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  • CLASSES

    Antidiuretic Hormones
    Vasopressin (ADH) and Analogs
    Vasopressors

    DEA CLASS

    Rx

    DESCRIPTION

    Parenteral exogenous antidiuretic hormone (ADH)
    Used for increasing blood pressure in adults with vasodilatory shock who remain hypotensive despite fluids and catecholamines and for prevention and treatment of postoperative abdominal distention in abdominal roentgenography
    Has catecholamine-sparing effect

    COMMON BRAND NAMES

    Pitressin, Vasostrict

    HOW SUPPLIED

    Pitressin/Vasopressin/Vasostrict Intramuscular Inj Sol: 1mL, 20U
    Pitressin/Vasopressin/Vasostrict Intravenous Inj Sol: 0.2U, 0.4U, 1mL, 20U
    Pitressin/Vasopressin/Vasostrict Subcutaneous Inj Sol: 1mL, 20U

    DOSAGE & INDICATIONS

    For the treatment of central diabetes insipidus.
    Intramuscular or Subcutaneous dosage
    Adults

    5 to 10 units IM or subcutaneously every 3 to 4 hours for 2 to 3 times daily as needed.

    Infants, Children, and Adolescents

    5 to 10 units IM or subcutaneously every 3 to 4 hours for 2 to 3 times daily as needed. Reduce the dose proportionally for pediatric patients.

    Intranasal dosage
    Adults

    Intranasal dosages (on cotton pledgets or topically as a spray) are determined for each patient individually.

    Children and Adolescents

    Intranasal dosages (on cotton pledgets or topically as a spray) are determined for each patient individually.

    Intravenous dosage (continuous infusion)†
    Adults

    0.0005 units/kg/hour (0.5 milliunits/kg/hour) continuous IV infusion; titrate by 0.0005 units/kg/hour (0.5 milliunits/kg/hour) every 5 to 10 minutes to achieve a urine output of approximately 100 mL/hour. Infusion rates more than 0.01 units/kg/hour (10 milliunits/kg/hour) are rarely required. However, reported doses are variable; weight-based infusion rates ranging from 0.00025 to 0.04 units/kg/hour (0.25 to 40 milliunits/kg/hour) have been recommended and standard infusions of 2.5 units/hour have been used.

    Infants, Children, and Adolescents

    0.0005 units/kg/hour (0.5 milliunits/kg/hour) continuous IV infusion; titrate by 0.0005 units/kg/hour (0.5 milliunits/kg/hour) every 5 to 10 minutes until urine output is decreased to less than 2 mL/kg/hour. Infusion rates more than 0.01 units/kg/hour (10 milliunits/kg/hour) are rarely required.

    For the treatment of hypotension in patients with vasodilatory shock (i.e., post-cardiotomy shock, septic shock) who remain hypotensive despite fluids and catecholamines.
    For patients with post-cardiotomy shock.
    Intravenous dosage
    Adults

    0.03 unit/minute continuous IV infusion; titrate by 0.005 unit/minute every 10 to 15 minutes to clinical response. Max: 0.1 unit/minute. After target blood pressure is maintained for 8 hours without the use of catecholamines, taper by 0.005 unit/minute every hour as tolerated to maintain target blood pressure.[58023]

    For patients with septic shock.
    Intravenous dosage
    Adults

    0.01 unit/minute continuous IV infusion; titrate by 0.005 unit/minute every 10 to 15 minutes to clinical response. Max: 0.07 unit/minute. After target blood pressure is maintained for 8 hours without the use of catecholamines, taper by 0.005 unit/minute every hour as tolerated to maintain target blood pressure.[58023] Guidelines recommend adding vasopressin to norepinephrine instead of escalating the dose of norepinephrine in patients with inadequate mean arterial pressures at norepinephrine doses of 0.25 to 0.5 mcg/kg/minute.

