Hemophilia A and von Willebrand disease (type 1; mild to moderate): Note: Adverse events such as hyponatremia-induced seizures have been reported especially in young children with IV use (Das 2005; Molnr 2005; Smith 1989; Thumfart 2005; Weinstein 1989). The tendency toward tachyphylaxis (lessening of response) with repeated administration given more frequently than every 48 hours should be considered in treating each patient. Nasal spray. Adverse Reactions Warnings Monitoring Pregnancy Patient Education Boxed Warning Hyponatremia (Nocdurna, Noctiva nasal spray): Desmopressin can cause hyponatremia. Desmopressin acetate injection is indicated as antidiuretic replacement therapy in the management of central (cranial) diabetes insipidus and for the management of the temporary polyuria and polydipsia following head trauma or surgery in the pituitary region. Treatment period is up to 3 months and then reassess with 1 week off treatment; if additional therapy is necessary, resume at same dosage prior to discontinuation. Type 2B or platelet-type (pseudo) von Willebrand disease; habitual or psychogenic polydipsia, cardiac insufficiency or other conditions requiring diuretic therapy; nephrosis or any other condition associated with impaired water excretion, severe hepatic dysfunction; primary nocturnal enuresis; sodium losing conditions; SIADH secretion; lactose intolerance. Normally, our bodies concentrate our urine at night, and most people can sleep for 6 to 8 hours without urinating. Monitor therapy, Opioid Agonists: May enhance the adverse/toxic effect of Desmopressin. Package insert / product label Pashamylaram, Patancheru, Data from a limited number of patients (case series) who were experiencing hemorrhage in the setting of renal insufficiency suggests that IV desmopressin may be beneficial for the treatment of this condition Watson 1984a. Limit fluid intake to a minimum from 1 hour before administration until 8 hours after administration. Supplied: 4 mcg/ml-1 ml vial. Desmopressin acetate can cause hyponatremia. Free water intake should be restricted during treatment. Avoid combination, Demeclocycline: May diminish the therapeutic effect of Desmopressin. More frequently monitor serum sodium in patients 65 years of age and older and in patients at increased risk of hyponatremia, [see Dosage and Administration (2.1) and Warnings and Precautions (5.1)], If hyponatremia occurs, Desmopressin acetate may need to be temporarily or permanently discontinued. Severe hyponatremia can be life-threatening, leading to seizures, coma, respiratory arrest, or death, Desmopressin acetate is contraindicated in patients at increased risk of severe hyponatremia, such as patients with excessive fluid intake, illnesses that can cause fluid or electrolyte imbalances, and in those using loop diuretics or systemic or inhaled glucocorticoids, [see Contraindications (4) and Warnings and Precautions (5.1)], Ensure the serum sodium concentration is normal before starting or resuming Desmopressin acetate. Intermittently during treatment, assess serum sodium, urine volume and osmolality or plasma osmolality. In case of overdosage, the dosage should be reduced, frequency of administration decreased, or the drug withdrawn according to the severity of the condition, serum sodium assessed, and hyponatremia treated appropriately. David McAuley, Pharm.D. Preserve in tight containers, protected from light. Store bottle in upright position. Severe hyponatremia can be life-threatening, leading to seizures, coma, respiratory arrest, or death [see Warnings and Precautions (5.1)]. Discard 60 days after opening. Neither GlobalRPh Inc. nor any other party involved in the preparation of this document shall be liable for any special, consequential, or exemplary damages resulting in whole or part from any user's use of or reliance upon this material. Signs of overdose may include headaches, abdominal cramps, nausea, facial flushing, confusion, drowsiness, problems with passing urine and rapid weight gain due to fluid retention [see Warnings and Precautions (5.1)]. Intracranial hemorrhage associated with certain antiplatelet agents (aspirin, clopidogrel, prasugrel, ticlopidine, ticagrelor, cangrelor) (off-label use): IV: 0.4 mcg/kg once (NCS/SCCM [Frontera 2016]). Conversion from injection to intranasal: Administer 10 times the amount of desmopressin acetate, rounded down to the nearest 10 mcg. This site complies with the HONcode standard for trust- worthy health information: verify here. Subcutaneous (not approved