Reducing nocturia in the elderly: a randomized placebo-controlled trial of staggered furosemide and desmopressin

Transition in enuresis patients: Identifying the gaps and opportunities for the future

BACKGROUND

Nocturnal enuresis is generally considered a children's condition, yet it may persist 1%-2% in adolescence and early adulthood. Refractory patients often demand follow-up by multidisciplinary teams, which is only restricted to some of the expert tertiary centers. However, there are no standardized transition programs/guidelines when follow-up must be passed from pediatric to adult healthcare providers.

AIM, MATERIALS & METHODS

To investigate this issue, we conducted a literature search on enuresis transition, which resulted in no articles. We, therefore, proceeded in a rescue search strategy: we explored papers on transition programs of conditions that may be related and/or complicated by enuresis, nocturia, or other urinary symptoms (chronic diseases, CKD, bladder dysfunction, kidney transplant, neurogenic bladder).

RESULTS

These programs emphasize the need for a multidisciplinary approach, a transition coordinator, and the importance of patient and parent participation, practices that could be adopted in enuresis. The lack of continuity in enuresis follow-up was highlighted when we investigated who was conducting research and publishing on enuresis and nocturia. Pediatric disciplines (50%) are mostly involved in children's studies, and urologists in the adult ones (37%).

DISCUSSION

We propose a stepwise approach for the transition of children with enuresis from pediatric to adult care, depending on the clinical subtype: from refractory patients who demand more complex, multidisciplinary care and would benefit from a transition coordinator up to children/young adults cured of enuresis but who persist in having or present lower urinary tract symptoms (LUTS)/nocturia later on. In any case, the transition process should be initiated early at the age of 12-14 years, with adequate information to the patient and parents regarding relapses or LUTS/nocturia occurrence and of the future treating general practitioner on the enuresis characteristics and comorbidities of the patient.

Pharmacotherapeutic options in the treatment of nocturia: update on current oral drug therapies

INTRODUCTION

Nocturia is a common urinary complaint among patients presenting with lower urinary tract symptoms and in recent years, there is a greater emphasis to tailor the treatment for nocturia in a more holistic and multidisciplinary manner given the potential multifactorial causes for nocturia.

AREAS COVERED

Current oral drug therapies can be classified into three main groups, namely, decreasing polyuria, targeting bladder capacity, and improving sleep-wake and circadian rhythm. The authors focus this article on these oral therapies and provide their expert opinion.

EXPERT OPINION

Treatment strategies should always involve lifestyle changes and behavioral modifications, with the targeted treatment of underlying medical conditions that may cause nocturia. Desmopressin remains the only drug approved specifically for the treatment of nocturia. Medications targeting the bladder and prostate can have secondary benefits in minimizing nocturnal frequency and urgency especially if the drug is taken at nighttime. Treatment of an underlying sleep disorder or circadian disorder can often help to increase total sleep time and quality, and perhaps reducing the nocturnal diuresis and nocturia episodes. Future studies in nocturia should improve the identification and diagnosis of underlying mechanisms that lead to nocturia, so treatment can become more streamlined, while at the same time, explore the role of various pharmacotherapeutic agents and novel therapy to reduce or eliminate nocturia.

Pharmacologic management of nocturnal polyuria: a contemporary assessment of efficacy, safety, and progress toward individualized treatment

This narrative review synthesizes current evidence on the medical management of nocturnal polyuria, including antidiuretic replacement therapy as well as other emerging modalities, with particular emphasis on areas of active investigation and future research directions. Relative to earlier formulations, the pharmacological profiles of novel desmopressin acetate nasal spray and orally disintegrating tablet formulations appear favorable in optimizing the balance between efficacy and safety. Additionally, several highly selective small-molecule arginine vasopressin 2 receptor agonists are under active development, while appropriately timed short-acting diuretics, pharmacotherapy for hypertension, nonsteroidal anti-inflammatory drugs, and sex hormone replacement therapy are also a focal point of extensive ongoing nocturnal polyuria research. Emerging laboratory technologies now make feasible a sub-stratification of nocturnal polyuria patients into substrate-based phenotypes for individualized treatment. An increasingly refined understanding of the pathogenesis of nocturnal polyuria, and arginine vasopressin dysregulation in particular, has also introduced new opportunities for point-of-care testing in patients with nocturnal polyuria.

