The use of desmopressin (DDAVP) for nocturia in women with multiple sclerosis

Nocturnal polyuria in the elderly person

Aging often disturbs the normal circadian rhythm of urine production. The nocturia commonly seen with aging may result from the loss of nighttime vasopressin production or release that develops by childhood. Restoring the nocturnal increase in vasopressin can have a dramatic clinical response: improved quality of life and less risk of nighttime falls in carefully selected and accurately diagnosed patients.

Nocturnal polyuria and antidiuretic hormone levels in spinal cord injury

OBJECTIVE

To establish baseline ADH levels in spinal cord injury patients and to evaluate whether spinal cord patients have attenuation of diurnal variation of ADH similar to children with enuresis and elderly with nocturnal polyuria.

DESIGN

Twenty-seven healthy quadriplegic patients, ASIA impairment scale A, were evaluated for serum ADH levels at night and during the day.

MAIN OUTCOME MEASURES

Evaluation of whether bladder overdistention caused by attenuation of diurnal variation of ADH is responsible for the episodes of autonomic dysreflexia and recurrent urinary tract infections in spinal cord injury patients who are on intermittent catheterization for bladder management.

RESULTS

A lack of diurnal variation of ADH in the subject population.

CONCLUSIONS

A trial of desaminocystein-D-arginine vasopressin (DDAVP) should be considered for patients with established attenuation of the diurnal variation ADH.

Nasal spray desmopressin treatment of bladder dysfunction in patients with multiple sclerosis

Bladder dysfunction with increased voiding frequency and incontinence is a common problem in patients with multiple sclerosis (MS). In the present study, the effect of the synthetic vasopressin analogue, desmopressin, was evaluated on the voiding frequency in 26 patients with MS suffering from socially handicapping voidings and incontinence problems during daytime. A two-week run-in observation period to establish normal voiding patterns was followed by a double-blind, placebo-controlled cross-over study with 20 micrograms intranasal desmopressin during daily activities. There was a significant decrease in the number of voidings during the 6-h period after intranasal intake of desmopressin. Side effects were well tolerated and there was no hyponatremia or hypertension registered. Intranasal desmopressin is an efficient and well-tolerated treatment of voiding problems in patients with MS during daily activities.

Primary nocturnal enuresis and desmopressin treatment: do psychosocial factors affect outcome?

Twenty-three patients (5 to 15 years of age) with primary nocturnal enuresis were treated with desmopressin (DDAVP) according to a four-step protocol with weekly reductions of daily doses (1 to 0.25 microgram/kg body weight) thus including aspects of behavior-oriented "bladder retention training". The rate of wet nights was significantly reduced while patients were on medication (p < 0.02), but the sample as a whole returned to baseline levels after medication was stopped. Six subjects (26%) were non-responders. A variety of psychological and psychosocial single factors did not significantly affect the outcome. However, a subgroup of seven patients assessed as "psychologically non-distressed" revealed better results both on medication (p < 0.02; reduction 73%) and off medication (p > or = 0.05; reduction 39%) compared to a "distressed" subgroup (N = 16). Both groups showed significant changes in wet nights over the treatment course (p < 0.02 and p > or = 0.002, respectively). There was no clear-cut relationship between laboratory data (urine volume, osmolality, vasopressin) and outcome in wet nights. Data did not suggest a subgroup of patients with particularly low nocturnal vasopressin (AVP) secretion and, thus, high rates of wet nights. Our results corroborated the finding that DDAVP is an effective substance in reducing wet nights in patients with primary nocturnal enuresis. However, with respect to major reductions and long-term results (off medication), these preliminary findings suggest that "psychological distress" seems to be a very important confounding outcome variable. Thus, careful consideration and assessment of psychological and psychosocial aspects of distress are recommended. Eventually, a combination of DDAVP treatment with counseling and/or psychotherapy may significantly improve results for the majority of patients and families.

Treatment with desmopressin in nocturia and nocturnal enuresis following traumatic brain injury

A trial of intranasal desmopressin was conducted in a patient with nocturia and nocturnal enuresis following a severe traumatic brain injury. Desmo pressin proved to be a safe and effective treatment. The frequency of nocturia and disturbed nights was significantly reduced (p <0.05) without any change in the frequency of micturition during waking hours. No side-effects were encountered.