    Infants†, Children†, and Adolescents†

    0.1 to 8 milliunits/kg/minute continuous IV infusion; this dosage range is not well established, based on several case series/reports and retrospective reviews demonstrating increased arterial blood pressure and urine output as well as decreased catecholamine requirements in pediatric shock.[54898] However, low dose vasopressin (0.5 to 2 milliunits/kg/minute continuous IV infusion) showed no clinical benefit and a trend towards increased mortality when used for pediatric vasodilatory shock during a randomized, double-blind, placebo-controlled trial (n = 65, age: 3 to 14 years).[54899] Septic shock guidelines suggest the addition of vasopressin or further titration of catecholamines in pediatric patients unresponsive to traditional vasopressor therapy.[64985]

    For postoperative abdominal distention (e.g., ileus).
    Intramuscular dosage
    Adults

    5 units IM every 3 to 4 hours as needed. May increase the dose to 10 units if necessary.

    For use in gastrointestinal radiography.
    Intramuscular or Subcutaneous dosage
    Adults

    10 units IM or subcutaneously for 2 doses at 2.5 and 0.5 hours before film exposure.

    For the treatment of variceal bleeding† or nonvariceal upper GI bleeding†.
    For the treatment of variceal bleeding† or nonvariceal upper GI bleeding† in pediatric patients.
    Intravenous dosage
    Children and Adolescents

    0.3 units/kg (Max: 20 units) IV followed by 0.002 to 0.005 units/kg/minute continuous IV infusion. May increase up to 0.01 units/kg/minute.

    For the treatment of variceal bleeding† in adults.
    Intravenous dosage
    Adults

    0.2 to 0.4 units/minute continuous IV infusion for 24 hours. May increase up to 0.8 units/minute. Always use in combination with IV nitroglycerin.

    For the treatment of cardiac arrest† including ventricular asystole† and pulseless electrical activity† (PEA) during cardiopulmonary resuscitation† (CPR).
    Intravenous or Intraosseous
    Adults

    20 units IV/IO per CPR cycle (Max: 100 units) plus epinephrine IV for up to 5 CPR cycles and methylprednisolone IV once intra-arrest followed by stress-dose hydrocortisone IV beginning 4 hours after resuscitation for in-hospital cardiac arrest (IHCA) requiring vasopressors improved survival to hospital discharge with favorable neurological status vs. epinephrine and placebo and may be considered in IHCA.[60265] Vasopressin offers no advantage as a substitute for epinephrine in cardiac arrest.

    †Indicates off-label use

    MAXIMUM DOSAGE

    Dependent on the route of administration and indication for therapy.

    DOSING CONSIDERATIONS

    Hepatic Impairment

    Specific guidelines for dosage adjustments in hepatic impairment are not available; it appears that no dosage adjustments are needed.

    Renal Impairment

    Specific guidelines for dosage adjustments in renal impairment are not available; it appears that no dosage adjustments are needed.

    ADMINISTRATION

    Injectable Administration

    Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.

    Intravenous Administration

    Dilution
    The 0.4 unit/mL and 0.6 unit/mL premixed solutions do not require further dilution prior to administration.
    Dilute the concentrated 20 units/mL solution to a concentration of 0.1 or 1 unit/mL in 0.9% Sodium Chloride Injection or 5% Dextrose Injection. A concentration of 1 unit/mL is suggested for patients with fluid restrictions.[58023]
    ASHP Recommended Standard Concentrations for Adult Continuous Infusions: 0.2 units/mL or 1 unit/mL for cardiac/vasopressor indications.[64020]
    ASHP Recommended Standard Concentrations for Pediatric Continuous Infusions: 0.04 units/mL, 0.2 units/mL, or 1 unit/mL for cardiac/vasopressor indications.
    Storage: Discard unused solution after 18 hours at room temperature or 24 hours under refrigeration.[58023]
     
    Continuous IV Infusion
    Administer through a central vein whenever possible; prolonged administration through a peripheral vein may result in extravasation and skin necrosis. If peripheral administration is necessary, use a 20-gauge or larger catheter and assess the site frequently. If extravasation occurs, administer 5 to 10 mg of phentolamine directly to the site.