Managing Nocturia in Frail Older Adults

This review discusses the available evidence in the current evaluation and treatment of nocturia in frail older adults. No evidence specifically evaluates the use of behavioral interventions in the treatment of the frail older adult with nocturia, but their use is supported in other cohorts. Behavioral modifications and optimal management of comorbidities remain the first-line treatment for all age groups and should be emphasized in the frail due to their favorable safety profile. No studies specific to the frail older adult support the use of pharmacotherapy. Some evidence exists for the efficacy of several agents in the older adult; however, this is difficult to extrapolate to the frail, and safety concerns abound. Desmopressin may be effective in the older adult, but a high risk of hyponatremia raises concerns for its safety, and therefore it is not recommended in the frail. α-Antagonists may have limited efficacy in men with known benign prostatic hyperplasia (BPH); they are relatively well tolerated, although the risk of orthostatic hypotension in the frail should be considered. β3-agonist trials suggest limited clinical utility. Antimuscarinics are not found to be useful in this cohort and are contraindicated in the frail older adult given the ability of antimuscarinics to cause cognitive impairment, delirium, and falls. No data examine the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the frail older adult. Additionally, the American Geriatrics Society Beers Criteria recommends against the use of muscarinics in those over the age of 75 years and therefore their use is not supported.

How can we develop a more clinically useful and robust algorithm for diagnosing and treating nocturia? ICI-RS 2017

AIMS

Nocturia, or waking up at night to void, is a highly prevalent and bothersome symptom. Currently, there is a lack of clear and consistent recommendations regarding evaluation and management of nocturia. The aim of this report is to discuss how to fill the gaps in our knowledge in order to develop a practical patient-oriented diagnostic and therapeutic algorithm for nocturia.

METHODS

This paper is a report of the presentations and subsequent discussion of a Think Tank session at the annual International Consultation on Incontinence Research Society (ICI-RS) in June 2017 in Bristol.

RESULTS AND CONCLUSION

Further investigations are needed to better understand the pathophysiology of nocturia, to allow improvement in diagnosis, and to optimize treatment by increasing efficacy and reducing adverse events. Patient-oriented practical guidelines on nocturia are needed to help clinicians from different disciplines diagnose and treat nocturia.

[Impact of medical and surgical treatments of LUTS on nocturia]

INTRODUCTION

Nocturia is the most frequently reported lower urinary tract symptom, but the impact of medical and surgical treatments on this symptom remains poorly evaluated. The objective of this work was to carry out a systematic review of the literature on the medical and surgical management of nocturia in men with bladder outlet obstruction due to benign prostatic hyperplasia.

MATERIAL AND METHOD

A systematic review of the literature was conducted including the effects of medical and surgical treatments on nocturia. Articles were selected by 3 independent reviewers before being analyzed and synthesized.

RESULTS

Among medical treatments, the most effective on nocturia seems to be desmopressin. Nevertheless, prescribing restrictions to men under 65 years of age hinder its use in routine practice. The effect of other medical treatments remains modest, although significant compared to placebo groups. The decrease in the number of nocturia would decrease from 0.25 to 0.7 in placebo group and from 0.29 to 1.1 in active treatment groups (alpha blocker, diuretic, anti-inflammatory, IPDE-5, 5 alpha reductase inhibitor). Surgical treatments seem to be more effective on nocturia. Although persistent in half of the patients undergoing surgery, the number of nocturia episodes decreased in 70% of them.

CONCLUSION

Nocturia is one of the most common urinary symptoms and the one that responds the least to the proposed medical and surgical treatments. The information given to patients by urologists must emphasize the modest effects to be expected in this area.

