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Vasopressin: Drug information

Vasopressin: Drug information
2024© UpToDate, Inc. and its affiliates and/or licensors. All Rights Reserved.
For additional information see "Vasopressin: Patient drug information" and "Vasopressin: Pediatric drug information"

For abbreviations, symbols, and age group definitions show table
Brand Names: US
  • Vasostrict
Pharmacologic Category
  • Antidiuretic Hormone Analog;
  • Hormone, Posterior Pituitary
Dosing: Adult
Cadaveric organ recovery

Cadaveric organ recovery (hormone replacement therapy) (off-label use): Based on limited data: Note: Use if hypotensive despite adequate fluid resuscitation, left ventricular ejection fraction <45%, low systemic vascular resistance (SVR), or if diabetes insipidus is present. Use in combination with levothyroxine (or liothyronine), methylprednisolone, and continuous insulin infusion (goal blood glucose: 120 to 180 mg/dL) (Ref).

IV: Initial: 0.01 to 0.04 units/minute (Ref); some experts recommend a bolus of 1 unit followed by 0.01 to 0.1 units/minute titrated to a SVR of 800 to 1,200 dyne•second/cm5 (usual dose: 0.01 to 0.04 units/minute) (Ref).

Diabetes insipidus, central

Diabetes insipidus, central (acute) (off-label use): Note: Dosage is highly variable; titrated based on serum and urine sodium and osmolality in addition to fluid balance and urine output. Vasopressin may be considered for short-term use in some neurocritical care settings due to its short duration of action (Ref). Use in neurosurgical patients is generally limited to the early postoperative period (eg, days 1 to 4); use caution in this setting to avoid overtreatment, as diabetes insipidus may spontaneously resolve or revert to syndrome of inappropriate antidiuretic hormone secretion/hyponatremia (Ref).

SUBQ (off-label route): 5 to 10 units 2 to 3 times daily as needed (Ref).

Continuous infusion: IV: Continuous infusion has not been formally evaluated in the post-neurosurgical adult. However, some clinicians may convert SUBQ requirement to an hourly continuous IV infusion rate with careful titration based on urine output (Ref). Specific protocols may vary.

Gastroesophageal variceal hemorrhage

Gastroesophageal variceal hemorrhage (alternative agent) (off-label use): Note: Other therapies (eg, octreotide) may be preferred (Ref).

Continuous infusion: IV: Initial: 0.2 to 0.4 units/minute, may titrate dose as needed to a maximum dose of 0.8 units/minute; maximum duration is 24 hours at highest effective dose (to reduce incidence of adverse effects). Administer IV nitroglycerin concurrently to prevent ischemic complications; monitor closely for signs/symptoms of ischemia (myocardial, peripheral, bowel) (Ref).

Septic shock and other vasodilatory shock states

Septic shock and other vasodilatory shock states (adjunctive agent): Note: Considered as adjunctive use when goal mean arterial pressure (MAP) not achieved with initial catecholamine vasopressor (eg, norepinephrine) or to decrease catecholamine vasopressor dosage requirements. In general, maintain goal MAP (eg, ~65 mm Hg); consider use if patient is in shock or has hypoperfusion during or after fluid resuscitation (Ref).

Shock, sepsis:

Continuous infusion: IV: 0.03 units/minute added to norepinephrine as a fixed dose (not titrated); usual dosage range: 0.01 to 0.04 units/minute; doses >0.04 units/minute should be reserved for salvage therapy due to potential risk of ischemic complications (eg, skin, cardiac, splanchnic) (Ref).

Discontinuation in septic shock: Multiple studies describe clinically significant hypotension when vasopressin is discontinued prior to norepinephrine. When discontinuing therapy, consider slowly tapering by 0.01 units/minute every 30 to 60 minutes to reduce the risk of hypotension; monitor MAP when discontinuing vasopressin (Ref).

Shock, post-cardiotomy: Continuous infusion: IV: Initial: 0.03 units/minute. If the target blood pressure response is not achieved, titrate up by 0.005 units/minute at 10- to 15-minute intervals (maximum dose: 0.1 units/minute). After target blood pressure has been maintained for 8 hours without the use of catecholamines, taper by 0.005 units/minute every hour as tolerated to maintain target blood pressure.

Dosing: Kidney Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Hepatic Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Older Adult

Refer to adult dosing.

