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Vasopressin

Class: Pituitary
VA Class: HS702
CAS Number: 11000-17-2
Brands: Vasostrict

Introduction

Exogenous antidiuretic hormone (ADH); maintains serum osmolality in normal range and acts as a vasopressor.152 157 167 170

Uses for Vasopressin

Vasodilatory Shock

Used to increase BP in patients with vasodilatory shock (e.g., postcardiotomy shock, septic shock) who remain hypotensive despite adequate fluid resuscitation and catecholamines (e.g., norepinephrine).151 157 167 168 169 172 173

Appears to have a catecholamine-sparing effect; however, effect on mortality remains unclear.167 169 173

The Surviving Sepsis Campaign International Guidelines for Management of Sepsis and Septic Shock recommend norepinephrine as the first-line vasopressor of choice in adults with septic shock; may add vasopressin if further increase in mean arterial pressure (MAP) required or to reduce dosage requirements of norepinephrine.169

Advanced Cardiovascular Life Support

Used for its vasopressor effects in patients with cardiac arrest.152 153 157 400 401

Previously recommended in ACLS guidelines as a substitute for epinephrine in adults with cardiac arrest since both drugs comparably effective.152 153 157 160 161 163 166 400 157 401 However, vasopressin has been removed from the current ACLS guideline in an effort to simplify the management approach when therapies are found to be equivalent.400 405

High-quality CPR and defibrillation are the only proven interventions to increase survival to hospital discharge in ACLS.400 401 Other resuscitative efforts, including drug therapy, are considered secondary and should be performed without compromising the quality and timely delivery of chest compressions and defibrillation.400 401

Diabetes Insipidus

Has been used to control polydypsia, polyuria, and dehydration in patients with central diabetes insipidus;170 171 176 however, desmopressin is considered drug of choice for this use.171 176 177

Impractical for chronic therapy because of its short duration of action.b

Not effective in controlling polyuria caused by renal disease, nephrogenic diabetes insipidus, hypokalemia or hypercalcemia, or polyuria secondary to the administration of demeclocycline or lithium carbonate.b

Abdominal Distention

Has been used to stimulate peristalsis in the management of intestinal paresis, postoperative abdominal distention, and distention complicating pneumonias or toxemias.b

Abdominal Radiographic Procedures

Has been used prior to abdominal radiographic procedures to dispel interfering gas shadows and/or to concentrate the contrast media.b

Diagnostic Uses

Has been used as a provocative test for pituitary release of growth hormone and corticotropin; however, other diagnostic tests (e.g., insulin tolerance test) are considered more reliable diagnostic indicators of growth hormone reserve.b

GI Hemorrhage

Has been administered IV or intra-arterially into the superior mesenteric artery as an adjunct in the treatment of acute and life-threatening, massive GI hemorrhage caused by various conditions (e.g., esophageal varices, inflammatory bowel disease,178 peptic ulcer disease, esophagogastritis, esophageal laceration, acute gastritis, colitis associated with Behcet’s disease, colonic diverticulosis, Mallory-Weiss syndrome, intestinal perforation).b

May provide effective control of bleeding, but there is no evidence that the drug improves overall survival.b In addition, there is a high recurrence of bleeding when discontinued.182

Clinical usefulness also limited by adverse effects.180 182 183 Other vasoactive agents with fewer adverse effects (e.g., octreotide) preferred.179 180 183

Vasopressin Dosage and Administration

Administration

Administer by IV infusion for vasodilatory shock.167

Also has been administered by IM or sub-Q injection for other uses (e.g., postoperative abdominal distention, diabetes insipidus).170 172

Also has been applied topically (e.g., with a cotton pledget, nasal spray, or dropper) to nasal mucosa in patients with diabetes insipidus.170

Has been administered by intraosseous (IO) injection in the ACLS setting, generally when IV access not readily available; onset of action and systemic concentrations are comparable to those achieved with venous administration.400 401 403

Also has been administered via endotracheal tube if vascular access (IV or IO) cannot be established during cardiac arrest.401

Has been administered by intra-arterial infusion in patients with GI hemorrhage; requires specialized techniques and should only be performed by clinicians familiar with this method of administration.b (See Risks of Intra-arterial Administration under Cautions.)

For solution and drug compatibility information, see Compatibility under Stability.

