Does Desmopressin Stop Bleeding Expansion in Patients with Intracranial Hemorrhage and a History of Alcohol Use?

By Dr. Karen Berger

In short, no. In our analysis, giving a drug (desmopressin) that is used to reverse bleeding in patients taking antiplatelet medications was not associated with harm, but also did not reduce bleeding expansion in patients with alcohol use and intracranial hemorrhage.

Intracranial hemorrhage (ICH) is classified as any bleed inside the skull, including the brain tissue. It can be caused by trauma, such as from a motor vehicle accident, or spontaneously from a ruptured blood vessel or in patients taking blood thinners. ICH is a neurologic emergency and requires rapid treatment to prevent expansion of the bleed which occurs in over a third of patients and may predict poor neurologic outcomes. Two common treatment modalities include aggressive blood pressure lowering and reversal of any blood thinners. Patients with alcohol use (AU) and alcohol use disorder (AUD) may have decreased platelet clotting and an increased risk of bleeding expansion. Desmopressin (also known as DDAVP) may decrease bleeding expansion in patients who are taking antiplatelet agents. Therefore, many have explored its use for other indications such as patients with presumed platelet dysfunction from AUD. However, its use may also increase the risk of hyponatremia (low serum sodium) which can worsen brain swelling. It is possible that its effects on platelet function may also lead to an increase in clotting events. Guidelines for bleeding reversal recommend consideration of desmopressin for patients with an ICH who are taking antiplatelet medications, however, they do not comment on patients with presumed platelet dysfunction such as those with AUD. At our institution, some doctors administered desmopressin to patients with AU-associated intracranial hemorrhage and we therefore sought to evaluate if this practice was safe and effective.

We reviewed all adult patients who had brain scan findings consistent with ICH and a confirmed or suspected history of AU or AUD upon admission. Patients who received desmopressin were compared to those who did not receive it. To see if desmopressin was effective we reviewed the follow up brain scans to determine whether there was any bleeding expansion on the repeat scan. In total, 52 patients were included in the safety analysis (27 who received desmopressin and 25 who did not). Hyponatremia and clotting events were similar between the two groups, suggesting that DDAVP did not cause harm. There were 39 patients evaluated for bleeding expansion. This number decreased from 52 because not all patients had a repeat scan that allowed us to assess this endpoint. There was no difference in bleeding expansion between the two groups and these findings were consistent after adjusting for differences in some of the patient characteristics. Although our findings are thought provoking, there are several limitations to our analysis. Firstly, it was retrospective, meaning that we did not randomly assign patients to a particular group. The use of the medication was based on the prescriber’s discretion and there was no protocol for which patients should receive desmopressin. This may have introduced selection bias since it is possible that sicker patients may have been selected to receive drug therapy (or vice versa, those who were more likely to be deemed salvageable may have been more likely to receive drug therapy). It was also very challenging to identify patients with AU and AUD given the lack of consistent documentation in the medical record or an unknown medical history on presentation to the hospital. These patients mostly had traumatic intracranial hemorrhage which may not be applicable to other types of brain bleeds that happen spontaneously (without trauma).

This was a small study, but based on our results, we concluded that desmopressin was not associated with major safety concerns, but also not with a benefit in preventing bleeding expansion in patients with AU or AUD and ICH. Despite theoretical benefits, this study suggests that the use of desmopressin in patients with AU and AUD-associated intracranial hemorrhage may not be helpful.

read the article

Article Details
The Safety and Efficacy of Desmopressin in Patients With Intracranial Hemorrhage and a History of Alcohol Use
Michelle Gunther, PharmD, Corey J. Witenko, PharmD, BCPS, BCCCP, Morgan Prust, MD, David Salerno, PharmD, BCPS, and Karen Berger, PharmD, BCPS, BCCCP
First published online July 21, 2021
DOI: 10.1177/08850666211031494
Journal of Intensive Care Medicine

About the Author

Featured

Dr. Karen Berger is currently an Assistant Professor of Pharmacy Practice at Nova Southeastern University and practices at Broward Health Medical Center in the Trauma and Medical ICUs. She received her doctor of pharmacy from the University of Florida and went on to complete her PGY1 pharmacy residency at Yale-New Haven Hospital and her PGY2 critical care residency at the University of Illinois Medical Center at Chicago, where she acted as chief resident. Prior to joining the NSU team, Dr. Berger practiced at NewYork-Presbyterian Hospital, Weill Cornell Medical Center as a neurocritical care clinical pharmacy manager. Dr. Berger currently serves as the Chair for the Society of Critical Care Medicine (SCCM) Clinical Pharmacy and Pharmacology Section, Immediate Past Chair of the Neurocritical Care Society (NCS) Marketing and Communications Committee, and member of the NCS Pharmacy Section Leadership Committee. In 2019, she became a Fellow of the American College of Critical Care Medicine and in 2020 she became a fellow of the American Society of Health-system Pharmacy. Dr. Berger is board certified in pharmacotherapy and critical care pharmacotherapy. She has provided numerous professional presentations on bleeding reversal at local, regional, and international meetings and authored publications in a variety of pharmacy and interdisciplinary journals. She currently serves as the Co-Chair of the NCS Status Epilepticus Guidelines Committee.