Dosing: Pediatric

(For additional information see "Vasopressin: Pediatric drug information")

Note: Units of measure vary by indication and age (ie, milliunits/kg/hour, units/kg/hour, milliunits/kg/minute, units/kg/minute; units/minute, units/hour); extra precautions should be taken.

Diabetes insipidus

Diabetes insipidus: Note: Highly variable dosage; titrate dosage based upon serum and urine sodium and osmolality in addition to fluid balance and urine output. Children and Adolescents: IM, SubQ: 2.5 to 10 units 2 to 4 times daily (Ref).

Central diabetes insipidus: Limited data available: Infants, Children, and Adolescents: Continuous IV infusion: Initial: 0.5 milliunits/kg/hour; titrate upward in 0.5 milliunits/kg/hour increments at approximately 10-minute intervals to target urine output (suggested output target: <2 mL/kg/hour) (Ref); infusion rates up to 10 milliunits/kg/hour have been reported (Ref). Note: Use in conjunction with fluid therapy, monitor urine output and specific gravity, serum and urine electrolytes (primarily Na), and plasma osmolality.

Cadaveric organ donations

Cadaveric organ donations (hormone replacement therapy): Limited data available (Ref): Infants, Children, and Adolescents: Continuous IV infusion: Initial: 0.5 to 1 milliunits/kg/hour; titrate dose to maintain targeted urine output. In a retrospective case-controlled study (n=34, age: 8.2 ± 6.2 years), a mean dose of 41 milliunits/kg/hour was reported with a range of 0.2 milliunits/kg/hour to 150 milliunits/kg/hour (Ref).

GI hemorrhage

GI hemorrhage: Limited data available: Children and Adolescents: Continuous IV infusion: Initial: 2 to 5 milliunits/kg/minute; titrate dose as needed; maximum dose: 10 milliunits/kg/minute (Ref); usual adult dosing range is 0.2 to 0.4 units/minute up to a maximum rate of 0.8 units/minute (Ref). Note: Higher doses have not been associated with greater efficacy but have been associated with increased risk of complications (Ref).

Pulseless arrest, ventricular fibrillation, ventricular tachycardia

Pulseless arrest, ventricular fibrillation, ventricular tachycardia: Limited data available: Infants, Children, and Adolescents: IV: 0.4 units/kg as a single dose after traditional resuscitation methods and at least two doses of epinephrine have been administered. Note: Due to insufficient evidence, no formal recommendations for or against the routine use of vasopressin during pediatric cardiac arrest are provided (Ref).

Vasodilatory shock with hypotension unresponsive to fluid resuscitation and exogenous catecholamines

Vasodilatory shock with hypotension unresponsive to fluid resuscitation and exogenous catecholamines: Limited data available; efficacy results have varied (Ref): Infants, Children, and Adolescents: Continuous IV infusion: 0.17 to 8 milliunits/kg/minute (0.01 to 0.48 units/kg/hour) has been used; dosing based on retrospective reviews and case reports that have shown increases in arterial blood pressure and urine output and also allowed for dosage reductions of additional vasopressors (Ref). The only double-blind, placebo-controlled trial (n=65, age: 3 to 14 years) evaluated a dose of 0.5 to 2 milliunits/kg/minute (0.03 to 0.12 units/kg/hour) at multiple centers and found no significant difference in the time to reach hemodynamic stability and a trend toward increased mortality in the vasopressin group was noted. Based on these findings, the authors did not recommend routine use of vasopressin (Ref). Note: Abrupt discontinuation of infusion may result in hypotension; to discontinue, gradually taper infusion.

Dosing: Kidney Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Hepatic Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling.

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.

Frequency not defined:

Cardiovascular: Atrial fibrillation, bradycardia, ischemic heart disease, limb ischemia (distal), low cardiac output, right heart failure, shock (hemorrhagic)

Dermatologic: Skin lesion (ischemic)

Endocrine & metabolic: Hyponatremia

Gastrointestinal: Mesenteric ischemia

Hematologic & oncologic: Decreased platelet count, hemorrhage (intractable)

Hepatic: Increased serum bilirubin

Renal: Renal insufficiency

Postmarketing: Endocrine & metabolic: Diabetes insipidus (reversible)

Contraindications

Hypersensitivity to vasopressin or any component of the formulation; hypersensitivity to chlorobutanol (Vasostrict 10 mL vial only).