    Intramuscular Administration

    Inject deeply into a large muscle.
    When used for gastrointestinal radiography, consider administering an enema before the first dose of vasopressin.

    Subcutaneous Administration

    Inject subcutaneously taking care not to inject intradermally.
    When used for gastrointestinal radiography, consider administering an enema before the first dose of vasopressin.

    Other Administration Route(s)

    Intraosseous Administration
    NOTE: Vasopressin is not FDA-approved for intraosseous administration.
    During cardiopulmonary resuscitation, the same dosage may be given via the intraosseous route if IV access is unsuccessful or not feasible.

    STORAGE

    Generic:
    - Store at room temperature (between 59 to 86 degrees F)
    Pitressin:
    - Discard product if it contains particulate matter, is cloudy, or discolored
    - Discard unused portion. Do not store for later use.
    - Do not expose product to temperatures above 77 degrees F
    - Do not freeze
    - May be stored at room temperature (68 to 77 degrees F) for up to 12 months after removal from refrigeration
    - Reconstituted product should be used within 18 hours
    - Store reconstituted product in refrigerator (36 to 46 degrees F) and administer within 24 hours
    - Store unopened containers in refrigerator (36 to 46 degrees F)
    Vasostrict:
    - Discard product if it contains particulate matter, is cloudy, or discolored
    - Discard unused portion. Do not store for later use.
    - Do not expose product to temperatures above 77 degrees F
    - Do not freeze
    - May be stored at room temperature (68 to 77 degrees F) for up to 12 months after removal from refrigeration
    - Store between 36 to 46 degrees F

    CONTRAINDICATIONS / PRECAUTIONS

    General Information

    Vasopressin is contraindicated in patients with a known hypersensitivity vasopressin, 8-L-arginine vasopressin, or any of the product components.[47253] [58023] The Vasostrict 10 mL multi-dose vial contains chlorobutanol and is contraindicated in patients with a known hypersensitivity to chlorobutanol.[58023]

    Coronary artery disease, heart failure

    Use vasopressin with caution in patients with heart failure or any state in which a rapid addition to extracellular water may produce hazard for an already overburdened system. Vasopressin may also decrease cardiac index. Do not use vasopressin in patients with vascular disease, especially coronary artery disease, except with extreme caution. In such patients, even small doses may precipitate anginal pain, and with larger doses, the possibility of myocardial infarction should be considered.[47253] [58023]

    Renal disease

    Vasopressin is contraindicated in patients with chronic nephritis accompanied by nitrogen retention. Do not administer vasopressin to patients with this renal disease until acceptable nitrogen concentrations are attained.[47253]

    Migraine, seizure disorder

    Use vasopressin with caution in patients with a seizure disorder or migraine. A rapid addition to extracellular water may exacerbate these conditions.[47253]

    Asthma

    Use vasopressin with caution in patients with asthma. A rapid addition to extracellular water may exacerbate this condition.[47253]

    Pregnancy

    Use vasopressin during pregnancy only if clearly needed. There are no available data on vasopressin use in pregnant women to inform a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. It is not known if vasopressin can cause fetal harm when administered to pregnant women or if it can affect reproductive capacity. Because of increased clearance of vasopressin in the second and third trimester, the vasopressin dose may need to be increased. Vasopressin may produce tonic uterine contractions that could threaten the continuation of pregnancy.[47253] [58023]

    Breast-feeding

    Use vasopressin with caution when administering to a breast-feeding woman. There are no data on the presence of vasopressin in human milk, the effects on the breast-fed infant, or the effects on milk production.

