Risks occurring when desmopressin is omitted or delayed in patients with cranial diabetes insipidus

A stage one alert has been issued to raise awareness of the risk of severe dehydration and death caused by an omission or delay of desmopressin in patients with cranial diabetes insipidus.

Cranial diabetes insipidus is a rare disorder of the pituitary gland characterised by an inability to produce antidiuretic hormone (ADH), resulting in the production of large volumes of dilute urine – if left untreated this can lead to life-threatening dehydration and hypernatraemia. Treatment is a synthetic form of ADH known as desmopressin, which is considered a life sustaining medication.

Following reports of patient safety incidents caused by an omission or delay in the provision of desmopressin, providers of NHS care are asked to consider if immediate action needs to be taken locally to raise awareness and reduce the risk of these incidents from occurring. The main themes identified as causes include a lack of awareness of the critical nature of desmopressin amongst medical, pharmacy and nursing staff, and poor availability of the medication within inpatient clinical areas.

Patient safety alerts are shared rapidly with healthcare providers via the Central Alerting System (CAS).

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