Warnings/Precautions

Concerns related to adverse effects:

• Diabetes insipidus: Reversible diabetes insipidus may occur following discontinuation of vasopressin therapy; signs/symptoms may include polyuria, dilute urine, and hypernatremia. Monitor electrolytes, fluid status, and urine output after vasopressin discontinuation. Readministration of vasopressin (or desmopressin) may be needed to correct fluid and electrolyte imbalances.

• Extravasation: Vesicant; ensure proper needle or catheter placement prior to and during infusion. Extravasation may lead to severe vasoconstriction and localized tissue necrosis; also, gangrene of extremities, tongue, and ischemic colitis. Avoid extravasation.

• Water intoxication: May cause water intoxication; early signs include drowsiness, listlessness, and headache; these should be recognized to prevent coma and seizures.

Disease-related concerns:

• Cardiovascular disease: Use with caution in patients with cardiovascular disease, including arteriosclerosis; may worsen cardiac output.

• Migraine: Use with caution in patients with a history of migraines.

• Renal impairment: Use with caution in patients with renal disease.

• Vascular disease: Use with caution in patients with vascular disease.

Warnings: Additional Pediatric Considerations

May cause hyponatremia; frequency not well-defined in pediatric patients and may vary based on indication. In young pediatric patients (mean age: 5.2 months; including neonates) who received a vasopressin infusion for hemodynamic instability following complex cardiac surgery, the observed incidence of hyponatremia (defined as serum Na <135 mEq/L) was statistically higher in the vasopressin group than the control (48% vs 17%, p=0.004) and the decrease in serum sodium concentration was significantly greater (9.9 mEq/L vs 7.5 mEq/L, p=0.009); it was also observed that the decrease in the serum Na was more rapid in the vasopressin group (Davalos 2013). With other uses in pediatric patients, hyponatremia has not been characterized; monitor fluid balance, serum Na and urine output closely.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Intravenous:

Vasostrict: 0.2 units/mL (100 mL); 0.4 units/mL (100 mL); 20 units/mL (1 mL)

Vasostrict: 20 units/mL (10 mL) [contains chlorobutanol (chlorobutol)]

Generic: 20 units/mL (1 mL, 10 mL)

Solution, Intravenous [preservative free]:

Generic: 20 units/mL (1 mL); 20 units/100 mL in NaCl 0.9% (100 mL); 40 units/100 mL in NaCl 0.9% (100 mL)

Generic Equivalent Available: US

Yes

Pricing: US

Solution (Vasopressin Intravenous)

20 units/mL (per mL): $27.60 - $189.66

Solution (Vasopressin-Sodium Chloride Intravenous)

20UT/100ML 0.9% (per mL): $0.90

40UT/100ML 0.9% (per mL): $1.80

Solution (Vasostrict Intravenous)

0.2 units/mL (per mL): $2.55

0.4 units/mL (per mL): $5.10

20 units/mL (per mL): $97.20

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Injection:

Generic: 20 units/mL (1 mL, 2 mL, 5 mL)

Administration: Adult

SUBQ (off-label route): Administer without further dilution.

Continuous IV infusion: Dilute 1 mL and 10 mL vials prior to administration; premixed vials (20 units/100 mL and 40 units/100 mL) requiring no further dilution are also available for single use. Infusion through central line is recommended.

Vesicant; ensure proper needle or catheter placement prior to and during infusion; avoid extravasation.

Extravasation management: If extravasation occurs, stop infusion immediately; leave cannula/needle in place temporarily but do NOT flush the line; gently aspirate extravasated solution, then remove needle/cannula; elevate extremity; apply dry, warm compresses. Initiate topical nitroglycerin (Ref).

Nitroglycerin (topical): Nitroglycerin topical 2% ointment: Apply a 1-inch strip to the site of ischemia to cover the affected area; may repeat every 8 hours as necessary (Ref).

Alternatives to nitroglycerin (Ref):

Phentolamine: SUBQ: Dilute 5 to 10 mg in 10 mL NS and administer into extravasation site as soon as possible after extravasation; if IV catheter remains in place, administer initial dose IV through the infiltrated catheter; may repeat in 60 minutes if patient remains symptomatic (Ref).

Terbutaline:

Large extravasations: SUBQ: Infiltrate affected extravasation area with terbutaline 1 mg using a solution of terbutaline 1 mg diluted in 10 mL NS; may repeat dose after 15 minutes (Ref).

