Wirkung von Botulinumtoxin A in der ein- und mehrmaligen Behandlung der überaktiven Blase

[Short version of the S2k guideline on drug therapy of neurogenic lower urinary tract dysfunction (NLUTD)]

BACKGROUND

In Germany about one million patients suffer from neurogenic lower urinary tract dysfunction (NLUTD). If left untreated, various forms of NLUTD can lead to secondary damage of the lower and upper urinary tract. Thus, the guideline was developed for the drug therapy of patients with NLUTD, who frequently require lifelong care and aftercare.

METHODS

The guideline was developed in a consensus process with several meetings and online reviews, and final recommendations were decided on in online consensus meetings. Ballots were sent to elected officials of the contributing professional societies. Level of consensus was given for each coordinated recommendation ( https://www.awmf.org/leitlinien/detail/ll/043-053.html ). RESULTS/MOST IMPORTANT RECOMMENDATIONS: (Video)urodynamic classification of the NLUTD should be conducted before the use of antimuscarinic drugs (84.2%). Approved oral antimuscarinics should be used as first choice. Contraindications must be respected (100%). If oral treatment is ineffective or in the case of adverse drug reaction (ADRs) alternatively instillation of oxybutynin solution intravesically (83%) or onabotulinumneurotoxine (OBoNT) injection should be offered (89.5%). In case of failure or ADRs of antimuscarinics, β3 sympathomimetic mirabegron can be used to treat neurogenic detrusor overactivity (NDO) (off-label use) (100%). In case of paraplegia below C8 or multiple sclerosis with an expanded disability status scale (EDSS) of ≤ 6.5, OBoNT injection can be offered as an alternative (89.5%). Drug therapy for NDO should be started early in newborns/young children (84.2%). Conservative, nondrug therapy should be considered in frail elderly (94.7%). No parasympathomimetic therapy should be used to treat neurogenic detrusor underactivity (94.7%).

CONCLUSION

Precise knowledge of the neurological underlying disease/sequence of trauma and the exact classification of the NLUTD are required for development of individualized therapy.

Medium- to long-term outcomes of botulinum toxin A for idiopathic overactive bladder

Botulinum toxin A (BoNT-A) has become an important therapeutic tool in the management of refractory overactive bladder (OAB). Over the last decade, there have been growing numbers of patients receiving repeat injections and these outcomes have begun to be reported in large, high-quality cohorts. This article reviews the current evidence for the medium- to long-term use of BoNT-A in adults with idiopathic detrusor overactivity (IDO) receiving repeat injections. We find that medium-term outcomes are encouraging but long-term outcomes are not as extensively reported. There is high-quality evidence that efficacy following the first injection persists across multiple treatment cycles. There are no additional safety concerns from repeat injections up to six treatment cycles. However, there is a need for further data to confirm the efficacy and safety of BoNT-A beyond the follow-up period in the current literature.

Changes in prostaglandin E2 in patients with idiopathic overactive bladder syndrome after botulinum toxin type A treatment: is there a clinical benefit?

BACKGROUND

The causality of overactive bladder syndrome (OAB) is still not fully understood. Several studies indicate a significant increase of prostaglandin E2 (PGE2) in patients with OAB. However, in order to clarify whether these compounds can help to objectify the clinical diagnosis, further studies are needed. This prospective study aims to analyze PGE2 blood levels (sPGE2) in patients with OAB before and after botulinum toxin type A (BoNT-A) therapy.

METHODS

Blood samples were obtained from 56 patients (52y, 18-87) with idiopathic OAB. sPGE2 levels were measured before and 4 weeks after BoNT-A treatment by enzyme linked immunosorbent assay (ELISA). 31 healthy persons with normal bladder function served as control group (59 y, 21-72). sPGE2 was set in relation to clinical data and the severity of OAB (wet/dry). The statistical data analysis was performed by using the non-parametric Mann-Whitney U test and paired t-test.

RESULTS

Significant higher sPGE2 levels were detected in patients with OAB compared to members of the control group (2750 pg/ml vs. 1674 pg/ml, p < 0.005). Furthermore sPGE2 levels were increased in patients with OAB wet compared to OAB dry (p <0.01). In 30 patients sPGE2 levels decreased significantly after BoNT-A treatment compared to baseline (2995 pg/ml vs. 1486 pg/ml, p <0.005). Patients reported an average drug effect of 9 month (0-19); incontinence pads were needed significantly less frequent (p < 0.05). 3 patients reported no postoperative effect. sPGE2 increased in two patients compared to initial levels, a single patient showed a remotely decreased sPGE2. Six patients were treated repeatedly with BoNT-A after showing an sPGE2 re-rise.

CONCLUSIONS

sPGE2-level is increased in patients with OAB. We could prove a significant decrease of sPGE2 after BoNT-A treatment. In this small cohort we could demonstrate a correlation between OAB and sPGE2, especially in the non-responder group. The use of sPGE2 as a biomarker in diagnostics and follow-up after therapy seems promising. To what extent sPGE2 can be useful as such needs to be examined prospectively in a larger population.

[Is the validated ICIQ-SF suitable for evaluation of OAB patients? A data analysis of intravesicular botulinum toxin therapy]

BACKGROUND

The following data analysis studied the aspects of patient satisfaction following onabotulinum toxin A (BTX-A) treatment including modification of certain parameters, such as frequency of micturition and the use of pads and in particular, the applicability of the international consultation on incontinence questionnaire short form (ICIQ-SF) and the urgency perception scale (UPS) in patients with an overactive bladder (OAB).