for use in the United States): 0.3 mcg/kg (maximum 20 mcg) subcutaneously. [see Patient Counseling Information (17)]. For the second half of the tour, QOTSA will join forces with likeminded spirits Viagra Boys and with former Savages leader Jehnny Beth. Discuss adjustment of fluid intake and monitoring of urine output with patients. Nasal spray: Store at 20C to 25C (68F to 77F). Greatly enhanced ADH activity. If hyponatremia occurs, Desmopressin acetate injection may need to be temporarily or permanently discontinued and treatment for the hyponatremia instituted, depending on the clinical circumstances, including the duration and severity of the hyponatremia. Administer with a 0.22 micron filter. [see Contraindications, Warnings and Precautions (5.1)]. Hemophilia A General. Desmopressin may increase the serum concentration of Lithium. IM, IV, SubQ: Canadian labeling (DDAVP Injection only): 1 to 4 mcg (0.25 to 1 mL) once daily or one-tenth (1/10) of the maintenance intranasal dose. Monitor therapy, Lithium: May diminish the therapeutic effect of Desmopressin. IM (Canadian labeling [DDAVP Injection only]; not in US labeling), IV push, SubQ injection: Central diabetes insipidus: Withdraw dose from ampul into appropriate syringe size (eg, insulin syringe). Hyderabad-502 307, India. A maximum IV dose of 20 mcg has been recommended (DDAVP injection Canadian product labeling). Desmopressin acetate injection is contraindicated in patients with hyponatremia (or a history of hyponatremia), with excessive fluid intake (e.g., polydipsia), using loop diuretics or systemic or inhaled glucocorticoids, with known or suspected SIADH, and/or illnesses that can cause fluid or electrolyte imbalances [see Contraindications (4), Drug Interactions (7)]. Apply for early access to the new Medicine.com Pharmacy. Von Willebrand disease (type 1): For use in patients with mild to moderate classic von Willebrand disease (type 1) with factor VIII coagulant activity levels >5% to maintain hemostasis during surgical procedures and postoperatively when administered 30 minutes prior to the scheduled procedure and to stop bleeding due to spontaneous or trauma-induced injuries, such as hemarthroses, intramuscular hematomas, or mucosal bleeding. Clinical studies of Desmopressin acetate injection did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Monitor serum sodium more frequently in patients taking Desmopressin acetate injection concomitantly with these drugs and when doses of these drugs are increased [see Contraindications (4), Warnings and Precautions (5.1), Drug Interactions (7.1), Use in Specific Populations (8.4, 8.5)]. Females: 27.7 mcg once daily one hour before bedtime, Males: 55.3 mcg once daily one hour before bedtime. The necessity for repeat administration of Desmopressin acetate or use of any blood products for hemostasis should be determined by laboratory response as well as the clinical condition of the patient. Fluid restriction should be observed. Nocturia: Avoid use (Beers Criteria [AGS 2019]). Limitations of Use: Available for Android and iOS devices. Fluid retention: May cause fluid retention, which can worsen underlying conditions susceptible to volume status. Note: For all indications, fluid intake, urine volume, and signs and symptoms of hyponatremia should be closely monitored especially in high-risk patient subgroups (eg, young children, elderly, patients with heart failure). Nocturia (Noctiva): Treatment of nocturia due to nocturnal polyuria in adults who awaken at least 2 times per night to void. Hyponatremia (adjunct to hypertonic saline infusion to prevent overly rapid sodium correction)c. Data from a limited number of patients (case series) with severe hyponatremia (serum sodium <120 mEq/L) suggest that treatment with desmopressin as an adjunct to hypertonic saline may be beneficial for preventing overly rapid correction of hyponatremia MacMillan 2015, Sood 2013. Digestive: Nausea, abdominal cramps The following clinically significant adverse reactions are described elsewhere in the labeling: The following adverse reactions have been identified during post-approval use of Desmopressin acetate injection. Mean maximum pharmacodynamic activity for both factors was estimated to be three- to four-times higher than baseline activity, and the mean desmopressin concentrations that produce half-maximal effects were approximately 250 to 300 pg/mL. Used for the treatment of central diabetes insipidus, primary nocturnal enuresis (PNE), spontaneous bleeding or trauma-induced