Vasopressin
Also known as: ADH, Antidiuretic Hormone, Arginine Vasopressin, AVP, Pitressin, Vasostrict
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Summary
Vasopressin is an approved prescription nonapeptide hormone used intravenously, intranasally, or subcutaneously to raise blood pressure in acute shock states. Clinical trials have examined it as an adjunct or alternative to norepinephrine in septic shock and as a first‑line agent for vasoplegic shock after cardiac surgery. Studies report mixed effects on mortality, kidney function, and composite complications, while highlighting a distinct safety profile compared with catecholamine vasopressors.
Mechanism of Action
When administered, vasopressin binds to vasopressin receptors on vascular smooth muscle, producing vasoconstriction that increases systemic vascular resistance and arterial pressure. Its V2‑receptor activity also promotes renal water reabsorption, contributing to its antidiuretic effect. These actions underlie its use as a vasopressor in shock.
What the Research Shows
Randomised trials in septic shock (VASST 2008, VANISH 2016) found no overall mortality benefit for vasopressin versus norepinephrine, though VASST suggested lower 28‑day mortality in less severe shock. VANISH showed no improvement in kidney‑failure‑free days but a modest reduction in renal replacement therapy. An individual‑patient data meta‑analysis (2019) confirmed no mortality effect, a small increase in digital ischaemia, fewer arrhythmias, and a tentative reduction in dialysis need. A network meta‑analysis (2023) ranked vasopressin between norepinephrine and terlipressin for mortality. In vasoplegic shock after cardiac surgery (VANCS 2017), vasopressin lowered a composite of death or severe complications compared with norepinephrine.
Reported Benefits
Evidence suggests vasopressin may reduce the need for renal replacement therapy in septic shock and lower the incidence of cardiac arrhythmias. In postoperative vasoplegic shock, it decreased a composite endpoint of death and serious complications. These potential advantages are drawn from individual trials and meta‑analyses, though the magnitude of benefit varies across studies.
Limitations of the Evidence
Across multiple randomised trials, vasopressin has not demonstrated a consistent mortality advantage. Findings on renal outcomes are not robust to all sensitivity analyses, and confidence intervals are often wide. Most data focus on intensive‑care populations with septic or vasoplegic shock, limiting generalisability. Long‑term outcomes and cost‑effectiveness remain unstudied.
Safety Considerations
Serious adverse events occurred at similar rates to norepinephrine, but vasopressin was associated with a modest increase in digital (limb) ischaemia. Rates of mesenteric ischaemia, myocardial infarction, and hyponatraemia were comparable between groups. Clinicians should monitor peripheral perfusion and electrolyte status during infusion.
How It Is Administered
Vasopressin is supplied as a sterile solution for intravenous infusion, commonly titrated between 0.01 and 0.06 U min⁻¹ in shock protocols. It can also be given subcutaneously or intranasally for other indications, but shock studies used continuous IV dosing. Dosing is adjusted to maintain target arterial pressure.
Routes of Administration
Goals & Uses
- Esophageal variceal bleedingGastroenterologyHigh
- Cardiac arrest resuscitationEmergency MedicineModerate
- Diabetes insipidusEndocrineHigh
- Control of esophageal variceal bleedingGastroenterologyModerate
- Treatment of distributive/vasodilatory shockHemodynamic SupportHigh
- Management of central diabetes insipidusEndocrinologyHigh
- Septic ShockCritical CareModerate
- Postoperative hypotension (vasoplegic syndrome)Perioperative CareModerate
Contraindications
- Known hypersensitivity to vasopressin or excipientsAllergy/ImmunologyHigh
- Severe coronary artery disease (relative)CardiovascularModerate
- Severe coronary artery diseaseCardiovascularHigh
- Hypersensitivity to vasopressinImmunologicHigh
- Chronic nephritis with nitrogen retentionRenalHigh
- HyponatremiaElectrolyte/MetabolicModerate
- Uncontrolled hypertensionCardiovascularModerate
Adverse Effects
- Headache / pallor / sweatingNeurological/SystemicCommon
- HypertensionCardiovascularCommonHigh blood pressure
- Hyponatremia / water intoxicationMetabolicCommon
- HeadacheNeurologicCommonPain in the head or upper neck
- Nausea, vomiting, abdominal crampingGastrointestinalCommon
- Cardiac ischemiaCardiovascularUncommon
- Myocardial ischemia / anginaCardiovascularUncommon
- Peripheral ischemia / digital necrosisVascularUncommon
Drug Interactions
- Indomethacin / NSAIDsModerate
- Tricyclic antidepressants (e.g., clomipramine)Moderate
- Thiazide diureticsModerate
- LithiumModerate
- Vasodilators (e.g., nitroglycerin)Low
- Catecholamines (norepinephrine, epinephrine)Moderate
Population Constraints
- PregnancyReproductive SafetyRelative
- Patients with heart failureCardiovascularRelative
- Pediatric patientsAgeRelative
- ElderlyAgeRelative
- Pediatric (neonates)AgeRelative
- Elderly patientsAgeRelative
Regulatory Status
- European UnionApprovedApproved: central diabetes insipidus, esophageal variceal bleeding, vasodilatory shock
- United StatesApprovedApproved: central diabetes insipidus, esophageal variceal bleeding, vasodilatory shock
- United KingdomApprovedApproved: central diabetes insipidus, esophageal variceal bleeding, vasodilatory shock
Approved in the US, EU and UK for diabetes insipidus, variceal bleeding, and vasodilatory shock; administered as injection or nasal spray.
