Desmopressin melt improves response and compliance compared with tablet in treatment of primary monosymptomatic nocturnal enuresis

Desmopressin as a hemostatic and blood sparing agent in bleeding disorders

Intranasal, subcutaneous, or intravenous desmopressin can be utilized to release von Willebrand Factor and Factor VIII into circulation, enhance platelet adhesion and shorten bleeding time. Due to these properties, desmopressin can be effective in controlling bleeding in mild hemophilia A, certain subtypes of von Willebrand disease and in acute bleeding from uremia, end stage renal disease, and liver disease. Its use, however, can be complicated by hyponatremia and rarely arterial thrombotic events. While desmopressin has also been used as a prophylactic blood sparing agent in orthopedic, renal, and hepatic procedures, clinical studies have shown limited benefit in these settings. The purpose of this article is to review the evidence for desmopressin in primary hematologic disorders, discuss its mechanism of action and evaluate its utility as a hemostatic and blood sparing product in various bleeding conditions.

Primary enuresis in adults: pathogenesis, clinical course and modern approaches to treatment: A review

The review article presents current data on the epidemiology, classification, pathogenesis, risk factors, diagnosis, and features of the clinical course of primary enuresis in adults. The main methods of treatment of patients with primary enuresis are described in detail. It has been shown that in the treatment of this category of patients, the leading role is given to the use of a synthetic analogue of the antidiuretic hormone desmopressin. A detailed analysis of the pharmacological properties and clinical use of desmopressin in patients with primary enuresis is presented. The advantages of prescribing a sublingual form of desmopressin, which ensures its high efficiency and good tolerability of therapy.

Vasopressin and Its Analogues: From Natural Hormones to Multitasking Peptides

Human neurohormone vasopressin (AVP) is synthesized in overlapping regions in the hypothalamus. It is mainly known for its vasoconstricting abilities, and it is responsible for the regulation of plasma osmolality by maintaining fluid homeostasis. Over years, many attempts have been made to modify this hormone and find AVP analogues with different pharmacological profiles that could overcome its limitations. Non-peptide AVP analogues with low molecular weight presented good affinity to AVP receptors. Natural peptide counterparts, found in animals, are successfully applied as therapeutics; for instance, lypressin used in treatment of diabetes insipidus. Synthetic peptide analogues compensate for the shortcomings of AVP. Desmopressin is more resistant to proteolysis and presents mainly antidiuretic effects, while terlipressin is a long-acting AVP analogue and a drug recommended in the treatment of varicose bleeding in patients with liver cirrhosis. Recently published results on diverse applications of AVP analogues in medicinal practice, including potential lypressin, terlipressin and ornipressin in the treatment of SARS-CoV-2, are discussed.

Desmopressin therapy in children and adults: pharmacological considerations and clinical implications

PURPOSE

This review aims to provide prescribing clinicians a deeper appreciation of desmopressin's clinical indications and formulation types, to better balance efficacy and safety through proper formulation selection.

BACKGROUND

Since its discovery 50 years ago, desmopressin's antidiuretic properties have been used for central diabetes insipidus, primary monosymptomatic nocturnal enuresis and adult nocturnal polyuria, while its coagulant effects are useful for mild hemophilia A and von Willebrand Disease. During this time, newer formulations of desmopressin have also been introduced to the market raising questions on interchangeability, dose conversion and safety. The wide array of clinical indications and variable pharmacokinetic properties of different desmopressin preparations raises the possibility of medication error, especially the risk of hyponatraemia.

METHODOLOGY

A narrative review to explore clinically relevant aspects of desmopressin therapy, synthesising information obtained from searches of published literature.

RESULTS

We identified that the risk factors for developing hyponatremia include extremes of age, existing comorbidity, drug interaction, intranasal formulations and intercurrent illness. We describe the dose equivalence between all formulations to facilitate conversion. We highlight that in view of inter-subject variability, close monitoring is recommended when switching preparations. We found that paediatric data remains limited, leading to recent proposals for age- and weight-based dosing regimens.

CONCLUSION

The risk of hyponatremia, albeit small, can be reduced by adhering to the indication-specific doses and taking steps to govern the safe prescription of the drug. Further paediatric clinical trials are awaited to expand the evidence base of childhood desmopressin therapy.

An Integrated Paediatric Population PK/PD Analysis of dDAVP: How do PK Differences Translate to Clinical Outcomes?

