Indications

Vaptan is indicated in-
. Hypervolemic or euvolemic hyponatremia.
. Autosomal dominant polycystic kidney disease.

Pharmacology

Tolvaptan is a selective vasopressin V2-receptor antagonist. Tolvaptan affinity for the V2-receptor is 29 times greater than for the V1a-receptor. When taken orally, 15 to 60 mg doses of Tolvaptan
antagonize the effect of vasopressin and cause an increase in urine water excretion that results in an increase in free water clearance (aquaresis), a decrease in urine osmolality, and a resulting increase
in serum sodium concentrations. Urinary excretion of sodium and potassium and plasma potassium concentrations are not significantly changed.

Dosage & Administration

Hypervolemic or euvolemic hyponatremia: The usual starting dose for Tolvaptan is 15 mg administered once daily without regard to meals. Increase the dose to 30 mg once daily, after at least 24
hours, to a maximum of 60 mg once daily, as needed to achieve the desired level of serum sodium. Do not use for more than 30 days due to the risk of hepatotoxicity.

Autosomal dominant polycystic kidney disease (ADPKD):
. Initially: 60 mg/day in divided doses (given as 45 mg upon wakening and 15 mg 8 hours later);
. Titrate per response and tolerability at intervals of at least 7 days between titrations to 90 mg/day in divided doses (given as 60 mg upon wakening and 30 mg 8 hours later) followed by 120
mg/day in divided doses (given as 90 mg upon wakening and 30 mg 8 hours later).
. Maintain urine osmolality of <300 mOsm/kg if possible; if the maximum dose is not tolerated, administration of a lower dose with the goal of achieving urine osmolality of 250 to 300 m0sm/kg is
reasonable.

Interaction

Other Drugs Affecting Exposure to Vaptan:
. CYP 3A Inhibitors: Vaptan is a substrate of CYP 3A. CYP 3A inhibitors can lead to a marked increase in Vaptan concentrations. Do not use Vaptan with strong inhibitors of CYP 3A and avoid
concomitant use with moderate CYP 3A inhibitors.
. CYP 3A Inducers: Avoid co-administration of CYP 3A inducers (e.g., Rifampin, Rifabutin, Rifapentin, Barbiturates, Phenytoin, Carbamazepine) with Vaptan, as this can lead to a reduction in the
plasma concentration of Vaptan and decreased effectiveness of Vaptan treatment. If co-administered with CYP 3A inducers, the dose of Vaptan may need to be increased.
. P-gp Inhibitors: The dose of Vaptan may have to be reduced when Vaptan is co-administered with P-gp inhibitors, e.g., Cyclosporine.

Contraindications

Hypersensitivity to the active substance or to any of the excipients, anuria, volume depletion, hypovolemic hyponatremia, hypernatremia, Patients who cannot perceive thirst, pregnancy, breast-
feeding.

Side Effects

The most common side effects of Vaptan are: thirst, dry mouth, weakness, constipation, making large amounts of urine and urinating often & increased blood sugar levels.

Pregnancy & Lactation

There are no or limited amount of data from the use of Tolvaptan in pregnant women. Studies in animals have shown reproductive toxicity. The potential risk for humans is unknown. Tolvaptan is
contraindicated during pregnancy. Women of childbearing potential have to use effective contraception during Tolvaptan treatment. It is unknown whether Tolvaptan is excreted in human milk.

Precautions & Warnings

Too rapid correction of serum sodium can cause serious neurologic sequelae.