Evidence & Sources
- Journal ArticleModerateGordon AC, et al.2016-01-01T00:00:00.000000Z
- Journal ArticleHighJia L, et al.2023-01-01T00:00:00.000000Z
- Journal ArticleHighNagendran M, et al.2019-01-01T00:00:00.000000Z
- Journal ArticleHighAvni T, et al.2015-01-01T00:00:00.000000Z
- Journal ArticleModerateHajjar LA, et al.2017-01-01T00:00:00.000000Z
- Journal ArticleModerateRussell JA, et al.2008-01-01T00:00:00.000000Z
Frequently Asked Questions
How does vasopressin differ from norepinephrine as a vasopressor?
Vasopressin raises blood pressure by activating vasopressin receptors that cause direct vasoconstriction, whereas norepinephrine works mainly through adrenergic receptors. This different pathway can result in fewer arrhythmias but a higher risk of peripheral ischaemia.
In which clinical situations has vasopressin shown benefit?
Trials have shown vasopressin may lower the need for renal replacement therapy in septic shock and reduce a composite of death or severe complications in vasoplegic shock after cardiac surgery. No consistent mortality benefit has been demonstrated.
What are the main risks associated with vasopressin therapy?
The principal safety concerns are digital (limb) ischaemia and, less frequently, mesenteric ischaemia. Overall serious adverse event rates are similar to norepinephrine, but clinicians should watch for signs of impaired peripheral perfusion and electrolyte disturbances.
What is Vasopressin?
Vasopressin is an approved prescription nonapeptide hormone used intravenously, intranasally, or subcutaneously to raise blood pressure in acute shock states. Clinical trials have examined it as an adjunct or alternative to norepinephrine in septic shock and as a first‑line agent for vasoplegic shock after cardiac surgery. Studies report mixed effects on mortality, kidney function, and composite complications, while highlighting a distinct safety profile compared with catecholamine vasopressors.
What is Vasopressin used for?
Vasopressin is educationally associated with: Esophageal variceal bleeding, Cardiac arrest resuscitation, Diabetes insipidus, Control of esophageal variceal bleeding, Treatment of distributive/vasodilatory shock, Management of central diabetes insipidus, Septic Shock, Postoperative hypotension (vasoplegic syndrome). Educational only — not medical advice.
How is Vasopressin administered?
Recorded routes of administration: Intranasal, Intravenous, Subcutaneous.
What are the potential side effects of Vasopressin?
Reported adverse effects include: Headache / pallor / sweating, Hypertension, Hyponatremia / water intoxication, Headache, Nausea, vomiting, abdominal cramping, Cardiac ischemia, Myocardial ischemia / angina, Peripheral ischemia / digital necrosis. This list is not exhaustive — consult a qualified clinician.
Who should avoid Vasopressin?
Recorded contraindications: Known hypersensitivity to vasopressin or excipients, Severe coronary artery disease (relative), Severe coronary artery disease, Hypersensitivity to vasopressin, Chronic nephritis with nitrogen retention, Hyponatremia, Uncontrolled hypertension. Consult a qualified clinician before use.