An Evaluation of a Proactive Versus Reactive Desmopressin Dosing Strategy for Sodium Overcorrection

Introduction: The 2024 American Society for Nephrology Treatment Guidelines for Hyponatremia recommend use of desmopressin for both prevention and treatment of hyponatremia overcorrection. Depending on a patient’s sodium level, appropriate sodium correction rates are up to 8 mmol/L in the first 24 hours and 18 mmol/L in the first 48 hours. When used to prevent sodium overcorrection, desmopressin is combined with hypertonic saline to help avoid rapid increases in sodium levels that are associated with osmotic demyelination syndrome. In contrast, a reactive dosing strategy uses a combination of desmopressin and dextrose 5% in water after sodium levels have overcorrected. The strategy for use of desmopressin for hyponatremia overcorrection treatment is not standardized. This study compared a desmopressin proactive versus reactive dosing strategy for sodium overcorrection.


Methods: This was a descriptive, retrospective study in adult intensive care unit (ICU) patients with hyponatremia who received desmopressin for sodium correction from June 2023 to June 2025. The primary endpoint was the 24-hour sodium correction rate. Secondary endpoints included 8- and 16-hour sodium correction rates, time to hyponatremia resolution, time to desmopressin and fluid discontinuation after hyponatremia resolution, and ICU length of stay.


Results: Forty-two patients were included; 15 received desmopressin proactively versus 27 received desmopressin reactively. The median age was 63, and 74% of patients were admitted to the medical ICU. The most common proactive desmopressin dose was 2mg every 8 hours; desmopressin reactive dosing was variable. The 24-hour sodium correction rate was 4.7 mmol/L and 9.8 mmol/L in the proactive and reactive groups, respectively. The reactive group had faster correction rates at both 8- and 16-hours. The median time to hyponatremia resolution in the proactive group was 2.6 days compared to the reactive group at 3.2 days. Desmopressin was continued for a median 6 hours and 27 hours after hyponatremia resolution for the proactive and reactive group, respectively. ICU length of stay was similar between both groups.


Conclusions: In this study, proactive desmopressin dosing resulted in a lower 24-hour sodium correction rate and faster time to hyponatremia resolution compared to reactive dosing.