Nasal-Spray-Alternatives

Alternatives to Desmopressin Nasal Spray

With the recalled Stimate Nasal Spray not expected to be available until at least 2023, here are some other treatment options.
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What alternatives are there for Stimate Nasal Spray? 

That’s a question that many patients and parents in the bleeding disorders community have been asking since the summer of 2020, when Ferring Pharmaceuticals issued a voluntary recall of the nasal spray version of desmopressin (DDAVP). The nasal spray is commonly used to treat von Willebrand disease (VWD) and mild hemophilia A and is sold under the brand name Stimate.

Desmopressin is a synthetic analogue of vasopressin, which boosts plasma levels of von Willebrand factor and factor VIII and helps stop bleeding. The nasal spray is often prescribed for people with frequent nosebleeds, serious bruising or heavy menstrual periods (menorrhagia). DDAVP is also sometimes given to people before procedures that involve the mucous membranes, such as dental work, as well as for home treatment of minor injuries and before minor surgeries. 

Stimate, which is owned and manufactured by Ferring Pharmaceuticals and distributed and sold in the United States by CSL Behring, was recalled due to superpotency, meaning that some products contained higher-than-specified amounts of the medication. In 2021, the company announced that the nasal spray will not be available until the second half of 2023 at the earliest.

Here are some other medication options that are available as alternatives to the recalled nasal spray:

Antifibrinolytics

Oral medications such as tranexamic acid (Lysteda) and aminocaproic acid (Amicar) help promote blood clotting by preventing the breakdown of fibrin, which is the main protein involved in a blood clot. 

Robert Sidonio Jr., MD, director of hemostasis and thrombosis clinical operations at the Aflac Cancer and Blood Disorders Center of Children’s Healthcare of Atlanta, says he often prescribes high doses of an antifibrinolytic instead of DDAVP for patients with mildly reduced levels of VWF or mild hemophilia A or B who are having minor mucosal surgeries. “We have been following this strategy for a while now, and we also apply it to non-mucosal procedures, such as skin biopsies, ear tube placement, colonoscopies and tattoos,” Sidonio says.

IV or Subcutaneous DDAVP

Before the nasal spray version was introduced, DDAVP was primarily given as an injection, either intravenously or subcutaneously. Both of these options are still available.

“If DDAVP is working well for someone and they want to be maintained on the same medication, then subcutaneous injections of DDAVP, which patients can be taught to do at home, are an option that’s worth considering,” says Alexis Koon, PharmD, a hematology/oncology pharmacy resident at Atrium Health Carolinas Medical Center in Charlotte, North Carolina, who recently co-authored a paper outlining alternatives to the recalled nasal spray. Sidonio notes, however, that subcutaneous DDAVP is less practical for obese and overweight patients because of the high volume of injections needed in addition to the higher rate of side effects like facial flushing, headaches and nausea.

Factor Replacement Products

Patients who have more severe VWD or who don’t respond to DDAVP are often prescribed factor replacement therapy, which is injected into a vein in the arm to replace the missing factor in the blood. 

“If the patient has a clinically severe phenotype of VWD and it isn’t clear how invasive the procedure is, then we will need to rely on factor replacement, typically one dose prior to the procedure, followed by a prolonged course of an antifibrinolytic with possible additional factor doses,” Sidonio says. “For persons with mild hemophilia A and B, we have definitely been using more single-dose factor replacement, particularly if their levels are below 30%.”