Desmopressin (as Desmopressin acetate) 240 microgram DDAVP
Melt 240microgram oral lyophilisates sugar-free | 100 tablet P £202.14
▶ DesmoMelt (Ferring Pharmaceuticals Ltd)
Desmopressin (as Desmopressin acetate)
120 microgram DesmoMelt 120microgram oral lyophilisates sugarfree | 30 tablet P £30.34 DT = £30.34
Desmopressin (as Desmopressin acetate)
240 microgram DesmoMelt 240microgram oral lyophilisates sugarfree | 30 tablet P £60.68 DT = £60.68
▶ Noqdirna (Ferring Pharmaceuticals Ltd)
Desmopressin (as Desmopressin acetate) 25 microgram Noqdirna
25microgram oral lyophilisates sugar-free | 30 tablet P £15.16 DT
Desmopressin (as Desmopressin acetate)
50 microgram Noqdirna 50microgram oral lyophilisates sugar-free
| 30 tablet P £15.16 DT = £15.16
▶ DDAVP (Ferring Pharmaceuticals Ltd)
Desmopressin acetate 100 microgram per 1 ml DDAVP
100micrograms/ml intranasal solution | 2.5 ml P £9.72 DT = £9.72
▶ BY INTRAMUSCULAR INJECTION, OR BY SUBCUTANEOUS
▶ Adult: 5–20 units every 4 hours
Initial control of oesophageal variceal bleeding
▶ Adult: 20 units, dose to be administered over
l CONTRA-INDICATIONS Chronic nephritis (until reasonable
blood nitrogen concentrations attained). vascular disease
(especially disease of coronary arteries) unless extreme
l CAUTIONS Asthma . avoid fluid overload . conditions which
might be aggravated by water retention . epilepsy . heart
failure . hypertension . migraine
l PREGNANCY Oxytocic effect in third trimester.
l BREAST FEEDING Not known to be harmful.
l DIRECTIONS FOR ADMINISTRATION
▶ With intravenous use For intravenous infusion (argipressin),
give intermittently in Glucose 5%; suggested
concentration 20 units/100mL given over 15 minutes.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Vasopressin (Non-proprietary)
Argipressin 20 unit per 1 ml Argipressin 20units/1ml solution for
injection ampoules | 10 ampoule P £850.00 (Hospital only)
Other drugs used for Syndrome of inappropriate
antidiuretic hormone secretion Demeclocycline
DIURETICS › SELECTIVE VASOPRESSIN V2-
l DRUG ACTION Tolvaptan is a vasopressin V2-receptor
Autosomal dominant polycystic kidney disease in adults
with CKD stage 1 to 4 at initiation of treatment with
evidence of rapidly progressing disease (initiated by a
▶ Adult: Initially 60 mg daily in 2 divided doses for at
least a week, 45 mg in the morning before breakfast,
and then 15 mg taken 8 hours later; increased to 90 mg
daily in 2 divided doses for at least a week, 60 mg in the
morning before breakfast, and then 30 mg taken
8 hours later, then increased if tolerated to 120 mg
daily in 2 divided doses, 90 mg in the morning before
breakfast, and then 30 mg taken 8 hours later, dose
titration should be performed cautiously; patients may
down-titrate to lower doses based on tolerability
DOSE ADJUSTMENTS DUE TO INTERACTIONS
▶ For Jinarc ®, manufacturer advises reduce dose with
concurrent use of potent CYP3A4 inhibitors—if daily
dose 90 mg or 120 mg, reduce to 30 mg once daily (can
be further reduced to 15 mg once daily if not tolerated);
if daily dose 60 mg, reduce to 15 mg once daily.
Manufacturer also advises reduce dose with concurrent
use of moderate CYP3A4 inhibitors or ciprofloxacin—if
daily dose 120 mg, reduce to 60 mg daily (45 mg in
morning and 15 mg taken 8 hours later); if daily dose
90 mg, reduce to 45 mg daily (30 mg in morning and
15 mg taken 8 hours later); if daily dose 60 mg, reduce
to 30 mg daily (15 mg in morning and 15 mg taken
Hyponatraemia secondary to syndrome of inappropriate
antidiuretic hormone secretion (initiated in hospital or
▶ Adult: Initially 15 mg once daily, increased if necessary
up to 60 mg once daily, a reduced starting dose of
7.5 mg once daily should be considered for patients at
risk of overly rapid correction of serum-sodium
l CONTRA-INDICATIONS Anuria . hypernatraemia . hypovolaemic hyponatraemia . impaired perception of
GENERAL CAUTIONS Abnormal liver function tests and/or
signs or symptoms of liver injury (do not initiate if the
criteria for permanent discontinuation are met—consult
product literature). diabetes mellitus . patients at risk of
dehydration (ensure adequate fluid intake). urinary
outflow obstruction (increased risk of acute retention)
▶ When used for autosomal dominant polycystic kidney
disease serum-sodium abnormalities (correct before
▶ When used for hyponatraemia secondary to syndrome of
inappropriate antidiuretic hormone secretion patients at risk of
demyelination syndromes (e.g hypoxia, alcoholism and
l INTERACTIONS → Appendix 1: tolvaptan
BNF 78 Syndrome of inappropriate antidiuretic hormone secretion 669
▶ Frequency not known Acute hepatic failure (cases requiring
liver transplantation reported)
SIDE-EFFECTS, FURTHER INFORMATION Interrupt treatment
and perform liver-function tests promptly if symptoms of
hepatic impairment occur (anorexia, nausea, vomiting,
fatigue, abdominal pain, jaundice, dark urine, pruritus)—
l PREGNANCY Avoid—toxicity in animal studies.