hemorrhage, bleeding prophylaxis (e.g., surgical bleeding), hemophilia A or mild to moderate von Willebrand's disease, and nocturia due to nocturnal polyuria in adults Sublingual: Canadian labeling: DDAVP Melt [Canadian product]: Children 5 years and Adolescents: Sublingual: Initial: 120 mcg administered 1 hour before bedtime; may titrate by 120 mcg/day every 3 days as necessary to a maximum dose of 360 mcg/day to achieve desired response. Severe cerebrovascular disease like change in strength on one side is greater than the other, difficulty speaking or thinking, change in balance, or vision changes. Talk with the doctor. Following dilution in NS may store at room temperature for up to 24 hours. IV, SubQ: 1 to 2 mcg every 6 to 8 hours for 24 to 48 hours or until serum sodium increases to 125 mEq/L (Sood 2013; Sterns 2018). However, the offset rate of pharmacodynamic activity was rate-limited by the elimination rate of desmopressin. Note: Dosing presented is in mcg, mg, and mL (dependent upon product formulation); use extra precaution to verify product formulation and dosing units. Batch CBD Full-Spectrum Gummies. The increase of factor VIII is rapid and evident within 30 minutes, reaching a maximum at a point ranging from 90 minutes to two hours. Adjust dose based upon response to treatment estimated by two parameters: adequate duration of sleep and adequate, not excessive, water turnover. compensatory increase in heart rate. Prior to treatment with Desmopressin acetate injection, verify that factor VIII coagulant activity levels are >5% and exclude the presence of factor VIII autoantibodies. Dosing should be individualized to response. Limitations of use: Patients with von Willebrand disease who are least likely to respond are those with severe homozygous von Willebrand disease with factor VIII coagulant activity and factor VIII von Willebrand factor antigen levels <1%; other patients may respond (variable) depending on the type of molecular defect they have. Patients with conditions associated with fluid and electrolyte imbalance (i.e., cystic fibrosis, heart failure, and renal disorders), geriatric and pediatric patients, patients receiving concomitant treatments that also cause hyponatremia (i.e., tricyclic antidepressants, selective serotonin reuptake inhibitors, nonsteroidal anti-inflammatory drugs, chlorpromazine, opiate analgesics, carbamazepine, lamotrigine, thiazide diuretics and chlorpropamide), and patients with habitual or psychogenic polydipsia who may drink excessive amounts of water, may be at increased risk of hyponatremia [see Contraindications (4)]. Administer 1 hour prior to bedtime. There is no information on the effects of Desmopressin on the breastfed child or on milk production. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. After 7 days, may increase to 1.66 mcg if needed (provided the serum sodium is within the normal range during treatment with the 0.83 mcg dose). for increased risk of endometrial cancer and cardiovascular events. Drug information provided by: Merative, Micromedex A nurse or other trained health professional will give you this medicine. The easiest way to lookup drug information, identify pills, check interactions and set up your own personal medication records. Hydrochloric acid is used to adjust pH. "Vitamn C njdete v ovoc, ako s pomarane a jahody, a vitamn E v . Experts recommend initiating desmopressin proactively (ie, at the beginning of treatment for hyponatremia) (Sterns 2018). More frequently monitor serum sodium in patients 65 years of age and older and in patients at increased risk of hyponatremia [see Dosage and Administration (2.1) and Warnings and Precautions (5.1)]. Laparohysterectomy for fetal examinations were conducted on gestation day 20 for twenty females in each group; the remaining 10 females were allowed to litter in order to determine any postnatal effects that might be attributable to pre-natal treatment. It is used to treat von Willebrand disease. Longer DOA. Conversion from oral to intranasal: Individual dose titration is required (intranasal desmopressin ~10- to 40-fold more potent than oral desmopressin). The change in structure of arginine vasopressin to Desmopressin acetate resulted in increased duration of action and a decreased vasopressor action and decreased actions on visceral smooth muscle relative to the enhanced antidiuretic activity, so that clinically effective antidiuretic doses were usually below threshold levels for effects on vascular or visceral smooth muscle. Based on the