    ADVERSE REACTIONS

    Severe

    water intoxication / Delayed / Incidence not known
    diabetes insipidus / Delayed / Incidence not known
    anaphylactic shock / Rapid / Incidence not known
    cardiac arrest / Early / Incidence not known
    atrial fibrillation / Early / Incidence not known
    myocardial infarction / Delayed / Incidence not known
    bradycardia / Rapid / Incidence not known
    heart failure / Delayed / Incidence not known

    Moderate

    hyponatremia / Delayed / Incidence not known
    angina / Early / Incidence not known
    peripheral vasoconstriction / Rapid / Incidence not known
    bleeding / Early / Incidence not known
    hyperbilirubinemia / Delayed / Incidence not known

    Mild

    tremor / Early / Incidence not known
    vertigo / Early / Incidence not known
    urticaria / Rapid / Incidence not known
    pallor / Early / Incidence not known
    flatulence / Early / Incidence not known
    vomiting / Early / Incidence not known
    abdominal pain / Early / Incidence not known
    nausea / Early / Incidence not known
    hyperhidrosis / Delayed / Incidence not known

    DRUG INTERACTIONS

    Acetaminophen; Chlorpheniramine; Dextromethorphan; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Acetaminophen; Dextromethorphan; Guaifenesin; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Acetaminophen; Dextromethorphan; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Acetaminophen; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Acrivastine; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Amitriptyline: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as tricyclic antidepressants. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Belladonna Alkaloids; Ergotamine; Phenobarbital: (Major) Avoid concomitant use of ergot alkaloids and vasopressors due to synergistic vasoconstriction and severe hypertension.
    Brompheniramine; Hydrocodone; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Brompheniramine; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Brompheniramine; Pseudoephedrine; Dextromethorphan: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Carbamazepine: (Minor) Carbamazepine may cause additive hyponatremia or antidiuretic effects when combined with vasopressin, ADH.
    Carbetapentane; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Carbinoxamine; Dextromethorphan; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Carbinoxamine; Hydrocodone; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Carbinoxamine; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Cetirizine; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Chlophedianol; Dexchlorpheniramine; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Chlordiazepoxide; Amitriptyline: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as tricyclic antidepressants. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Chlorpheniramine; Dextromethorphan; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Chlorpheniramine; Dihydrocodeine; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Chlorpheniramine; Guaifenesin; Hydrocodone; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Chlorpheniramine; Hydrocodone; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Chlorpheniramine; Ibuprofen; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Chlorpheniramine; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Chlorpropamide: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as chlorpropamide. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Citalopram: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as selective serotonin reuptake inhibitors. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Clomipramine: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as tricyclic antidepressants. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Clozapine: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing diabetes insipidus, such as clozapine. Use together may decrease the pressor and antidiuretic effects of vasopressin.
    Codeine; Guaifenesin; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Corticorelin, Ovine: (Major) The coadministration of corticorelin, ovine and vasopressin, ADH has resulted in a synergistic effect on the secretion of corticotropin, with a less marked synergistic response on cortisol secretion. The concomitant use of corticorelin and vasopressin should be avoided.
    Cyclophosphamide: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as cyclophosphamide. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Demeclocycline: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing diabetes insipidus, such as demeclocycline. Use together may decrease the pressor and antidiuretic effects of vasopressin.
    Desipramine: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as tricyclic antidepressants. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Desloratadine; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Desmopressin: (Moderate) Although the pressor activity of desmopressin is very low compared to its antidiuretic activity, large doses of desmopressin should be used with other pressor agents like vasopressin, ADH only with careful patient monitoring.
    Dexbrompheniramine; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Dexchlorpheniramine; Dextromethorphan; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Dextromethorphan; Guaifenesin; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Diethylpropion: (Major) Diethylpropion has vasopressor effects. Coadministration with other vasopressors may have the potential for serious cardiac adverse effects such as hypertensive crisis and cardiac arrhythmias.
    Dihydrocodeine; Guaifenesin; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Dihydroergotamine: (Major) Avoid concomitant use of ergot alkaloids and vasopressors due to synergistic vasoconstriction and severe hypertension.