An open, in-patient incremental safety and efficacy study of desmopressin in women with multiple sclerosis and nocturia

OBJECTIVES

To examine the safety and efficacy of desmopressin in three doses given to women with multiple sclerosis to treat nocturia with or without enuresis.

PATIENTS AND METHODS

Eight women with clinically confirmed multiple sclerosis and nocturia with or without enuresis were entered as in-patients into an open, nonrandomized, placebo-controlled study of incremental doses of 20, 40 and 60 micrograms desmopressin. Urinary and serum sodium, plasma arginine vasopressin and urine osmolality were monitored every 4 h for 24 h. A single dose of placebo or desmopressin was given during each of four 24-h periods.

RESULTS

There was a significant decrease in nocturnal urinary volumes and a significant increase in nocturnal urinary osmolalities in patients taking desmopressin when compared with those taking a placebo, but there was no difference among the desmopressin doses. There was no significant difference in serum sodium level between the desmopressin doses. However, at the end of the 24-h period with the 60 micrograms dose, serum sodium was decreased significantly.

CONCLUSIONS

Neither a significant decrease in nocturnal urinary volumes nor an increase in urinary osmolality was achieved by doses of desmopressin > 20 micrograms. A dose of 60 g was associated with a decreased serum sodium level at the end of the 24-h period but there was no biochemical hyponatraemia. Because there were no benefits and a possibility of clinical hyponatraemia with higher doses, doses of > 20 micrograms desmopressin cannot be recommended.

The nocturnal polyuria syndrome (NPS)

1. The nocturnal polyuria syndrome (NPS) is characterized by an increased nocturnal urine output. The diurnal rhythm in the antidiuretic hormone (ADH) system is absent, and often there is no detectable ADH in the plasma at all during the night. The 24-hr urine output is normal or only moderately increased. Men without nocturnal micturition, normally have a substantial increase in their nocturnal plasma ADH, while those with a need to micturate during the night have the same ADH level at night as in the daytime. Women have lower ADH levels than men, and no nocturnal increase in ADH irrespective of nocturnal voiding. Subjects with an increased nocturnal voiding frequency due to increased nocturnal urine output have an increased thirst, most markedly at night. They often avoid drinking in the evening, but they are unable to resist the impulse to drink during the night. People with polyuria at night wake up often because of the need to void, and accordingly are often tired during the day. 2. An increased nocturnal urine output can be reduced by administration of desmopressin at night. In a short-term study of elderly sufferers from NPS, treated with 20 micrograms desmopressin as nose drops in the evening the nocturnal urine output was reduced from 65 +/- 8% of the 24-hr urine output before treatment to 50 +/- 15% during treatment. In another study elderly with NPS were treated with 40 micrograms desmopressin as an intranasal aerosol in the evening.(ABSTRACT TRUNCATED AT 250 WORDS)

Desmopressin in the treatment of nocturia and enuresis in patients with multiple sclerosis

OBJECTIVES

To assess whether the synthetic vasopressin analogue desmopressin [1-desamino 8-D-arginine vasopressin] is efficacious and safe in the management of nocturia +/- enuresis in patients with multiple sclerosis.

PATIENTS AND METHODS

Twenty-two women and 11 men, under 65 years of age, with clinically definite multiple sclerosis and nocturnal frequency +/- enuresis were entered into the study. A two week placebo run-in, to establish normal voiding patterns, followed by a double-blind, placebo-controlled, cross-over study of 20 micrograms intranasal desmopressin at night-time was carried out.

RESULTS

Desmopressin caused a significant decrease in nocturnal urinary frequency, nocturnal urinary volume and the percentage of total daily urine passed at night. There was no significant fall in plasma sodium with desmopressin although there were two cases of asymptomatic hyponatraemia.

CONCLUSION

Desmopressin is an efficacious and safe treatment for nocturia +/- enuresis in patients with multiple sclerosis.