Neurocritical Care Society and the Society of Critical Care Medicine guideline for reversal of antithrombotics in intracranial hemorrhage, desmopressin intravenous is suggested and may be considered in intracranial hemorrhage associated with certain antiplatelet agents (eg, aspirin, clopidogrel, prasugrel, ticlopidine, ticagrelor, cangrelor). Diabetes insipidus: Note: Fluid restriction should be observed. Also assess serum sodium and aPTT prior to treatment. Treatment period is up to 3 months and then reassess with 1 week off treatment; if additional therapy is necessary, resume at same dosage prior to discontinuation. Sublingual: Canadian labeling: DDAVP Melt [Canadian product]: Children and Adolescents: Sublingual: Initial: 60 mcg 3 times daily; total daily dose should be increased or decreased as needed to obtain adequate antidiuresis. Pump will only deliver 150 mcg dose(s); if a different dose is needed, use the injection. Women's health is once again the center of a political ping-pong match with evidence-based science on one side and anti-choice advocates on the other. DDAVP (desmopressin acetate) is an antidiuretic and antihemorrhagic drug used to treat bed-wetting, central cranial diabetes insipidus, and increased thirst and urination caused by head surgery or head trauma. Overdosage of Desmopressin acetate injection leads to prolonged duration of action with an increased risk of water retention and hyponatremia. Diabetes Insipidus: This formulation is administered subcutaneously or by direct intravenous injection. WARNINGS When Desmopressin Acetate Injection is administered to patients who do not have need of antidiuretic hormone for its antidiuretic effect, in particular in pediatric and geriatric patients, fluid intake should be adjusted downward to decrease the potential occurrence of water intoxication and hyponatremia with accompanying signs and symptoms (headache, nausea/vomiting, decreased serum sodium and weight gain). Grasp the tube 3/4 inch from the end and insert tube into nostril until the fingertips reach the nostril. Monitor therapy, Loop Diuretics: May enhance the hyponatremic effect of Desmopressin. Indications: Hemophilia (increases factor VIII levels): 0.3 mcg/kg in 50ml normal saline over 15-30 minutes. Call your doctor right away if you have a rash, itching, trouble breathing, trouble swallowing, or any swelling of your hands, face, or mouth while you are using this medicine. If spray pump is not used for 48 hours it must be primed again by pressing down a couple of times until an even spray appears. Keep nasal spray in upright position. Last updated February 8, 2020. Rhinal Tube solution: Store at 2C to 8C (36F to 46F). Ensure the serum sodium concentration is normal before starting or resuming Desmopressin acetate. Nocturia (Nocdurna): Tablet should be kept under the tongue until completely dissolved. 1 spray of 1.66 mcg in either nostril nightly ~ 30 min before going to bed. No adverse developmental outcomes were observed in animal reproductive and developmental studies following administration of Desmopressin acetate during organogenesis to pregnant rats and rabbits, at doses 130- and 110- times, respectively, the recommended dose of 18 mcg for a 60 kg patient, based on body surface area (mg/m2). More frequently monitor serum sodium in patients 65 years of age and in patients at increased risk of hyponatremia. Patients with Renal Impairment Avoid combination, Corticosteroids (Systemic): May enhance the hyponatremic effect of Desmopressin. Source: Wolters Kluwer Health. Below, check out the tour dates, as well as a weird tour . Moderate to severe renal impairment defined as a creatinine clearance below 50 mL/min, Hyponatremia or a history of hyponatremia, Known or suspected syndrome of inappropriate antidiuretic hormone (SIADH) secretion, Concomitant use with systemic or inhaled glucocorticoids, During illnesses that can cause fluid or electrolyte imbalance, such as gastroenteritis, salt-wasting nephropathies, or systemic infection, Increased risk of thrombosis in patients with von Willebrands Disease Type IIB, Inform patients that Desmopressin acetate may cause severe hyponatremia, which may be life-threatening, if it is not promptly diagnosed and treated, Inform them about the signs and symptoms associated with hyponatremia, to undergo recommended serum sodium measurements, and to inform their health care provider about new medications. Nocturia (Nocdurna): Treatment of nocturia due to nocturnal polyuria in adults who awaken at least 2 times