IV Administration

Dilution

Must dilute the commercially available 20-units/mL injection with 0.9% sodium chloride or 5% dextrose injection prior to IV administration.167 Manufacturer recommends dilution to the following final concentrations depending on patient's fluid status:167

Patients who are not fluid restricted: Prepare concentration of 0.1 units/mL by mixing 50 units (2.5 mL) of vasopressin injection with 500 mL of diluent.167

Patients who are fluid restricted: Prepare concentration of 1 unit/mL by mixing 100 units (5 mL) of vasopressin injection with 100 mL of diluent.167

Discard unused portions of the diluted solution after 18 hours at room temperature or 24 hours under refrigeration.167

Rate of Administration

Individualize IV infusion rates based on response.167

Dosage

Potency of vasopressin is standardized according to pressor activity in rats and is expressed in USP posterior pituitary (pressor) units.b

Pediatric Patients

Diabetes Insipidus
IM or Sub-Q

Usually has been given in proportionately reduced dosage (from adult dosage).170

Dosage of 2.5–10 units 2–4 times daily has been given.b

Abdominal Distention
IM

Usually has been given in proportionately reduced dosage (from adult dosage).170

Abdominal Radiographic Procedures
IM or Sub-Q

Usually has been given in proportionately reduced dosage (from adult dosage).170

Diagnostic Uses
Provocative Testing for Growth Hormone and Corticotropin Release
IM

0.3 units/kg has been given.b

Adults

Vasodilatory Shock
IV Infusion

Individualize dosage; in general, titrate to lowest dose compatible with a clinically acceptable response.167 Goal of therapy is to optimize and maintain perfusion to critical organs without causing ischemic complications.167

Patients with postcardiotomy shock: Manufacturer recommends initial dosage of 0.03 units/minute.167 If target BP response not achieved, may increase infusion rate by 0.005 units/minute at intervals of 10–15 minutes to a maximum of 0.1 units/minute.167

Patients with septic shock: Manufacturer recommends initial dosage of 0.01 units/minute.167 If target BP response not achieved, may increase infusion rate by 0.005 units/minute at intervals of 10–15 minutes to a maximum of 0.07 units/minute.167

After target BP has been maintained for 8 hours without use of catecholamines, taper vasopressin infusion rate by 0.005 units/minute every hour as tolerated to maintain target BP.167

ACLS
IV/IO

40 units (given as a single dose) has been used to replace first or second dose of epinephrine in the treatment of cardiac arrest.157 400 401

Diabetes Insipidus
IM or Sub-Q

Has been given in a dosage of 5–10 units 2–3 times daily as needed;170 dosage range of 5–60 units daily.b

Abdominal Distention
IM

Initial dose of 5 units has been given with subsequent doses every 3–4 hours and doses increased to 10 units if necessary.170

Abdominal Radiographic Procedures
IM or Sub-Q

Usually, two 10-unit injections have been given (the first injection at 2 hours and the second injection at 30 minutes) prior to exposure of the radiographs.170

Diagnostic Uses
Provocative Testing for Growth Hormone and Corticotropin Release
IM

Dose of 10 units has been given.b

GI Hemorrhage

Has been administered by continuous IV or intra-arterial infusion after dilution with 0.9% sodium chloride or 5% dextrose injection to a concentration of 0.1–1 unit/mL.b Continuous IV infusion is preferred.b (See Risks of Intra-arterial Administration under Cautions.)

Dosage is empiric and must be individualized according to response and tolerance.b Because many of the adverse effects are dose related, the lowest possible effective dosage should be used.b

IV Infusion

Has been initiated at 0.2–0.4 units/minute and progressively increased to maximum of 0.6–0.9 units/minute based on individual patient response.180 183

To minimize adverse effects, some experts recommend concomitant use of IV nitroglycerin (initiated at 40 mcg/minute, increased to a maximum of 400 mcg/minute).180 183

Some experts recommend continuous use for no longer than 24 hours.180

Intra-arterial Infusion

Dosage of 0.1–0.5 units/minute has been used.b

Special Populations

Hepatic Impairment

No specific dosage recommendations; titrate to effect.168

Renal Impairment

No specific dosage recommendations; titrate to effect.168

Geriatric Patients

Select dosage with caution, usually starting at the low end of the dosage range, because of possible age-related decreases in hepatic, renal, or cardiac function and of concomitant disease or other drug therapy.167

Cautions for Vasopressin

Contraindications

  • Known allergy or hypersensitivity (e.g., anaphylaxis) to synthetic vasopressin or chlorobutanol (a preservative in the formulation).167 170