Small extravasations: SUBQ: Infiltrate affected extravasation area with terbutaline 0.5 mg using a solution of terbutaline 1 mg diluted in 1 mL NS; may repeat dose after 15 minutes (Ref).

Administration: Pediatric

Parenteral:

IM, SUBQ: Administer without further dilution.

Continuous IV infusion: Dilute prior to administration. Infusion through central line is strongly recommended.

Vesicant; ensure proper needle or catheter placement prior to and during infusion; avoid extravasation. If extravasation occurs, stop infusion immediately; leave cannula/needle in place temporarily but do NOT flush the line; gently aspirate extravasated solution, then remove needle/cannula unless needed for IV antidote; elevate extremity; apply dry, warm compresses. Initiate phentolamine (or alternative antidote) (Ref).

Usual Infusion Concentrations: Adult

IV infusion: 50 units in 500 mL (concentration: 0.1 unit/mL) or 100 units in 100 mL (concentration: 1 unit/mL) of D5W or NS

Usual Infusion Concentrations: Pediatric

IV infusion: 0.04 units/mL, 0.2 units/mL, or 1 unit/mL.

Use: Labeled Indications

Septic shock and other vasodilatory shock states: To increase BP in adults with vasodilatory shock (eg, postcardiotomy or sepsis) who remain hypotensive despite fluid resuscitation and catecholamines.

Use: Off-Label: Adult

Cadaveric organ recovery (hormone replacement therapy); Diabetes insipidus, central (acute); Gastroesophageal variceal hemorrhage

Medication Safety Issues
Sound-alike/look-alike issues:

PIT or Pitressin (old names sometimes used to describe vasopressin) may be confused with Pitocin

Vasopressin may be confused with desmopressin

High alert medication:

The Institute for Safe Medication Practices (ISMP) includes this medication (IV or intraosseous administration) among its list of drugs which have a heightened risk of causing significant patient harm when used in error (High-Alert Medications in Acute Care Settings).

Administration issues:

Use care when prescribing and/or administering vasopressin solutions. Close attention should be given to concentration of solution, route of administration, dose, and rate of administration (units/minute, units/kg/minute, units/kg/hour).

Metabolism/Transport Effects

None known.

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.

Alpha-/Beta-Agonists (Direct-Acting): May enhance the hypertensive effect of Vasopressin. The effect of other hemodynamic parameters may also be enhanced. Risk C: Monitor therapy

Bradycardia-Causing Agents: May enhance the bradycardic effect of other Bradycardia-Causing Agents. Risk C: Monitor therapy

Ceritinib: Bradycardia-Causing Agents may enhance the bradycardic effect of Ceritinib. Management: If this combination cannot be avoided, monitor patients for evidence of symptomatic bradycardia, and closely monitor blood pressure and heart rate during therapy. Risk D: Consider therapy modification

Desmopressin: Hyponatremia-Associated Agents may enhance the hyponatremic effect of Desmopressin. Risk C: Monitor therapy

Drugs Suspected of Causing Diabetes Insipidus: May diminish the therapeutic effect of Vasopressin. Specifically, the pressor and antidiuretic hormone effects of vasopressin may be decreased. Risk C: Monitor therapy

Drugs Suspected of Causing SIADH: May enhance the therapeutic effect of Vasopressin. Specifically, the pressor and antidiuretic effects of vasopressin may be increased. Risk C: Monitor therapy

Etrasimod: May enhance the bradycardic effect of Bradycardia-Causing Agents. Risk C: Monitor therapy

Fexinidazole: Bradycardia-Causing Agents may enhance the arrhythmogenic effect of Fexinidazole. Risk X: Avoid combination

Fingolimod: Bradycardia-Causing Agents may enhance the bradycardic effect of Fingolimod. Management: Consult with the prescriber of any bradycardia-causing agent to see if the agent could be switched to an agent that does not cause bradycardia prior to initiating fingolimod. If combined, perform continuous ECG monitoring after the first fingolimod dose. Risk D: Consider therapy modification

Indomethacin: May enhance the therapeutic effect of Vasopressin. Specifically, vasopressin effects on cardiac index and systemic vascular resistance may be enhanced. Risk C: Monitor therapy

Ivabradine: Bradycardia-Causing Agents may enhance the bradycardic effect of Ivabradine. Risk C: Monitor therapy

