Home blood sodium monitoring, sliding-scale fluid prescription and subcutaneous DDAVP for infantile diabetes insipidus with impaired thirst mechanism

Abstract

Background/AimsInfants with diabetes insipidus (DI), especially those with impaired thirst mechanism or hypothalamic hyperphagia, are prone to severe sodium fluctuations, often requiring hospitalization. We aimed to avoid dangerous fluctuations in serum sodium and improve parental independence.MethodsA 16-month old girl with central DI, absent thirst mechanism and hyperphagia following surgery for hypothalamic astrocytoma had erratic absorption of oral DDAVP during chemotherapy cycles. She required prolonged hospitalizations for hypernatremia and hyponatremic seizure. Intensive monitoring of fluid balance, weight and clinical assessment of hydration were not helpful in predicting serum sodium. Discharge home was deemed unsafe. Oral DDAVP was switched to subcutaneous (twice-daily injections, starting with 0.01mcg/dose, increasing to 0.024mcg/dose). The parents adjusted daily fluid allocation by sliding-scale, according to the blood sodium level (measured by handheld i-STAT analyser, Abbott). We adjusted the DDAVP dose if fluid allocation differed from maintenance requirements for 3 consecutive days.ResultsAfter 2.5 months, sodium was better controlled, with 84% of levels within reference range (135-145 mmol/L) vs. only 51% on the old regimen (p = 0.0001). The sodium ranged from 132-154 mmol/L, compared to 120–156 on the old regimen. She was discharged home.ConclusionThis practical regimen improved sodium control, parental independence, and allowed discharge home.

When Thirst Ceases to Exist: A Case Report and Literature Review of Adipsic Diabetes Insipidus Following Coil Embolization of a Ruptured Anterior Communicating Artery Aneurysm

“…Patients are furthermore prescribed desmopressin (DDAVP) to achieve a urine output of 1.5-2 liters daily. The dosage of desmopressin varies, as well as formulation (oral: 100- 250 micrograms twice daily; intranasal 3-10 micrograms twice per day) [ 62 , 63 ]. Oral absorption is often less preferable due to the significant variation with individuals and must be taken on an empty stomach [ 110 ].…”

Adipsic Diabetes Insipidus in Children: A Case Report and Practical Guide

“…Some pediatric endocrinologists have prescribed a home sodium monitoring device for patients with adipsic DI in combination with a sliding-scale fluid prescription plan, with an 84% success rate in maintaining plasma sodium at the reference range [ 17 ]. Unfortunately, this device is not always available.…”

Daily Sodium Monitoring and Fluid Intake Protocol: Preventing Recurrent Hospitalization in Adipsic Diabetes Insipidus

“…His DI was successfully managed with a purely weight-based protocol guiding fluid intake. Hameed et al [8] reported on a pediatric patient (age 16 months) whose sodium levels varied dramatically, with both hypernatremia and hyponatremia. This fluctuation was thought to be partially related to an infantile drive to drink that is motivated not only by thirst but by hunger.…”