DDAVP in the urological management of the difficult neurogenic bladder in spinal cord injury: preliminary report

The purpose of this study is to determine the efficacy of desmopressin (DDAVP), a synthetic analogue of antidiuretic hormone, as an alternative therapy in the management of spinal cord injured (SCI) patients with neurogenic bladder dysfunction unresponsive to conventional therapy. Seven SCI patients (three men and four women) were treated with DDAVP after urodynamic evaluation. Despite treatment with anticholinergic agents, urodynamic evaluation demonstrated uninhibited detrusor contractions exceeding 30 cm H2O pressure at less than 300 ml cystometric capacity in all seven patients. Three patients had been managed with intermittent self-catheterization, but had socially unacceptable short intervals between catheterizations. Two women with incomplete injury were afflicted with significant nocturia (> 3 episodes/night). The remaining two patients managed with intermittent self-catheterization were troubled with nocturnal enuresis. The patients received 10 micrograms intranasal DDAVP once every 24 hours. Prior to DDAVP administration, the four patients who used DDAVP nightly experienced a median of four episodes of nocturia. After one month of DDAVP treatment, two patients had only one episode of nocturia per night and in the other two patients, nocturnal enuresis was completely eliminated. Three patients used daytime DDAVP administration at work to avoid frequent catheterization. The median period between bladder catheterizations increased from 2.5 hours before DDAVP to 6 hours while using DDAVP. Symptomatic improvement persisted during the follow-up period of 6-20 months (mean = 12). Side effects were infrequent; only one patient complained of transient headaches. Neither hyponatremia nor serum electrolyte abnormalities occurred. Our preliminary results suggest that DDAVP is safe and effective in the symptomatic management of complicated neurogenic bladder dysfunction in selected SCI patients.

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Urodynamics has profoundly changed our understanding of the physiopathology of urinary incontinence which is, first and foremost, a functional problem. The urodynamic study is the only diagnostic tool which makes it possible to explore the functioning of the urethra and bladder. As such, it constitutes the cornerstone of our therapeutic strategy.

Desmopressin: a new principle for symptomatic treatment of urgency and incontinence in patients with multiple sclerosis

Thirteen patients with advanced multiple sclerosis and urge urinary incontinence were treated with desmopressin--a synthetic analogue of antidiuretic hormone--in a double-blind cross-over study. The micturition frequency decreased significantly (p less than 0.05). Less leakage was considered valuable for daily life. Peroral medication was favourable in these patients with muscular dysfunction. Side-effects were few.

Current concepts in the treatment of disorders of micturition

Disorders of micturition may be divided into disturbances of the storage function of the bladder, and disturbances of the emptying function. The main symptoms of disturbances of storage function are frequency, urgency and incontinence. Hyperactivity of the bladder may lead to urge incontinence, and incompetence of the urethral closure mechanism to stress incontinence. There are many drugs available for treating bladder hyperactivity, but their efficacy as judged from controlled clinical trials (when available) is often limited. Bladder contraction in man is mediated by stimulation of muscarinic receptors, and when given parenterally anticholinergic drugs have been shown to depress bladder hyperactivity irrespective of the underlying cause. Clinically, however, treatment of urge incontinence with anticholinergic drugs is often unsatisfactory. Lack of effect of oral treatment and systemic side effects limit the use of available agents. Drugs with "mixed" actions (anticholinergic and 'direct' muscle effects), for example oxybutynin and terodiline, have well-documented efficacy in bladder hyperactivity. Side effects are common with oxybutynin; terodiline seems to be well tolerated. The aim of drug treatment of stress incontinence is to increase outflow resistance. Although there is only limited possibility of improving the condition with drugs, beneficial effects can be obtained in some patients by use of orally active alpha-adrenoceptor agonists (e.g. phenylpropanolamine) and/or oestrogens. The main symptom of disturbed bladder emptying is urinary retention. Drug therapy is aimed at improving the contractile activity of the detrusor or reducing urethral outflow resistance. Drugs used for improving bladder contractility include parasympathomimetic agents, e.g. bethanechol or carbachol, and intravesical instillation of prostaglandins. Although the efficacy of both types of treatment is open to question, bethanechol seems to be widely used. Increased outflow resistance may be seen in patients with parasympathetic decentralization of the lower urinary tract or in patients with benign prostatic hypertrophy. These patients may respond favourably to alpha-adrenoceptor blockers such as phenoxybenzamine or prazosin.