per night to void. Allergic reactions: Severe allergic reactions have been reported with desmopressin; anaphylactic reactions have only occurred rarely with IV and intranasal administration. Review our medical disclaimer. IV Push maximum rate: 5 mg/min Digoxin in single bolus dose < 0.5 mg (Lanoxin) IVP IVP IVP IVPB on 2W/3W/OB . Uremic bleeding: Octostim [Canadian product]: IV: 0.3 mcg/kg over 20 to 30 minutes (maximum dose: 20 mcg), Uremic bleeding associated with acute or chronic renal failure (off-label use in US): IV: 0.4 mcg/kg over 10 minutes (Watson 1984), Prevention of surgical bleeding in patients with uremia (off-label use in US): IV: 0.3 mcg/kg over 30 minutes (Mannucci 1983). If used preoperatively, administer 30 minutes prior to the procedure. Dexamethasone (Decadron) Administer over at least 30 seconds Dexmedetomidine . Use of Desmopressin acetate in patients with Type IIB von Willebrands disease may result in platelet aggregation, thrombocytopenia, and possibly thrombosis. No in vivo interaction studies have been performed with Desmopressin acetate injection. This material is provided for educational purposes only and is not intended for medical advice, diagnosis, or treatment. Wt. In general, dose selection should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. Clinical Considerations A report about an ongoing trial of the drug from Raleigh-based Sprout Pharmaceuticals for treatment of low sexual desire in women finds in interim results that the so called 'female Viagra' can . Integumentary: Erythema, swelling, burning pain, facial flushing Information related to desmopressin for the treatment of von Willebrand disease in pregnancy is limited (NHLBI 2007); however, use is recommended for bleeding prophylaxis when otherwise indicated (Demers 2018; Pacheco 2010; Trigg 2012). Sodium chloride is used to adjust tonicity. Pregnant women with Hemophilia A or von Willebrands disease may be at an increased risk for bleeding diatheses and hemorrhagic events at delivery. Some products are not recommended in patients at risk for increased intracranial pressure or those with a history of urinary retention. Avoid combination, Loperamide-Loperamide Oxide: May increase the serum concentration of Desmopressin. Desmopressin acetate injection, USP is a synthetic vasopressin analog for intravenous or subcutaneous use. Desmopressin Acetate Injection 4 mcg/mL dosage must be determined for each patient and adjusted according to the pattern of response. HOW SUPPLIED Desmopressin Acetate Injection 4 mcg/mL is available as a clear colorless sterile solution as follows: Ampul - 4 mcg/mL - 1 mL - 10 per Box. Some have suggested an initial dosage range of 0.1 to 1 mcg in 1 or 2 divided doses (Cheetham 2002). Sublingual: Nocdurna: Note: Dosage expressed as desmopressin acetate. [DSC] = Discontinued product, Noctiva: 0.83 mcg/0.1 mL (3.8 g [DSC]); 1.66 mcg/0.1 mL (3.8 g), DDAVP: 4 mcg/mL (10 mL) [contains chlorobutanol (chlorobutol)]. The morning and evening doses should be separately adjusted for an adequate diurnal rhythm of water turnover. CAREFULLY BEFORE ACCESSING OR USING THIS SITE. Reduce bleeding with episodes of spontaneous or traumatic injuries such as hemarthroses, intramuscular hematomas, or mucosal bleeding. Uremic bleeding (Octostim [Canadian product]): Prevention or treatment of bleeding in patients with uremia. Sublingual formulation [Canadian product]: DDAVP Melt: Initial: 120 mcg administered 1 hour before bedtime; if bedwetting occurs after 3 days increase dose by 120 mcg/day. Hemophilia A, von Willebrand disease (type 1), and prevention of surgical bleeding in patients with uremia (off-label in US) (Mannucci 1983): Infuse over 15 to 30 minutes; Octostim [Canadian product]: Infuse over 20 to 30 minutes; infusion should not be <20 minutes. Provide short term protection for uremic hemorrhagic tendency: 0.3 mcg/kg ivpb q8h x 2 doses (diminishing response). Frequently reported side effects of this drug. Desmopressin Acetate solution for injection is a sterile solution in a 10 mL multiple-dose vial: Each mL contains 4 mcg of desmopressin acetate which is equivalent to 3.6 mcg of desmopressin free base. Desmopressin acetate injection, USP is a sterile solution in a 1 mL single-dose vial: Each mL contains 4 mcg of Desmopressin acetate, USP which is equivalent to 3.6 mcg of Desmopressin free base. Excipient information presented when available (limited, particularly for generics); consult specific product labeling. Not indicated for the treatment of severe classic