  • Some manufacturers state that drug is also contraindicated in patients with chronic nephritis accompanied by nitrogen retention, until reasonable nitrogen concentrations are attained.170

Warnings/Precautions

Warnings

Cardiovascular Effects

In large doses, may cause increased BP, bradycardia, arrhythmias, heart block, peripheral vascular constriction or collapse, coronary insufficiency, decreased cardiac output, myocardial ischemia, or MI.b

Patients with impaired cardiac response may experience worsening cardiac output.167 Use with caution in patients with vascular disease (especially of the coronary arteries) since even small doses can precipitate angina.b

Aggressive treatment in patients with vasodilatory shock can compromise perfusion of organs, including those of the GI tract.167

Diseases in Which Rapid Addition to Extracellular Fluids May Be Hazardous

Use cautiously in patients with seizure disorders, migraine, asthma, heart failure, vascular disease (especially of the coronary arteries), angina pectoris, coronary thrombosis, renal disease, goiter with cardiac complications, arteriosclerosis, or any other disease in which rapid addition to extracellular fluids may be hazardous.b

Water Intoxication

May produce water intoxication.b

Observe closely for signs of possible development (see Monitoring under Cautions) to prevent ensuing seizures, coma, and death.b

Water intoxication may be treated with water restriction and temporary withdrawal of vasopressin until polyuria occurs.b

Severe water intoxication may require osmotic diuresis (e.g., with mannitol, hypertonic dextrose, or urea alone or with furosemide).b

Sensitivity Reactions

Hypersensitivity

Hypersensitivity reactions characterized by urticaria, angioedema, bronchoconstriction, fever, rash, wheezing, dyspnea, circulatory collapse, cardiac arrest, and anaphylaxis, reported.b

Appropriate agents for the treatment of hypersensitivity reactions should be readily available.b

General Precautions

Polyuria

Caution in preoperative and postoperative polyuric patients, since vasopressin requirements may be considerably less than normal.b

Monitoring

Monitor fluid intake and output closely, especially in comatose or semicomatose patients.b

Monitor electrolyte balance periodically.b

Perform ECGs periodically during therapy.b

Observe for early signs of water intoxication (e.g., drowsiness, listlessness, headache, confusion, anuria, weight gain).b (See Water Intoxication under Cautions.)

Risks of Intra-arterial Administration

Risk of coronary thrombosis, mesenteric infarction, venous thrombosis, infarction and necrosis of the small bowel, and peripheral emboli resulting from intra-arterial catheterization and infusion into the superior mesenteric artery.b

Specific Populations

Pregnancy

Category C.167 170

Not known whether vasopressin can cause fetal harm when administered to pregnant women or affect reproduction capacity; use only if potential benefit justifies potential risk to fetus.167 170

May produce tonic uterine contractions that could threaten the continuation of pregnancy.167

Clearance increased in second or third trimester of pregnancy; dosage >0.1 units/minute may be required in patients with postcardiotomy shock and dosage >0.07 units/minute may be required in patients with septic shock.167

Lactation

Not known whether vasopressin is distributed into human milk.167 Some manufacturers recommend use with caution.170 Oral absorption in nursing infants considered unlikely since drug is rapidly destroyed in the GI tract.167

Consider advising a lactating woman to pump and discard breast milk for 1.5 hours after receiving drug to minimize potential exposure to the infant.167

Pediatric Use

Children are particularly sensitive to vasopressin’s effects (e.g., volume/hydration disturbances); exercise caution.b

Safety and efficacy in pediatric patients with vasodilatory shock not established.167

Geriatric Use

Geriatric patients are particularly sensitive to vasopressin’s effects; exercise caution.b

Insufficient experience in patients ≥65 years of age to determine whether geriatric patients respond differently than younger adults.167 (See Geriatric Patients under Dosage and Administration.)