    Dopamine: (Moderate) Monitor blood pressure and carefully adjust doses during concomitant use of dopamine and vasopressin due to the risk for hypertension. Concomitant use is expected to result in an additive effect on mean arterial blood pressure and other hemodynamic parameters.
    Doxepin: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as tricyclic antidepressants. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Enalapril, Enalaprilat: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as enalapril. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Enalapril; Felodipine: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as enalapril. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Enalapril; Hydrochlorothiazide, HCTZ: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as enalapril. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Ergoloid Mesylates: (Major) Avoid concomitant use of ergot alkaloids and vasopressors due to synergistic vasoconstriction and severe hypertension.
    Ergonovine: (Major) Avoid concomitant use of ergot alkaloids and vasopressors due to synergistic vasoconstriction and severe hypertension.
    Ergot alkaloids: (Major) Avoid concomitant use of ergot alkaloids and vasopressors due to synergistic vasoconstriction and severe hypertension.
    Ergotamine: (Major) Avoid concomitant use of ergot alkaloids and vasopressors due to synergistic vasoconstriction and severe hypertension.
    Ergotamine; Caffeine: (Major) Avoid concomitant use of ergot alkaloids and vasopressors due to synergistic vasoconstriction and severe hypertension.
    Escitalopram: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as selective serotonin reuptake inhibitors. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Felbamate: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as felbamate. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Fexofenadine; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Fludrocortisone: (Minor) Fludrocortisone can enhance the antidiuretic effect of vasopressin.
    Fluoxetine: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as selective serotonin reuptake inhibitors. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Fluvoxamine: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as selective serotonin reuptake inhibitors. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Foscarnet: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing diabetes insipidus, such as foscarnet. Use together may decrease the pressor and antidiuretic effects of vasopressin.
    Furosemide: (Minor) Use of furosemide with vasopressin increases the effect of vasopressin on osmolar clearance and urine flow. Furosemide increases osmolar clearance 4-fold and urine flow 9-fold when coadministered with exogenous vasopressin in healthy subjects.
    Guaifenesin; Hydrocodone; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Guaifenesin; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Haloperidol: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as haloperidol. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Heparin: (Minor) Heparin can decrease the antidiuretic response to vasopressin.
    Hydrochlorothiazide, HCTZ; Methyldopa: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as methyldopa. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Hydrocodone; Potassium Guaiacolsulfonate; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Hydrocodone; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Ibuprofen; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Ifosfamide: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as ifosfamide. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Imipramine: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as tricyclic antidepressants. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Indomethacin: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with indomethacin. Use together may prolong the effect of vasopressin on cardiac index and systemic vascular resistance. Indomethacin more than doubles the time to offset for vasopressin's effect on peripheral vascular resistance and cardiac output in healthy subjects.
    Ionic Contrast Media: (Major) The intravascular injection of a contrast medium should never be made after the administration of vasopressors since they strongly potentiate neurologic effects. Serious neurologic sequelae, including permanent paralysis, have been reported after cerebral arteriography, selective spinal arteriography, and arteriography of vessels supplying the spinal cord.
    Ketamine: (Moderate) Closely monitor vital signs when ketamine and vasopressin are coadministered; consider dose adjustment individualized to the patient's clinical situation. Vasopressin may enhance the sympathomimetic effects of ketamine.
    Lithium: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing diabetes insipidus, such as lithium. Use together may decrease the pressor and antidiuretic effects of vasopressin.
    Loratadine; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Mecamylamine: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with ganglionic blocking agents, such as mecamylamine. Use together may increase the effect of vasopressin on mean arterial blood pressure.
    Methyldopa: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as methyldopa. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Methylergonovine: (Major) Avoid concomitant use of ergot alkaloids and vasopressors due to synergistic vasoconstriction and severe hypertension.
    Methylphenidate Derivatives: (Moderate) Methylphenidate derivatives can potentiate the actions of both exogenous (such as dopamine and epinephrine) and endogenous (such as norepinephrine) vasopressors. It is advisable to monitor cardiac function if these medications are coadministered. Vasopressors include medications such as epinephrine, dopamine, midodrine, and non-prescription medications such as pseudoephedrine and phenylephrine.
