluid restrictions
  • Report
    • Symptoms of liver damage; e.g., fatigue, anorexia, abdominal pain, dark urine, yellowing of the skin or eyes
    • Symptoms of elevated sodium; e.g., muscle pain or weakness, mood changes, tachycardia
    • Inability to pass urine
Transcript

Antidiuretic hormone, or ADH for short, is the primary hormone that regulates fluid balance in the body, and is normally produced by the hypothalamus and stored in the posterior pituitary, which are both located within the brain.

Now, ADH disorders arise when the pituitary releases too much or too little of it. These disorders include diabetes insipidus, which results from a decrease in ADH; and syndrome of inappropriate ADH secretion, or SIADH for short, which results from an increased secretion of ADH.

Okay, so on one end of the spectrum, there’s ADH deficiency, which causes diabetes insipidus. This disorder is treated with ADH replacement therapy, which involves medications like vasopressin, which is a synthetic form of ADH, and desmopressin, which is a vasopressin analogue.

Both medications can be administered subcutaneously. In addition, vasopressin can be administered intramuscularly, and desmopressin can be administered orally, intranasally, or intravenously.

Once administered, these medications act on the kidneys by mimicking the actions of ADH, ultimately promoting the reabsorption of water at the distal convoluted tubule and collecting duct.

Now, these medications may cause side effects like headache, lethargy, and flushing. Other important side effects include nausea, vomiting, heartburn, and abdominal cramps.

In addition, clients who take vasopressin may present with urticaria and vertigo. These medications also cause vasoconstriction, resulting in cardiovascular side effects. Clients on vasopressin may experience chest pain, and even myocardial infarction.

On the other hand, clients taking desmopressin may develop hypertension, tachycardia, and palpitations. In addition, desmopressin may cause anaphylactic reactions. Finally, desmopressin can lead to water intoxication and hyponatremia, which can cause seizures and fatal brain dysfunction.

Alright, now these medications are contraindicated in hyponatremia, and that’s a boxed warning, since it can lead to seizures! In addition, they should be used with caution in clients with severe renal disease, and those with coronary artery disease, since they may cause vasoconstriction.

In addition, vasopressin should be used with caution in clients who experience migraines, seizures, or asthma. On the other hand, desmopressin is also used with caution in those with nephrogenic diabetes insipidus, as well as in clients with cystic fibrosis, hypertension, and electrolyte imbalances.

On the opposite end of the spectrum, there’s ADH excess, which causes syndrome of inappropriate antidiuretic hormone secretion, or SIADH for short.

This disorder is treated with vasopressin receptor antagonists, such as conivaptan, which is administered intravenously, and tolvaptan, which is given orally. Once administered, these medications inhibit the action of ADH, ultimately promoting water excretion in urine.

Side effects of vasopressin receptor antagonists include nausea, vomiting, constipation, as well as polyuria and dehydration. In addition, clients taking conivaptan may experience headache, confusion, insomnia, and increased thirst.

Some clients may also develop injection site reactions, orthostatic hypotension, and electrolyte abnormalities, such as hypokalemia, hypomagnesemia, and hyponatremia.

On the other hand, clients taking tolvaptan may present with dizziness and fever, as well as electrolyte abnormalities like hyperkalemia and hypernatremia, and may develop hyperglycemia.

Finally, tolvaptan may cause strokes, ventricular fibrillation, disseminated intravascular coagulation or DIC, and bleeding, as well as pulmonary embolism, respiratory depression, and rhabdomyolysis.

Lastly, tolvaptan has a boxed warning for hepatotoxicity and for osmotic demyelination syndrome, especially if the hyponatremia from SIADH is corrected too quickly.

Finally, vasopressin receptor antagonists are contraindicated in clients presenting with hypovolemia, and should be used with caution during pregnancy and breastfeeding. Additional precautions for conivaptan include orthostatic hypertension, heart failure, and renal disease.

On the other hand, tolvaptan is also contraindicated in clients with anuria or autosomal dominant polycystic kidney disease, and should be used with caution also in children and elderly clients.

In addition, tolvaptan should be administered in specialized care settings, where blood sodium levels can be carefully monitored during treatment. Finally, caution should be taken in clients with dehydration, hyperkalemia, malnutrition, alcoholism, or hepatic disease.

Sources
  1. "Mosby's 2021 Nursing Drug Reference" Mosby (2020)
  2. "Pharmacology" Elsevier Health Sciences (2014)
  3. "Focus on Nursing Pharmacology" LWW (2019)
  4. "Saunders Comprehensive Review for the NCLEX-RN Examination" Saunders (2016)
  5. "Gold Standard Drug Database"  ()