MON-004 - Incretin Therapy May Alter Desmopressin Efficacy in Patients with Arginine Vasopressin Deficiency: A Case Report

Introduction: Arginine vasopressin deficiency (AVP-D) is a common complication following pituitary surgery, and desmopressin, a synthetic analog of vasopressin, is the mainstay of treatment. Desmopressin is available in multiple formulations, including intravenous, subcutaneous, oral, and intranasal preparations. Due to ease of administration, oral formulations are widely used; however, the absorption of oral peptide medications can be influenced by several factors, including gastric acidity, fasting status, and gastric motility.

In recent years, incretin therapies have been increasingly prescribed for the management of type 2 diabetes mellitus, obesity, and other metabolic conditions. Through their effects on gastrointestinal motility, particularly delayed gastric emptying, as well as their renal actions promoting natriuresis and diuresis, incretin therapies may alter the pharmacokinetics and pharmacodynamics of oral desmopressin.

Case presentation: Here, we present the case of a 51-year-old woman with medical history significant for primary hypothyroidism, Class III obesity treated with tizepatide, hypertension, chronic migraine headaches who developed permanent AVP-D following pituitary mass resection. Post operatively, symptoms of AVP-D were under control, with stable laboratory findings noted for serum sodium level of 137 mom/l, serum osmolarity 289 mOsm/kg, urine osmolarity 719 mOsm/kg on oral desmopressin tablet regimen of 0.1mg in the morning, 0.05 mg in the afternoon and 0.1 mg at bedtime but after resuming tirzepatide for the management of class III obesity post operatively, she experienced uncontrolled excessive thirst and polyuria occurring unpredictably throughout the day and night, significantly affecting her quality of life with laboratory findings noted for Serum Sodium level 143 mom/L, Urine Osmolarity 118 mOsm/kg. Given concern for variable and unpredictable oral desmopressin absorption due to concomitant tirzepatide therapy the patient was transitioned to nasal desmopressin spray (10 µg per spray, one spray twice daily) from oral Desmopressin formulation with resolution of symptoms and serum sodium improved to 139 mom/L.

Conclusion: This case highlights the potential impact of incretin therapy on the efficacy of oral desmopressin and emphasizes the importance of closely monitoring fluid balance and serum sodium levels in patients receiving both therapies. Dose adjustment or an alternative route of desmopressin administration may be necessary to achieve optimal symptom control.

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