    Methysergide: (Major) Avoid concomitant use of ergot alkaloids and vasopressors due to synergistic vasoconstriction and severe hypertension.
    Naproxen; Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Non-Ionic Contrast Media: (Major) Do not administer non-ionic contrast media intra-arterially after the administration of vasopressors since they strongly potentiate neurologic effects.
    Norepinephrine: (Moderate) Monitor hemodynamics and adjust drug doses as needed when vasopressin and norepinephrine are used concomitantly. Use together is expected to result in an additive effect on mean arterial blood pressure and other hemodynamic parameters.
    Nortriptyline: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as tricyclic antidepressants. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Olanzapine; Fluoxetine: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as selective serotonin reuptake inhibitors. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Paroxetine: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as selective serotonin reuptake inhibitors. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Pentamidine: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as pentamidine. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Pergolide: (Major) Avoid concomitant use of ergot alkaloids and vasopressors due to synergistic vasoconstriction and severe hypertension.
    Perphenazine; Amitriptyline: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as tricyclic antidepressants. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Phendimetrazine: (Major) Phendimetrazine is a phenylalkaline sympathomimetic agent. All sympathomimetics and psychostimulants, including other anorexiants, should be used cautiously or avoided in patients receiving phendimetrazine. The combined use of these agents may have the potential for additive side effects, such as hypertensive crisis or cardiac arrhythmia.
    Phentermine: (Major) Because phentermine is a sympathomimetic and anorexic agent (i.e., psychostimulant) it should not be used in combination with other sympathomimetics. The combined use of these agents may have the potential for additive side effects, such as hypertensive crisis or cardiac arrhythmias.
    Phentermine; Topiramate: (Major) Because phentermine is a sympathomimetic and anorexic agent (i.e., psychostimulant) it should not be used in combination with other sympathomimetics. The combined use of these agents may have the potential for additive side effects, such as hypertensive crisis or cardiac arrhythmias.
    Protriptyline: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as tricyclic antidepressants. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Pseudoephedrine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Pseudoephedrine; Triprolidine: (Major) Pseudoephedrine can potentiate the effects and increase the toxicity of other sympathomimetics by adding to their sympathomimetic activity. Although no data are available, pseudoephedrine should be used cautiously in patients using significant quantities of other sympathomimetics.
    Racepinephrine: (Major) Racepinephrine is a sympathomimetic drug with agonist actions at both the alpha and beta receptors. Patients using racepinephrine inhalation are advised to avoid other non-prescription products containing sympathomimetics since additive adverse effects on the cardiovascular and nervous system are possible, some which may be undesirable. Side effects such as nausea, tremor, nervousness, difficulty with sleep, and increased heart rate or blood pressure may be additive. Patients should avoid use of non-prescription decongestants, such as phenylephrine and pseudoephedrine, while using racepinephrine inhalations. Patients should avoid dietary supplements containing ingredients that are reported or claimed to have a stimulant or weight-loss effect, such as ephedrine and ephedra, Ma huang, and phenylpropanolamine.
    Selective serotonin reuptake inhibitors: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as selective serotonin reuptake inhibitors. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Sertraline: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as selective serotonin reuptake inhibitors. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Solriamfetol: (Moderate) Monitor blood pressure and heart rate during coadministration of solriamfetol, a norepinephrine and dopamine reuptake inhibitor, and vasopressors. Concurrent use of solriamfetol and other medications that increase blood pressure and/or heart rate may increase the risk of such effects. Coadministration of solriamfetol with other drugs that increase blood pressure or heart rate has not been evaluated.
    Tricyclic antidepressants: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as tricyclic antidepressants. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Trimipramine: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as tricyclic antidepressants. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Urea: (Minor) Systemic urea can potentiate the antidiuretic effect of vasopressin, ADH when both drugs are used concurrently. Dosage adjustments may be required.
    Vincristine Liposomal: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as vincristine. Use together may increase the pressor and antidiuretic effects of vasopressin.
    Vincristine: (Moderate) Monitor hemodynamics and adjust the dose of vasopressin as needed when used concomitantly with drugs suspected of causing syndrome of inappropriate antidiuretic hormone (SIADH), such as vincristine. Use together may increase the pressor and antidiuretic effects of vasopressin.