Desmopressin for treating nocturia in men

OBJECTIVES

To assess the effects of desmopressin as compared to other interventions in the treatment of nocturia in men.

MATERIALS AND METHODS

We performed a comprehensive search using multiple databases and abstract proceedings with no restrictions on the language of publication or publication status, up until August 2017. We included randomised or quasi-randomised trials. Inclusion criteria were men with nocturia defined as one or more voids per night. Two review authors independently examined full-text reports, identified relevant studies, assessed the eligibility of studies for inclusion, extracted data, and assessed risk of bias. We performed statistical analyses using a random-effects model and assessed the quality of the evidence (QoE) according to Grades of Recommendation, Assessment, Development and Evaluation (GRADE).

RESULTS

We included 14 studies with 2 966 randomised men across five comparisons (we did not include one comparison [desmopressin vs behaviour modification] in the abstract due to a lack of data with regard to primary outcomes). Desmopressin vs placebo: based on short-term follow-up (≤3 months), desmopressin may have a similar effect on the number of nocturnal voids (mean difference [MD] -0.46, 95% confidence interval [CI] -0.94 to 0.01; low QoE). We are uncertain about the effect of desmopressin on major adverse events (risk ratio [RR] 0.97, 95% CI: 0.10-9.03; very low QoE). For intermediate-term follow-up (3-12 months), desmopressin may reduce the number of nocturnal voids in an appreciable number of men (MD -0.85, 95% CI: -1.17 to -0.53; low QoE). Desmopressin may result in little or no difference in major adverse events (RR 3.05, 95% CI: 0.13-73.39; low QoE). We found no evidence on quality of life. Desmopressin vs α-blocker (AB): based on short-term follow-up, desmopressin likely has a similar effect on the number of nocturnal voids (MD 0.30, 95% CI: -0.20 to 0.80; moderate QoE) and quality of life (MD 0.00, 95% CI: -0.35 to 0.35; moderate QoE). There were no major adverse events in either study group. Desmopressin plus AB vs AB alone: based on short-term follow-up, combined therapy likely results in a small, unimportant reduction in the number of nocturnal voids (MD -0.47, 95% CI: -0.73 to -0.21; moderate QoE) and quality of life (MD -0.29, 95% CI: -0.51 to -0.07; moderate QoE). The risk of major adverse events may be similar (RR 0.30, 95% CI: 0.01-7.32; low QoE). Desmopressin plus AB vs AB plus an anticholinergic: based on short-term follow-up, combined therapy likely results in little or no difference in the number of nocturnal voids (MD -0.43, 95% CI: -0.97 to 0.11; moderate QoE). We found no evidence on quality of life. There were no major adverse events in either study group.

CONCLUSIONS

Desmopressin may reduce the number of nocturnal voids compared to placebo up to 12 months of follow-up without increase in major adverse events. The effect on the number of nocturnal voids is likely similar to that of ABs with very infrequent major adverse events. There appears to be no added benefit in the combined use of an AB or an anticholinergic with desmopressin.

Pharmacotherapy for Nocturia

Purpose of Review

To assess current pharmacological principles used for treatment of nocturia/nocturnal polyuria.

Recent Findings

The pathophysiology of nocturia is often multifactorial, but two main mechanisms have been identified, occurring alone or in combination: low functional bladder capacity and nocturnal polyuria. The multifactorial pathophysiology not only implies several possible targets for therapeutic intervention but also means that it is unlikely that one treatment modality including drugs will be successful in all patients. Drugs approved for the treatment of male LUTS and male and female OAB are known to be far more effective for treatment of the daytime symptoms than for nocturia.

Summary

Several pharmacological principles have been tested with varying success. The treatment of choice should depend upon the main underlying cause, thus aiming primarily to increase bladder capacity by counteracting detrusor overactivity and/or reducing nocturnal polyuria. Using current available agents, effective, personalized treatment should be designed taking into account gender, co-morbidities, and identified etiological factors. However, there is a medical need for new, approved drugs for treatments for patients with nocturia.