Common Adverse Effects

Adverse effects associated with low doses are infrequent and mild, but increase in frequency and severity with high doses.b

Adverse effects reported with IV vasopressin for the treatment of vasodilatory shock include hemorrhagic shock, decreased platelets, intractable bleeding, right heart failure, atrial fibrillation, bradycardia, myocardial ischemia, mesenteric ischemia, increased bilirubin levels, acute renal insufficiency, distal limb ischemia, hyponatremia, and ischemic lesions.167

Other adverse effects include circumoral pallor, sweating, tremor, pounding in the head, abdominal cramps, passage of gas, vertigo, nausea, vomiting, and eructation.b In addition, diarrhea, intestinal hyperactivity, and uterine cramps may occur.b

Interactions for Vasopressin

Specific Drugs

Drug

Interaction

Comments

Alcohol

May block the antidiuretic activity of vasopressin170

Carbamazepine

May potentiate the antidiuretic response to vasopressin170

Catecholamines

Expected to result in an additive effect on MAP and other hemodynamic parameters167

Chlorpropamide

May potentiate the antidiuretic response to vasopressin170

Clofibrate

May potentiate the antidiuretic response to vasopressin170

Drugs causing diabetes insipidus (e.g., demeclocycline, lithium, foscarnet, clozapine)

May decrease pressor effect and antidiuretic activity of vasopressin167

Drugs causing SIADH (e.g., SSRIs, tricyclic antidepressants, haloperidol, chlorpropamide, enalapril, methyldopa, pentamidine, vincristine, cyclophosphamide, ifosfamide, felbamate)

May increase pressor effect and antidiuretic activity of vasopressin167

Fludrocortisone

May potentiate the antidiuretic response to vasopressin170

Furosemide

Increases effect of vasopressin on osmolar clearance and urine flow167

Heparin

May block the antidiuretic activity of vasopressin170

Indomethacin

May prolong effects of vasopressin on cardiac output and peripheral vascular resistance167

Norepinephrine

May block the antidiuretic activity of vasopressin170

Ganglionic blocking agents

May markedly increase sensitivity to the hormone’s pressor effects167

Urea

May potentiate the antidiuretic response to vasopressin170

Vasopressin Pharmacokinetics

Absorption

Destroyed by trypsin which is found in the GI tract and, therefore, must be administered parenterally or intranasally.b

Absorption of vasopressin through the nasal mucosa is relatively poor.b

Onset

Following IV administration, onset of pressor effect is rapid, with peak effect occurring within 15 minutes.167

Duration

Following sub-Q or IM administration, duration of antidiuretic activity is variable, but effects are usually maintained for 2–8 hours.170

Pressor effects fade within 20 minutes after discontinuance of IV infusion.167

Plasma Concentrations

Urine isotonicity is maintained when plasma concentrations of vasopressin are approximately 1 microunit/mL, while plasma concentrations of 4.5–6 microunits/mL produce maximum concentration of urine.b

Distribution

Extent

Distributed throughout the extracellular fluid.b

Not known whether vasopressin is distributed into human milk.167

Plasma Protein Binding

No evidence of plasma protein binding.b

Elimination

Metabolism

Predominantly metabolized by liver and kidneys.167

At sites relevant for pharmacologic activity, drug is cleaved by serine protease, carboxipeptidase, and disulfide oxidoreductase; metabolites not expected to be pharmacologically active.167

Elimination Route

Sub-Q: Approximately 5% of a dose is excreted in urine unchanged after 4 hours.170 b

IV: 5–15% of the total dosage appears in urine.167

Half-life

About 10–20 minutes.170

Apparent half-life is ≤10 minutes when administered by IV infusion at usual dosage for vasodilatory shock.167

Special Populations

Oxytocinase, a circulating enzyme produced early in pregnancy, is capable of cleaving the polypeptide; otherwise, plasma inactivation of vasopressin is negligible.b

Stability

Storage

Parenteral

Injection for IV Infusion

Store between 2–8°C; do not freeze.167

May store unopened vials at room temperature (20–25°C) for up to 12 months; once removed from the refrigerator, indicate revised 12-month expiration date on vial (unless manufacturer's original expiration date is sooner).167

Following dilution, solution is stable for 18 hours at room temperature or 24 hours under refrigeration.167 168

Compatibility

For information on systemic interactions resulting from concomitant use, see Interactions.