    PREGNANCY AND LACTATION

    Pregnancy

    Use vasopressin during pregnancy only if clearly needed. There are no available data on vasopressin use in pregnant women to inform a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. It is not known if vasopressin can cause fetal harm when administered to pregnant women or if it can affect reproductive capacity. Because of increased clearance of vasopressin in the second and third trimester, the vasopressin dose may need to be increased. Vasopressin may produce tonic uterine contractions that could threaten the continuation of pregnancy.[47253] [58023]

    Use vasopressin with caution when administering to a breast-feeding woman. There are no data on the presence of vasopressin in human milk, the effects on the breast-fed infant, or the effects on milk production.

    MECHANISM OF ACTION

    Vasopressin exerts its antidiuretic effects by increasing the resorption of water at the renal collecting ducts. Subsequently, urinary flow is reduced and urine osmolality is increased, thereby maintaining serum osmolality within an acceptable physiological range. At the cellular level, vasopressin stimulates adenylate cyclase activity. Increased adenylate cyclase activity increases the levels of cyclic adenosine monophosphate (cAMP) in the distal convoluted tubule and the collecting duct, thereby enhancing the permeability of the membrane to free water. Physiologic doses of vasopressin are administered to patients with neurohypophyseal diabetes insipidus to conserve the large amounts of water that are normally lost in the urine. In contrast to desmopressin, vasopressin induces the release of adrenocorticotropic hormone, increases plasma cortisol concentrations, and exhibits vasopressive and contractile action on visceral smooth muscle.
     
    Vasopressin stimulates the contraction of vascular smooth muscle in coronary, splanchnic, GI, pancreatic, skin, and muscular vascular beds. This effect is most prominent in the capillaries, small arterioles, and venules with less effect on the smooth musculature of large veins. Neither adrenergic agents nor vascular denervation prevents the direct effect of vasopressin on smooth muscle contractile elements. This vasoconstrictive property has been used in managing massive GI hemorrhage; however, vasopressin is no longer indicated for this purpose.

    PHARMACOKINETICS

    Vasopressin is administered parenterally. It does not appear to bind to plasma protein. Vd is 140 mL/kg. Vasopressin is degraded primarily in the liver and kidneys and has a plasma half-life of about 10 to 20 minutes.[47253] Metabolites are not expected to retain significant pharmacological activity. Approximately 5% of the dose is excreted unchanged in the urine.[47253] At infusion rates used in vasodilatory shock, the clearance of vasopressin is 9 to 25 mL/kg/minute.
     
    Affected cytochrome P450 isoenzymes and drug transporters: none

    Intravenous Route

    Onset of the pressor effect of vasopressin is rapid, peaking within 15 minutes. After infusion discontinuation, pressor effect fades within 20 minutes. At infusion rates used in vasodilatory shock, vasopressin clearance is 9 to 25 mL/kg/minute. Apparent half-life at this concentration is 10 minutes or less.

    Intramuscular Route

    The duration of antidiuretic effect is variable, but effects are usually maintained for 2 to 8 hours after IM vasopressin administration.[47253]

    Subcutaneous Route

    The duration of antidiuretic effect is variable, but effects are usually maintained for 2 to 8 hours after subcutaneous vasopressin administration.[47253]