l BREAST FEEDING Avoid—present in milk in animal studies.
l HEPATIC IMPAIRMENT Manufacturer advises caution in
severe impairment; avoid if abnormal liver-function tests
and/or signs or symptoms of liver injury meet the
requirements for permanent discontinuation—consult
l RENAL IMPAIRMENT No information available in severe
▶ Manufacturer advises monitor volume, fluid and
electrolyte status (risk of dehydration)—monitor
electrolytes at least every 3 months during long-term
▶ Manufacturer advises monitor liver function tests and for
symptoms of liver injury—consult product literature for
▶ When used for Autosomal dominant polycystic kidney
disease Manufacturer advises evaluate uric acid
concentration before treatment initiation and as clinically
indicated during treatment; monitor urine osmolality
▶ When used for Hyponatraemia secondary to syndrome of
inappropriate antidiuretic hormone secretion Manufacturer
advises monitor serum-sodium concentration no later
than 6 hours after treatment initiation, then monitor
serum-sodium and volume status at least every 6 hours
during the first 1–2 days of treatment and until dose
stabilised. If serum-sodium correction exceeds
6 mmol/litre during the first 6 hours or 8 mmol/litre in the
first 6–12 hours, frequency of monitoring should be
18 mmol/litre or greater in 48 hours.
l PATIENT AND CARER ADVICE For Jinarc ®, morning dose to
be taken 30 minutes before food, second dose can be taken
l NATIONAL FUNDING/ACCESS DECISIONS
▶ Tolvaptan for treating autosomal dominant polycystic kidney
disease (October 2015) NICE TA358
Tolvaptan (Jinarc ®) is recommended as an option for the
treatment of autosomal dominant polycystic kidney
. the patient has chronic kidney disease stage 2 or 3 at the
. there is evidence of rapidly progressing disease, and
. the manufacturer provides tolvaptan with the discount
agreed in the patient access scheme.
Patients currently receiving tolvaptan (Jinarc ®) whose
disease does not meet the above criteria should be able to
continue treatment until they and their NHS clinician
consider it appropriate to stop.
www.nice.org.uk/guidance/ta358
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 27
▶ Jinarc (Otsuka Pharmaceuticals (U.K.) Ltd) A
Tolvaptan 15 mg Jinarc 15mg tablets | 7 tablet P £302.05
Tolvaptan 30 mg Jinarc 30mg tablets | 7 tablet P £302.05
Tolvaptan 45 mg Jinarc 45mg tablets | 7 tablet P s
Tolvaptan 60 mg Jinarc 60mg tablets | 7 tablet P s
Tolvaptan 90 mg Jinarc 90mg tablets | 7 tablet P s
▶ Samsca (Otsuka Pharmaceuticals (U.K.) Ltd)
Tolvaptan 15 mg Samsca 15mg tablets | 10 tablet P £746.80
Tolvaptan 30 mg Samsca 30mg tablets | 10 tablet P £746.80
Dosages of corticosteroids vary widely in different diseases
and in different patients. If the use of a corticosteroid can
save or prolong life, as in exfoliative dermatitis, pemphigus,
acute leukaemia or acute transplant rejection, high doses
may need to be given, because the complications of therapy
are likely to be less serious than the effects of the disease
When long-term corticosteroid therapy is used in some
chronic diseases, the adverse effects of treatment may
become greater than the disabilities caused by the disease.
To minimise side-effects the maintenance dose should be
When potentially less harmful measures are ineffective
corticosteroids are used topically for the treatment of
inflammatory conditions of the skin. Corticosteroids should
be avoided or used only under specialist supervision in
Corticosteroids are used both topically (by rectum) and
systemically (by mouth or intravenously) in the management
of ulcerative colitis and Crohn’s disease. They are also
included in locally applied creams for haemorrhoids.
Use can be made of the mineralocorticoid activity of
fludrocortisone acetate p. 676 to treat postural hypotension
High-dose corticosteroids should be avoided for the
management of septic shock. However, there is evidence that
administration of lower doses of hydrocortisone p. 676 and
fludrocortisone acetate is of benefit in adrenocortical
insufficiency resulting from septic shock.