Solution CompatibilityHID

Compatible

Dextrose 5% in water

Sodium chloride 0.9%

Drug Compatibility
Admixture CompatibilityHID

Compatible

Verapamil HCl

Evaluated by pushing vasopressin through a Y-site over 5 seconds

Y-Site Compatibility HID

Compatible

Amiodarone HCl

Argatroban

Caspofungin acetate

Ceftaroline fosamil

Ciprofloxacin

Diltiazem HCl

Dobutamine HCl

Dopamine HCl

Epinephrine HCl

Fluconazole

Gentamicin sulfate

Heparin sodium

Hydroxyethyl starch 130/0.4 in sodium chloride 0.9%

Imipenem-cilastatin sodium

Insulin, regular

Lidocaine HCl

Linezolid

Meropenem

Metronidazole

Micafungin sodium

Milrinone lactate

Moxifloxacin HCl

Nitroglycerin

Norepinephrine bitartrate

Pantoprazole sodium

Phenylephrine HCl

Piperacillin sodium-tazobactam sodium

Procainamide HCl

Sodium bicarbonate

Telavancin HCl

Voriconazole

Incompatible

Furosemide

Phenytoin sodium

Actions

  • Exogenous vasopressin elicits all the pharmacologic responses usually produced by endogenous vasopressin (antidiuretic hormone);b primary physiologic role of vasopressin is to maintain serum osmolality within a normal range.167 170 b

  • The vasoconstrictive action of vasopressin is mediated by vascular V1 receptors;150 151 167 the vascular receptors are coupled to phospholipase C, resulting in release of calcium from sarcoplasmic reticulum in smooth muscle cells, leading to vasoconstriction.151 167

  • Causes vasoconstriction, particularly of capillaries and of small arterioles, resulting in decreased blood flow to the splanchnic, coronary, GI, pancreatic, skin, and muscular systems.167 b

  • When administered in therapeutic doses to patients with vasodilatory shock, increases systemic vascular resistance and MAP (with pressor effect proportional to infusion rate); also tends to decrease heart rate and cardiac output.167 No evidence of tachyphylaxis or tolerance to pressor effect.167

  • Produces relatively concentrated urine by increasing reabsorption of water by the renal tubules.170 Its action in regulating body fluid balance is mediated by renal vasopressin V2 receptors, which are coupled to adenyl cyclase and the generation of cyclic AMP.151 167 At the tubular level, vasopressin stimulates adenyl cyclase activity, leading to increases in cyclic adenosine monophosphate (AMP).b Cyclic AMP increases water permeability at the luminal surface of the distal convoluted tubule and collecting duct, resulting in increased urine osmolality and decreased urinary flow rate.b

  • Conserves up to 90% of the water that might otherwise be excreted in the urine. Vasopressin also increases reabsorption of urea by the collecting ducts.b

  • Increases coronary blood flow and the availability of oxygen to the myocardium.152 153

  • When administered into the celiac or superior mesenteric arteries, vasopressin constricts gastroduodenal, left gastric, superior mesenteric, and splenic arteries; however, hepatic arteries are not constricted and, instead, hepatic blood flow often increases.b

  • At pressor doses, triggers contraction of smooth muscles in the GI tract mediated by muscular V1 receptors and release of prolactin and ACTH via V3 receptors.167

  • In the intestinal tract, increases peristaltic activity, particularly of the large bowel; also causes an increase in GI sphincter pressure and a decrease in gastric secretion but has no effect on gastric acid concentration.

  • Oxytocic properties of vasopressin are minimal, but in large doses the drug may stimulate uterine contraction.170 b The hormone also possesses slight milk ejecting properties but its role during lactation is negligible.b

  • In addition to its peripheral effects, vasopressin causes release of corticotropin, growth hormone, and follicle-stimulating hormone.b

Advice to Patients

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs.167

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.167

  • Importance of informing patients of other important precautionary information.167 (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

Vasopressin

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

Injection, for IV infusion

20 units/mL

Vasostrict

Par

AHFS DI Essentials. © Copyright 2017, Selected Revisions August 7, 2017. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

References

Only references cited for selected revisions after 1984 are available electronically.

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151. Rozenfeld V, Cheng WM. The role of vasopressin in the treatment of vasodilation in shock states. Ann Pharmacother. 2000; 34:250-3. [PubMed 10676834]

152. Wenzel V, Krismer AC, Arntz H et al for the European Resuscitation Council Vasopressor during Cardiopulmonary Resuscitation Study Group. A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation. N Engl J Med. 2004; 350:105-13. [PubMed 14711909]

153. Mcintyre KM. Vasopressin in asystolic cardiac arrest. N Engl J Med. 2004; 350:179-81. [PubMed 14711918]

157. The American Heart Association. Guidelines 2005 for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2005; 112(Suppl I): IV1-211.

