Diabetes%20insipidus Treatment

• Choice of therapy depends on the severity of polyuria

Goals

• Determine and treat the underlying cause
• Adequate hydration and replacement of free water deficit
• Replacement of deficient hormone

Central DI

Desmopressin

• 1st-line pharmacotherapy agent
• Analogue of naturally occurring vasopressin
  • Antidiuretic effect is greater and more prolonged than vasopressin
  • Urine volume is decreased and osmolality is increased
  • Less vasopressor activity than vasopressin
• Oral, intranasal and parenteral forms are available

Chlorpropamide

• Use is limited to patients who have partial central DI
  • Patient still secretes vasopressin but in insufficient quantity
• May work by increasing sensitivity of renal tubules to circulating endogenous vasopressin
• Side effects and limited antidiuretic effect limit their use

Thiazide and Related Diuretics

• Use should be combined with low-osmolar and low-Na diet 
• May work by reducing extracellular Na and decreasing glomerular filtration
• Side effects and limited antidiuretic effect limit their use

Carbamazepine

• May enhance the response to ADH
• Can lower urine output by as much as 25-60%

Clofibrate

• Stimulates secretion of AVP

Nephrogenic DI

Desmopressin

• Treatment option for patients with partial nephrogenic DI

Thiazide and Related Diuretics

• Use should be combined with low-osmolar and low-Na diet
• Increase Na loss at the cortical diluting tubule by inhibiting Na reabsorption
• Can reduce urine output by almost 70%
• May combine with potassium (K)-sparing diuretic if hypokalemia occurs

Potassium-Sparing Diuretics

• Eg Amiloride 
• Act on the distal renal tubules, cause an increase in the excretion of Na and reduce the secretion of K
• No untoward effects reported when combined with thiazide diuretics to correct hypokalemia

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

• Eg Indomethacin, Tolmetin and Ibuprofen
• Prostaglandin synthetase inhibitors which reduce urine flow
• Treatment option for patients not responsive to thiazides and Amiloride
• May have an additive effect with thiazide diuretics in reducing water excretion in some patients

 Carbamazepine

• Increase endogenous secretion of AVP

Central DI

• Small children with DI may have rapid changes in osmolality
• Family needs to be educated to gauge appropriate fluid intake and urine output
  • Daily weight may be used as index of fluid balance
  • Regular measurement of electrolytes may be required especially during beginning stages of treatment
• A low-Na and low-protein diet is recommended
• Appetite, linear growth and temperature should be monitored during all clinic visits

Familial

• Genetic counseling and follow-up

Nephrogenic DI

Drug-Induced

• Discontinue offending agent
  • May take a few weeks to see improvement

Familial

• Infants: Human milk is preferred because of protein content (6%)
  • Decrease Na intake to 0.7 mEq/kg/day
• Children: 8% of total daily calories should be from protein
  • Na intake should be <0.7 mEq/kg/day
• Low-Na and low-osmolar diet
• Appetite, linear growth and temperature should be monitored during all clinic visits
• Genetic counseling and follow-up