Dexamethasone p. 675 and betamethasone p. 674 have
little if any mineralocorticoid action and their long duration
of action makes them particularly suitable for suppressing
corticotropin secretion in congenital adrenal hyperplasia
where the dose should be tailored to clinical response and by
measurement of adrenal androgens and
17-hydroxyprogesterone. In common with all
glucocorticoids their suppressive action on the
hypothalamic- pituitary-adrenal axis is greatest and most
prolonged when they are given at night. In most individuals
a single dose of dexamethasone at night, is sufficient to
inhibit corticotropin secretion for 24 hours. This is the basis
of the ‘overnight dexamethasone suppression test’ for
diagnosing Cushing’s syndrome.
Betamethasone and dexamethasone are also appropriate
for conditions where water retention would be a
670 Corticosteroid responsive conditions BNF 78
A corticosteroid may be used in the management of raised
intracranial pressure or cerebral oedema that occurs as a
result of malignancy (see Prescribing in palliative care p. 25);
high doses of betamethasone or dexamethasone are
generally used. However, a corticosteroid should not be used
for the management of head injury or stroke because it is
unlikely to be of benefit and may even be harmful.
In acute hypersensitivity reactions, such as angioedema of
the upper respiratory tract and anaphylaxis, corticosteroids
are indicated as an adjunct to emergency treatment with
adrenaline/epinephrine p. 222. In such cases hydrocortisone
(as sodium succinate) by intravenous injection may be
Corticosteroids are preferably used by inhalation in the
management of asthma but systemic therapy in association
with bronchodilators is required for the emergency
treatment of severe acute asthma.
Corticosteroids may also be useful in conditions such as
autoimmune hepatitis, rheumatoid arthritis and sarcoidosis;
they may also lead to remissions of acquired haemolytic
anaemia, and some cases of the nephrotic syndrome
(particularly in children) and thrombocytopenic purpura.
Corticosteroids can improve the prognosis of serious
conditions such as systemic lupus erythematosus, temporal
arteritis, and polyarteritis nodosa; the effects of the disease
process may be suppressed and symptoms relieved, but the
underlying condition is not cured, although it may
ultimately remit. It is usual to begin therapy in these
conditions at fairly high dose, and then to reduce the dose to
the lowest commensurate with disease control.
For other references to the use of corticosteroids see:
Prescribing in Palliative Care, immunosuppression,
rheumatic diseases, eye, otitis externa allergic rhinitis, and
MHRA/CHM advice: Corticosteroids: rare risk of central
serous chorioretinopathy with local as well as systemic
Central serous chorioretinopathy is a retinal disorder that
has been linked to the systemic use of corticosteroids.
Recently, it has also been reported after local administration
recommends that patients should be advised to report any
blurred vision or other visual disturbances with
corticosteroid treatment given by any route; consider
referral to an ophthalmologist for evaluation of possible
causes if a patient presents with vision problems.
Overdosage or prolonged use can exaggerate some of the
normal physiological actions of corticosteroids leading to
mineralocorticoid and glucocorticoid side-effects.
Mineralocorticoid side effects
Mineralocorticoid side effects are most marked with
fludrocortisone, but are significant with hydrocortisone,
corticotropin, and tetracosactide. Mineralocorticoid actions
are negligible with the high potency glucocorticoids,
betamethasone and dexamethasone, and occur only slightly
with methylprednisolone, prednisolone, and triamcinolone.
. osteoporosis, which is a danger, particularly in the elderly,
as it can result in osteoporotic fractures for example of the
. in addition high doses are associated with avascular
. muscle wasting (proximal myopathy) can also occur.
. corticosteroid therapy is also weakly linked with peptic
. psychiatric reactions may also occur.
Side-effects can be minimised by using lowest effective dose
for minimum period possible. The suppressive action of a
corticosteroid on cortisol secretion is least when it is given as
a single dose in the morning. In an attempt to reduce
pituitary-adrenal suppression further, the total dose for two
days can sometimes be taken as a single dose on alternate
days; alternate-day administration has not been very
successful in the management of asthma. Pituitary-adrenal
suppression can also be reduced by means of intermittent
therapy with short courses. In some conditions it may be
possible to reduce the dose of corticosteroid by adding a
small dose of an immunosuppressive drug.
should be used in preference to systemic treatment.
Inhaled corticosteroids have considerably fewer systemic
effects than oral corticosteroids, but adverse effects
including adrenal suppression have been reported. Use of
other corticosteroid therapy (including topical) or
concurrent use of drugs which inhibit corticosteroid
metabolism should be taken into account when assessing
systemic risk. In children, growth restriction associated with
systemic corticosteroid therapy does not seem to occur with
recommended doses of inhaled therapy; although initial
growth velocity may be reduced, there appears to be no
effect on achieving normal adult height. Large-volume
spacer devices should be used for administering inhaled
corticosteroids in children under 15 years; they are also
useful in older children and adults, particularly if high doses
are required. Spacer devices increase airway deposition and
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