Lacosamide: Bradycardia-Causing Agents may enhance the AV-blocking effect of Lacosamide. Risk C: Monitor therapy

Mecamylamine: May enhance the therapeutic effect of Vasopressin. Specifically, the effect of vasopressin on mean arterial blood pressure may be increased. Risk C: Monitor therapy

Midodrine: May enhance the bradycardic effect of Bradycardia-Causing Agents. Risk C: Monitor therapy

Ozanimod: May enhance the bradycardic effect of Bradycardia-Causing Agents. Risk C: Monitor therapy

Ponesimod: Bradycardia-Causing Agents may enhance the bradycardic effect of Ponesimod. Management: Avoid coadministration of ponesimod with drugs that may cause bradycardia when possible. If combined, monitor heart rate closely and consider obtaining a cardiology consult. Do not initiate ponesimod in patients on beta-blockers if HR is less than 55 bpm. Risk D: Consider therapy modification

Siponimod: Bradycardia-Causing Agents may enhance the bradycardic effect of Siponimod. Management: Avoid coadministration of siponimod with drugs that may cause bradycardia. If combined, consider obtaining a cardiology consult regarding patient monitoring. Risk D: Consider therapy modification

Tofacitinib: May enhance the bradycardic effect of Bradycardia-Causing Agents. Risk C: Monitor therapy

Pregnancy Considerations

Vasopressin may produce tonic uterine contractions. Due to pregnancy-induced physiologic changes, vasopressin clearance may be increased in the second and third trimesters; dose adjustment may be needed. Clearance returns to normal within 2 weeks postpartum.

Breastfeeding Considerations

It is not known if vasopressin is present in breast milk.

Monitoring Parameters

During therapy: Serum and urine sodium, urine-specific gravity, urine and serum osmolality; urine output, fluid input and output, BP, heart rate, digital/extremity infusion site for blanching/extravasation.

After discontinuation of therapy: Electrolytes, fluid status, and urine output (to assess for reversible diabetes insipidus).

Mechanism of Action

Vasopressin stimulates a family of arginine vasopressin (AVP) receptors, oxytocin receptors, and purinergic receptors (Russell 2011). Vasopressin, at therapeutic doses used for vasodilatory shock, stimulates the AVPR1a (or V1) receptor and increases systemic vascular resistance and mean arterial blood pressure; in response to these effects, a decrease in heart rate and cardiac output may be seen. When the AVPR2 (or V2) receptor is stimulated, cyclic adenosine monophosphate (cAMP) increases which in turn increases water permeability at the renal tubule resulting in decreased urine volume and increased osmolality. Vasopressin, at pressor doses, also causes smooth muscle contraction in the GI tract by stimulating muscular V1 receptors and release of prolactin and ACTH via AVPR1b (or V3) receptors.

Pharmacokinetics (Adult Data Unless Noted)

Onset of action:

Antidiuretic: Peak effect: 1 to 2 hours (Murphy-Human 2010).

Vasopressor effect: IV: Rapid with peak effect occurring within 15 minutes of initiation of continuous IV infusion.

Duration: SUBQ: Antidiuretic: 2 to 8 hours; IV: Vasopressor effect: Within 20 minutes after IV infusion terminated.

Absorption: None from GI tract, destroyed by trypsin in GI tract, must be administered parenterally.

Distribution: Vd: 140 mL/kg.

Protein binding: None.

Metabolism: Hepatic, renal (inactive metabolites).

Half-life elimination: IV, SubQ: 10 to 20 minutes (apparent half-life: ≤10 minutes).

Excretion: SUBQ: Urine (5% as unchanged drug) after 4 hours; IV: Urine (~6% as unchanged drug).

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (AE) United Arab Emirates: Pitressin;
  • (CO) Colombia: Vasopresina;
  • (EE) Estonia: Pitressin | Vascel;
  • (EG) Egypt: Pitressin;
  • (FI) Finland: Pitressin | Pitressin tannate oil;
  • (JP) Japan: Pitressin Tannate;
  • (KR) Korea, Republic of: Pitressin;
  • (PR) Puerto Rico: Pitressin | Vasostrict;
  • (QA) Qatar: Embesin;
  • (TH) Thailand: Pitressin Tannate;
  • (TW) Taiwan: Pitressin
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Topic 10039 Version 380.0

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