Vasopressin (ADH) - Natural Antidiuretic & Vasopressor Hormone — Pituitary & Renal
FDA-approved natural vasopressin for vasodilatory shock, cardiac arrest, diabetes insipidus, and GI bleeding.
Overview
Vasopressin (arginine vasopressin, antidiuretic hormone, ADH) is the natural posterior pituitary hormone with dual actions: V2 receptor-mediated antidiuretic effects (renal water reabsorption) and V1 receptor-mediated vasoconstriction. FDA-approved for vasodilatory shock (septic shock, post-cardiopulmonary bypass), cardiac arrest (ACLS algorithm), diabetes insipidus, and GI bleeding (esophageal varices). Unlike desmopressin (V2-selective), vasopressin activates both V1 and V2 receptors. VASST trial showed reduced mortality in less severe septic shock with vasopressin 0.01-0.03 U/min. In diabetes insipidus, shorter duration than desmopressin but useful for acute management. Vasoconstriction helps control variceal bleeding. High-dose vasopressin used in ACLS for refractory cardiac arrest.
Indications
- Vasodilatory shock (septic shock, post-cardiac surgery)
- Advanced cardiac life support (ACLS) - cardiac arrest
- Central diabetes insipidus (acute management)
- GI bleeding (esophageal/gastric varices)
- Coagulopathy bleeding (off-label, increases Factor VIII/vWF)
Mechanism of Action
Septic shock: pathologic vasodilation. DI: posterior pituitary ADH deficiency. Cardiac arrest: loss of vascular tone
Dosing
| Compound | Dose | Frequency | Notes |
|---|---|---|---|
| Vasopressin 20 U/mL injection | 0.01-0.03 U/min (units per minute) | Continuous IV infusion | Fixed-dose infusion; do not titrate above 0.04 U/min per VASST trial; use as adjunct to norepinephrine |
| Vasopressin 20 U/mL injection | 40 U IV push (one dose) | Single dose during CPR | Alternative to epinephrine in cardiac arrest algorithm; may give one dose to replace first or second epinephrine |
| Vasopressin 20 U/mL injection | 5-10 U SC or IM | Every 3-4 hours as needed | Short-acting; for acute DI only; transition to desmopressin for chronic management |
| Vasopressin 20 U/mL injection | 0.2-0.4 U/min initially, then 0.1-0.5 U/min | Continuous IV infusion | Vasoconstricts splanchnic circulation; octreotide now preferred due to better safety profile |
Evidence Grade
GRADE A
Safety & Contraindications
- ⚠️ PRESCRIPTION MEDICATION - ICU/critical care supervision required
- VASOCONSTRICTION RISKS: Myocardial ischemia, mesenteric ischemia, limb ischemia, skin necrosis (particularly at high doses)
- Hyponatremia/water intoxication: V2 receptor activation causes fluid retention; monitor serum sodium closely
- Contraindications: Coronary artery disease (relative), peripheral vascular disease, chronic renal failure
- Extravasation: Can cause severe tissue necrosis; central line preferred for continuous infusion
- NOT for chronic DI (use desmopressin instead - safer, longer-acting)
- Drug interactions: May potentiate pressor effects of catecholamines
- Requires continuous hemodynamic monitoring (ICU setting)