Desmopressin for treating nocturia in men

BACKGROUND

Nocturia is the bothersome symptom of awakening one or more times per night to void. Desmopressin is a commonly used medication for treating nocturia.

OBJECTIVES

To assess the effects of desmopressin as compared to other interventions in the treatment of nocturia in men.

SEARCH METHODS

We performed a comprehensive search of medical literature with no restrictions on the language of publication or publication status. The date of the latest search of all databases was August 2017.

SELECTION CRITERIA

We included randomized or quasi-randomized trials. Inclusion criteria were men with nocturia defined as one or more voids per night. Trials of children, adults with primary or secondary enuresis or underlying distinct disorders were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently classified studies and abstracted data from the included studies. We performed statistical analyses using a random-effects model and interpreted data according to the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We included 14 studies with 2966 randomized men across five comparisons. Desmopressin versus placebo: based on short-term follow-up (up to three months), desmopressin may have a similar effect on the number of nocturnal voids (mean difference (MD) -0.46, 95% confidence interval (CI) -0.94 to 0.01; low-quality evidence). We are uncertain about the effect of desmopressin on major adverse events at short-term follow-up (risk ratio (RR) 0.97, 95% CI 0.10 to 9.03; very low-quality evidence). For intermediate-term follow-up (three to 12 months), desmopressin may reduce the number of nocturnal voids in an appreciable number of participants (MD -0.85, 95% CI -1.17 to -0.53; low-quality evidence). Desmopressin may result in little or no difference in major adverse events at intermediate-term follow-up (RR 3.05, 95% CI 0.13 to 73.39; low-quality evidence). We found no evidence on quality of life. Subgroup analyses suggest a larger effect with oral, higher-dose formulations of desmopressin and in men with documented nocturnal polyuria. Desmopressin versus behavior modification: there were no data regarding the effect on the number of nocturnal voids, quality of life, or major adverse events. Desmopressin versus alpha-blocker: based on short-term follow-up, desmopressin likely has a similar effect on the number of nocturnal voids (MD 0.30, 95% CI -0.20 to 0.80; moderate-quality evidence) and quality of life (MD 0.00, 95% CI -0.35 to 0.35; moderate-quality evidence). There were no major adverse events in either study group. Desmopressin plus alpha-blocker versus alpha-blocker alone: based on short-term follow-up, combination therapy likely results in a small, unimportant reduction in the number of nocturnal voids (MD -0.47, 95% CI -0.73 to -0.21; moderate-quality evidence) and quality of life (MD -0.29, 95% CI -0.51 to -0.07; moderate-quality evidence). The risk of major adverse events may be similar (RR 0.30, 95% CI 0.01 to 7.32; low-quality evidence). Desmopressin plus alpha-blocker versus alpha-blocker plus an anticholinergic: based on short-term follow-up, combination therapy likely results in little or no difference in the number of nocturnal voids (MD -0.43, 95% CI -0.97 to 0.11; moderate-quality evidence). We found no evidence on quality of life. There were no major adverse events in either study group.

AUTHORS' CONCLUSIONS

Desmopressin may reduce the number of nocturnal voids in an appreciable number of participants compared to placebo in intermediate-term (three to 12 months) follow-up without increase in major adverse events. We found no evidence to compare its effects to behavior modification. The effect on the number of nocturnal voids is likely similar to that of alpha-blockers short-term with very infrequent major adverse events. There appears to be no added benefit in the combined use of desmopressin with an alpha-blocker or an anticholinergic. The findings of this review were limited by short-term follow-up, study limitations, and imprecision.

A systematic review of the efficacy and safety of desmopressin for nocturia in adults

PURPOSE

We systematically reviewed desmopressin as treatment for nocturia in generally healthy adults with a focus on benefits and harms.