INTRODUCTION

The bioequivalence of two formulations of desmopressin (dDAVP), a vasopressin analogue prescribed for nocturnal enuresis treatment in children, has been previously confirmed in adults but not in children. In this study, we aimed to study the pharmacokinetics (PK) and pharmacodynamics (PD) of these two formulations, in both fasted and fed children, including patients younger than 6 years of age.

METHODS

Previously published data from one PK study and one PK/PD study in children aged between 6 and 16 years were combined with a new PK/PD study in children aged between 6 months and 8 years, and analysed using population PK/PD modelling. Simulations were performed to further explore the relative bioavailability of both formulations and evaluate current dosing strategies.

RESULTS

The complex absorption behaviour of the lyophilizate was modelled using a double input, linked to a one-compartmental model with linear elimination and an indirect response model linking dDAVP concentration to produced urine volume and osmolality. The final model described the observed data well and elucidated the complexity of bioequivalence and therapeutic equivalence of the two formulations. Simulations showed that current dosing regimens using a fixed dose of lyophilizate 120 μg is not adequate for children, assuming children to be in the fed state when taking dDAVP. A new age- and weight-based dosing regimen was suggested and was shown to lead to improved, better tailored effects.

CONCLUSIONS

Bioequivalence and therapeutic equivalence data of two formulations of the same drug in adults cannot be readily extrapolated to children. This study shows the importance of well-designed paediatric clinical trials and how they can be analysed using mixed-effects modelling to make clinically relevant inferences. A follow-up clinical trial testing the proposed dDAVP dosing regimen should be performed.

CLINICAL TRIAL REGISTRATION

This trial has been registered at www.clinicaltrials.gov (identifier NCT02584231; EudraCT 2014-005200-13).

Does desmopressin withdrawal strategy affect relapse rates in monosymptomatic enuresis treatment?

Desmopressin plays a major role in the treatment of monosymptomatic enuresis but has the drawback of a high relapse rate after medical treatment. This study investigated the effect of the type of treatment termination on relapse in a large population of patients. A total of 1013 patients who were admitted with bedwetting to our paediatric urology clinic between October 2016 and April 2018 were evaluated retrospectively. Four hundred forty-seven monosymptomatic enuresis patients were treated with 120 μg/day oral desmopressin lyophilisate for 3 months, after which the treatment was terminated in one of two ways: immediate cessation of desmopressin (group 1; N = 209) and structured withdrawal (group 2; N = 238). In the structured withdrawal group, the patients continued to take desmopressin every other day for 15 days. All the patients were followed up 1 month after the drug was withdrawn, and the relapse rates were recorded. One month after cessation of treatment with oral desmopressin lyophilisate, the relapse rate in group 1 was 42.5% (89/209), and that in group 2 was 41.1% (98/238) (p > 0.05).Conclusion: This study, with the highest number of patients among reports in the literature, revealed that the methods used to terminate desmopressin treatment are not significantly different in monosymptomatic enuresis management. What is Known: • It is still unclear how to end the treatment in patients who are started desmopressin because of the complaint of monosymptomatic nocturnal enuresis. • Although there are papers in the literature suggesting that the drug should be discontinued gradually or by reducing the dose, there are also authors stating the opposite. What is New: • This study including vast amount of patients managed with desmopressin reveals that withdrawal strategy has no impact on relapse.

Vasopressin-Dependent Disorders: What Is New in Children?

Arginine vasopressin (AVP)-mediated osmoregulatory disorders, such as diabetes insipidus (DI) and syndrome of inappropriate secretion of antidiuretic hormone (SIADH) are common in the differential diagnosis for children with hypo- and hypernatremia and require timely recognition and treatment. DI is caused by a failure to concentrate urine secondary to impaired production of or response to AVP, resulting in hypernatremia. Newer methods of diagnosing DI include measuring copeptin levels; copeptin is AVP's chaperone protein and serves as a surrogate biomarker of AVP secretion. Intraoperative copeptin levels may also help predict the risk for developing DI after neurosurgical procedures. Copeptin levels hold diagnostic promise in other pediatric conditions, too. Recently, expanded genotype and phenotype correlations in inherited DI disorders have been described and may better predict the clinical course in affected children and infants. Similarly, newer formulations of synthetic AVP may improve pediatric DI treatment. In contrast to DI, SIADH, characterized by inappropriate AVP secretion, commonly leads to severe hyponatremia. Contemporary methods aid clinicians in distinguishing SIADH from other hyponatremic conditions, particularly cerebral salt wasting. Further research on the efficacy of therapies for pediatric SIADH is needed, although some adult treatments hold promise for pediatrics. Lastly, expansion of home point-of-care sodium testing may transform management of SIADH and DI in children. In this article, we review recent developments in the understanding of pathophysiology, diagnostic workup, and treatment of better outcomes and quality of life for children with these challenging disorders.