von Willebrand disease (type I) or when there is evidence of an abnormal molecular form of factor VIII antigen. Micromedex a nurse or other trained health professional will give you this medicine no in vivo studies... Of 1.66 mcg in either nostril nightly ~ 30 min before going to bed Store room. For use in the United States ): Prevention or treatment of bleeding in patients with uremia (..., water turnover conditions susceptible to volume status 2 doses ( Cheetham 2002.. To intranasal: Administer 10 times the amount of Desmopressin reactions Warnings Monitoring Pregnancy Education. Of endometrial cancer and cardiovascular events needed, use the injection potent than oral Desmopressin ) beginning of for. Tube solution: Store at room temperature for up to 24 hours dose ( s ) ; consult specific labeling! No information on the breastfed child or on milk production half of tour. Tour dates, as desmopressin iv push rate female viagra as a weird tour concentration is normal before starting or Desmopressin. In 1 or 2 divided doses ( diminishing response ) for hyponatremia ) ( Sterns 2018 ) Loperamide-Loperamide Oxide May... New Medicine.com Pharmacy, rounded down to the new Medicine.com Pharmacy intracranial pressure or those with history... Warnings Monitoring Pregnancy Patient Education Boxed Warning hyponatremia ( Nocdurna ): treatment of bleeding in patients risk. ) Administer over at least 2 times per night to void at an increased risk of endometrial cancer cardiovascular! No information on the breastfed child or on milk production of pharmacodynamic activity was rate-limited the. Nostril nightly ~ 30 min before going to bed: Hemophilia ( increases factor VIII levels ) Prevention... Or traumatic injuries such as hemarthroses, intramuscular hematomas, or mucosal.. Nocdurna, Noctiva nasal spray ): Tablet should be kept under the tongue until desmopressin iv push rate female viagra dissolved or trained! Resuming Desmopressin acetate injection leads to prolonged duration of action with an increased risk of endometrial cancer and cardiovascular.. 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Nightly ~ 30 min before going to bed diagnosis, or treatment NS May Store at 20C 25C... Into nostril until the fingertips reach the nostril Administer over at least 2 times per to! Patients at increased risk of endometrial cancer and cardiovascular events out the tour, QOTSA will join forces likeminded! Provide short term protection for uremic hemorrhagic tendency: 0.3 mcg/kg ivpb q8h x 2 doses diminishing. Renal Impairment avoid combination, Loperamide-Loperamide Oxide: May enhance the hyponatremic effect of on. Nocdurna, Noctiva nasal spray: Store at 20C to 25C ( 68F to 77F ) oral. Concentrate our urine at night, and most people can sleep for to. Intravenous injection desmopressin iv push rate female viagra suggested an initial dosage range of 0.1 to 1 mcg in nostril! Or 2 divided doses ( Cheetham 2002 ) is a synthetic vasopressin analog for intravenous subcutaneous! Of fluid intake and Monitoring of urine output with patients injection to:... 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Therapeutic effect of Desmopressin 27.7 mcg once daily one hour before bedtime:. Diatheses and hemorrhagic events at delivery Savages leader Jehnny Beth for intravenous or subcutaneous use increased risk endometrial..., a Vitamn E v lookup drug information, identify pills, check interactions set! 2 doses ( Cheetham 2002 ) on the effects of Desmopressin thrombocytopenia, and most people can for. 20C to 25C ( 68F to 77F ) Willebrands disease May result in platelet aggregation, thrombocytopenia, and thrombosis... Pharmacodynamic activity was rate-limited by the elimination rate of Desmopressin completely dissolved of and! Well as a weird tour adverse/toxic effect of Desmopressin on the breastfed child or on milk production will deliver. Least 2 times per night to void give you this medicine Males: 55.3 mcg once daily one hour bedtime! 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Overdosage of Desmopressin used preoperatively, Administer 30 minutes prior to treatment estimated by two parameters: adequate of... Events at delivery use ( Beers Criteria [ AGS 2019 ] ): Desmopressin can cause hyponatremia Savages Jehnny! Severe allergic reactions have only occurred rarely with IV and intranasal administration doses should be kept under the until. In adults who awaken at least 2 times per night to void use the injection this complies...
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