MATERIALS AND METHODS

After a literature search we identified 10 articles (2,191 patients) that met our inclusion criteria of parallel group design, randomized, controlled trials with information on at least 1 benefit or harm of desmopressin in patients with nocturia. We evaluated the quality of included trials based on The Cochrane Collaboration criteria, assessed heterogeneity using the I(2) statistic and performed random effects meta-analysis.

RESULTS

Studies were generally of high quality, although 4 used an active run-in period to titrate the dose and exclude patients with adverse effects or who were nonresponders. Thus, they were at high risk for bias. Desmopressin doses of at least 25 mcg or greater decreased nocturnal voids and increased time to first void. A dose of 100 mcg provided just more than an hour of additional sleep before the first void compared with placebo as well as 0.72 fewer voids per night. Higher doses provided no significant increase in benefit. Hyponatremia (RR 5.1) and headache (RR 4.3) were the most common adverse effects. Serious adverse effects were rare.

CONCLUSIONS

Desmopressin appears to offer a modest benefit for treating nocturia in generally healthy adults with adequate safety. The initial dose should be between 50 and 100 mcg. Higher doses should only be used with caution and a lower initial dose of 25 to 50 mcg is appropriate in elderly patients. All patients should be monitored for hyponatremia. The drug should be used with caution in patients with chronic lung disease due to the rare occurrence of respiratory failure. Additional well designed, adequately powered studies 1 or more years in duration are needed.

Safety and efficacy of desmopressin for the treatment of nocturia in elderly patients: a cohort study

PURPOSE

Desmopressin is used widely to treat nocturnal polyuria (NP), but there is concern of hyponatremia especially in elderly patients. This study aimed to evaluate the safety and efficacy of long-term desmopressin treatment in elderly patients with NP.

METHODS

Patients who were ≥65 years old with NP were analyzed. All patients were started on 0.1 mg desmopressin, and the dose was escalated to 0.2 mg depending on patient symptoms. All patients were educated the mechanism of desmopressin. The voiding diary and serum sodium levels were evaluated at baseline, 3-7 days after starting treatment and every 3-6 months. Safety was evaluated by hyponatremia, hyponatremic symptoms and other adverse drug events. The mean changes in number of nocturia and nocturnal urine volume (NUV) were evaluated for efficacy.

RESULTS

A total of 68 patients were included. The mean age was 72.6 (66-85) years. The mean night-time frequency was 3.0 ± 1.8 day, and the mean serum sodium level was 141.2 ± 2.1 mEq/L at baseline. The mean follow-up period was 27.9 months. The mean decrease in serum sodium level was 1.3 ± 3.4 mEq/L at the last follow-up (p = 0.003). Hyponatremia incidence was 4.4 %, and all patients recovered by stopping medication. Severe adverse events were not observed. The mean night-time frequency had decreased by 2.1, and the NUV had decreased by 374.2 ± 261.3 mL at the last follow-up (p < 0.001).

CONCLUSIONS

Desmopressin at doses below 0.2 mg is safe and effective in elderly patients with NP if patients are well informed and are closely followed up.

Efficacy and safety of desmopressin for treatment of nocturia: a systematic review and meta-analysis of double-blinded trials

PURPOSE

The purpose of this analysis was to evaluate the efficacy and safety of desmopressin for the treatment of nocturia.

METHODS

Databases including MEDLINE, EMBASE, ISI web of knowledge, the Cochrane Controlled Trial Register of Controlled Trials and Chinese Biological Medical Database were searched to identify randomized controlled trials (RCTs) that referred to the efficacy and safety of desmopressin for the treatment of nocturia. A systematic review and meta-analysis were conducted.

RESULTS

Five studies involving 619 participants were included for the meta-analysis, and 8 RCTs of cross-over design were also identified for the systematic review. The analysis revealed that desmopressin might significantly decrease the frequency of nocturnal voids, nocturnal urine volume and nocturnal diuresis, potentially resulting in an extended duration of the first sleep period and improved sleep quality. The adverse effects of desmopressin were similar to those observed in the placebo group.

CONCLUSIONS

Administered desmopressin was an effective and well-tolerated treatment for nocturia.