158. Miano TA, Crouch MA. Evolving role of vasopressin in the treatment of cardiac arrest. Pharmacotherapy. 2006; 26:828-39. [PubMed 16716136]

159. Guyette FX, Guimond GE, Hostler D et al. Vasopressin administered with epinephrine is associated with a return of a pulse in out-of-hospital cardiac arrest. Resuscitation. 2004; 63:277-82. [PubMed 15582762]

160. Lindner KH, Dirks B, Strohmenger HU et al. Randomised comparison of epinephrine and vasopressin in patients with out-of-hospital ventricular fibrillation. Lancet. 1997; 349:535-7. [PubMed 9048792]

161. Lindner KH, Prengel AW, Brinkmann A et al. Vasopressin administration in refractory cardiac arrest. Ann Intern Med. 1996; 124:1061-4. [PubMed 8633820]

162. Mann K, Berg RA, Nadkarni V. Beneficial effects of vasopressin in prolonged pediatric cardiac arrest: a case series. Resuscitation. 2002; 52:149-56. [PubMed 11841882]

163. Morris DC, Dereczyk BE, Grzybowski M et al. Vasopressin can increase coronary perfusion pressure during human cardiopulmonary resuscitation. Acad Emerg Med. 1997; 4:878-83. [PubMed 9305429]

164. Stiell IG, Hebert PC, Wells GA et al. Vasopressin versus epinephrine for inhospital cardiac arrest: a randomised controlled trial. Lancet. 2001; 358:105-9. [PubMed 11463411]

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167. Par Pharmaceutical Companies, Inc. Vasostrict (vasopressin injection, USP) prescribing information. Chestnut Ridge, NY; 2016 Feb.

168. US Food and Drug Administration. Center for Drug Evaluation and Research. Application number 204485Orig1s000: Summary Review: From FDA website. Accessed 2017 Feb.

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170. Fresenius Kabi USA, LLC. Vasopressin injection solution prescribing information. Lake Zurich, IL; 2013 Sep.

171. Di Iorgi N, Napoli F, Allegri AEM et al. Diabetes insipidus: diagnosis and management. Horm Res Paediatr. 2012; 77:69-84. [PubMed 22433947]

172. US Food and Drug Administration. Center for Drug Evaluation and Research. Application number 204485Orig1s000: Medical Review: From FDA website.

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175. Rosenzweig EB, Starc TJ, Chen JM et al. Intravenous arginine-vasopressin in children with vasodilatory shock after cardiac surgery. Circulation. 1999; 100(19 Suppl):II182-6. [PubMed 10567301]

176. Qureshi S, Galiveeti S, Bichet DG et al. Diabetes insipidus: celebrating a century of vasopressin therapy. Endocrinology. 2014; 155:4605-21. [PubMed 25211589]

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178. Alla VM, Ojili V, Gorthi J et al. Revisiting the past: intra-arterial vasopressin for severe gastrointestinal bleeding in Crohn's disease. J Crohns Colitis. 2010; 4:479-82. [PubMed 21122547]

179. Cremers I, Ribeiro S. Management of variceal and nonvariceal upper gastrointestinal bleeding in patients with cirrhosis. Therap Adv Gastroenterol. 2014; 7:206-16. [PubMed 25177367]

180. Garcia-Tsao G, Sanyal AJ, Grace ND et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007; 46:922-38. [PubMed 17879356]

181. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012; 107:345-60; quiz 361. [PubMed 22310222]

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183. Satapathy SK, Sanyal AJ. Nonendoscopic management strategies for acute esophagogastric variceal bleeding. Gastroenterol Clin North Am. 2014; 43:819-33. [PubMed 25440928]

400. Link MS, Berkow LC, Kudenchuk PJ et al. Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(18 Suppl 2):S444-64. [PubMed 26472995]

401. Neumar RW, Otto CW, Link MS et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010; 122(18 Suppl 3):S729-67. [PubMed 20956224]

403. Kleinman ME, Chameides L, Schexnayder SM et al. Part 14: pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010; 122(18 Suppl 3):S876-908. [PubMed 20956230]

405. Neumar RW, Shuster M, Callaway CW et al. Part 1: Executive Summary: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(18 Suppl 2):S315-67. [PubMed 26472989]

b. AHFS drug information 2018. McEvoy GK, ed. Vasopressin. Bethesda, MD: American Society of Health-System Pharmacists; 2018.

HID. Trissel LA. Handbook on injectable drugs. 19th ed. Bethesda, MD: American Society of Health-System Pharmacists; 2017:1214-6.

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