PATIENTS AND METHOD

In this study 40 female patients were questioned in the form of validated questionnaires (extended ICIQ-SF and UPS) before and after being injected with 300 IU of BTX-A in each detrusor muscle. The average age of the patients was 66 years. All patients experienced anticholinergic refractory, non-neurogenic OAB.

RESULTS

The recommendation rate and related patient satisfaction was 82.5 %. A significant decrease in the frequency of micturition by 50.9 % (p < 0.01) was reported as well as a significant reduction in the use of pads by 66.7 % (p < 0.01). The average number of ICIQ-SF points could be significantly (p < 0.01) reduced via BTX-A from 15.9 to 7.3. Moreover, BTX-A demonstrated a significant improvement in the urgency to urinate, which was illustrated through the UPS.

CONCLUSION

Treatment with BTX-A achieves significant improvements in female patients with anticholinergic refractory OAB with regard to the individual symptoms of OAB (e.g. pollakisuria, nocturia, undesired urination and urgency). The use of the ICIQ-SF as the only questionnaire in OAB diagnostics proved to be unsuitable as it does not include female patients with dry OAB to an adequate degree. A combination of various validated questionnaires, such as ICIQ-SF and UPS, proved to be useful.

Antibodies after botulinum toxin A injection into musculus detrusor vesicae: incidence and clinical relevance

OBJECTIVES

Botulinum toxin A (BTX-A) injection into the detrusor muscle has changed therapy options for patients with overactive bladder (OAB). However, in some patients, therapy fails or the effects of BTX-A decrease. The aim of this prospective study was to evaluate the incidence of BTX-A antibodies (BTX-A Abs) after injection of BTX-A and its clinical relevance.

METHODS

31 patients (27 women, 4 men) were treated with BTX-A for OAB between January 2009 and August 2010. Eleven patients were treated once, 16 patients were treated twice and 4 patients were treated three times. Blood was collected before and 3 months after the BTX-A injection and BTX-A Abs were determined.

RESULTS

In 5 patients (16%) BTX-A Abs were detectable after the BTX-A injection. The BTX-A Ab titer was clearly positive in 1 patient (3.2%). This patient showed complete failure of BTX-A therapy. In 4 patients (13%) BTX-A Abs were slightly positive after the first BTX-A injection. The second BTX-A injection showed no positive effects in only 1 patient with borderline BTX-A Ab titers; the second BTX-A injection was successful in 2 patients.

CONCLUSIONS

The incidence of BTX-A Abs should be verified in nonresponders. More data are necessary to check the clinical relevance and risk of BTX-A Ab formation, especially in long-term follow-up, to optimize patient selection for this minimally invasive treatment option in OAB.

[Value of nerve growth factor levels in overactive bladder syndrome: alterations after botulinum toxin therapy]

OBJECTIVES

Several studies discussing the pathology of overactive bladder suggested changes in urinary proteins. The neurotrophin "nerve growth factor" (NGF) seems to be an important marker in overactive bladder syndrome (OAB). In this prospectively designed study we evaluated NGF blood levels (sNGF) initially and after injection of botulinum toxin type A (BTX-A) in the detrusor muscle in patients suffering from idiopathic OAB.

MATERIALS AND METHODS

Blood samples were obtained from 26 patients (66.5 years, 28-83) with idiopathic OAB. sNGF levels were measured before and 4 weeks after BTX-A treatment by enzyme-linked immunosorbent assay (ELISA). A group of 32 healthy persons with normal bladder function served as controls (41 years, 19-60). sNGF was evaluated in relation to clinical data and the severity of OAB (wet/dry).

RESULTS

Significantly higher sNGF levels were detected in patients with OAB compared to the control group (58.8 vs 2.0 pg/ml, p<0.005). Further, sNGF levels were elevated in patients with wet OAB compared to patients with dry OAB (85.0 vs 0.73 pg/ml, p<0.005). Patients > 60 years showed significantly higher sNGF levels (77.2 vs 8.9 pg/ml, p<0.05) compared to younger OAB patients. After BTX-A therapy sNGF levels decreased significantly compared to baseline (p<0.005).

CONCLUSION

NGF appears to play a decisive role in OAB. Its use as a biomarker in both the diagnostics and follow-up after therapy seems promising. To what extent sNGF can be useful as a biomarker or in therapy monitoring needs to be examined prospectively in a larger population.

[Therapy-refractory overactive bladder: alternative treatment approaches]

The treatment of patients with overactive bladder (OAB) refractory to conventional treatment is gaining clinical significance. This article intends to review alternative therapy options for patients with OAB refractory to conventional treatment. A search of the PubMed database as well as the abstracts presented at the European Association of Urology and the American Urological Association annual meetings was conducted. Keywords used during this search included overactive bladder (OAB) refractory to conventional treatment, electromotive drug administration (EMDA), sacral neuromodulation, augmentation cystoplasty and cystectomy. Eighteen articles with an adequate number of patients were identified. All articles published before 2001 were not included in this analysis. Because of first-line treatment failure, 30% of the patients required alternative treatment. This included EMDA, botulinum toxin injections into the detrusor, sacral neuromodulation, augmentation cystoplasty or cystectomy. Based on this review it appears that a significant improvement in micturition parameters, continence and in quality of life was achieved. Overall EMDA, intradetrusor injections of botulinum toxin and sacral neuromodulation seem to be highly effective and safe. Augmentation cystoplasty or cystectomy remains the last choice of treatment in refractory cases.Overall EMDA, intradetrusor injections of botulinum toxin and sacral neuromodulation seem to be highly effective and safe. Augmentation cystoplasty or cystectomy remains to be the last choice of treatment in refractory cases.