Comparison of the efficacy of desmopressin fast-melting formulation and enuretic alarm in the treatment of monosymptomatic nocturnal enuresis

BACKGROUND

Primary monosymptomatic nocturnal enuresis (MNE) is a common pediatric condition and there are two firstline, evidence-based treatments available; desmopressin and the enuresis alarm. Although there are many studies comparing enuresis alarm and desmopressin treatments in the literature, most were conducted using old formulations of desmopressin.

OBJECTIVE

To compare the efficacy of desmopressin MELT formulation and enuresis alarm therapy in patients with MNE.

STUDY DESIGN

A total of 130 patients who had primary MNE were included in the study. The patients were divided into two groups using simple randomization; desmopressin MELT (Group 1, n = 66) and enuresis alarm (Group 2, n = 64). The patients were invited for a follow-up visit at the fourth, 12th and 24th weeks of treatment. Treatment response and compliance were evaluated using bed-wetting diary and ICSS criteria.

RESULTS

The mean age of the patients Group 1 and 2 was 11.2 + 3.3 and 10.2 + 3.4 years, respectively (p = 0.104). Complete response rate was similar at 4th week (53% vs. 37.3%, p = 0.162) and at 12th week (68.4% vs. 68.2%, p = 0.257). The relapse rate was significantly higher in the desmopressin MELT group than in the enuresis alarm group (48.9% vs 20.5%, p = 0.007). At the end of the study ten patients were excluded from the study because of loss to follow-up and/or side effects. The overall complete response rate was significantly higher in the enuresis alarm group than in the desmopressin MELT group at the end of the study (41.3% vs 64.9%, p = 0.035). When the intention to treat analysis population was considered, similarly the complete response rate was significantly higher in the enuresis alarm group than in the desmopressin MELT group (40.9% vs 64.1%, p = 0.027).

DISCUSSION

With regard to the management of children with MNE, our study revealed that desmopressin MELT and enuresis alarm both have high efficacy rates in primary MNE treatment both at 4th and 12th week. However, overall complete response rate was better in enuresis alarm treatment at 24th week. In addition, enuresis alarm treatment also presents as a more favorable relapse rate.

CONCLUSIONS

Enuresis alarm presented a more permanent treatment response and a lower relapse rate than desmopressin MELT formulation.

[Pharmaceutical Properties of Anti-inflammatory Analgesic Patches Using Acrylic Polymer]

The mock patches were prepared with novel acrylic polymers as adhesive layer where biphenyl-4-ylacetic acid (BAA) or 2-(2-fluorobiphenyl-4-yl) propanoic acid (FPA) was used as model active pharmaceutical ingredients (APIs). In addition, the mock patches were formulated with typical ester ingredients for transdermal dosage forms. The molecular state of the model APIs in the adhesive layer was observed by polarized microscope and microscopic Raman spectroscopy, which contains both conventional and low frequency (LF) region. Crystallization behavior would be depended on the interaction between API and polymers in the adhesive layer. In particular, LF Raman measurement was useful to discriminate API polymorphs. The pharmaceutical properties including dissolution and skin permeation of APIs were also evaluated for mock patches. The drug release and transdermal permeation were enhanced with the ester ingredients such as isopropyl myristate and diethyl sebacate due to their diffusion to the test solution or the skin stratum corneum as well as reducing the interaction between API and polymers. Further, the tack strength was not changed, but the peel strength was weakened by the additives. Thus, the adhesive properties were controllable by formulation with the additives. These findings could enable to evaluate the interaction between API and the polymers for adhesive layer and select the appropriate polymer and additives for used APIs when designing the drug products.

Pediatric Pharmacology of Desmopressin in Children with Enuresis: A Comprehensive Review

Desmopressin is a synthetic analogue of the natural antidiuretic hormone arginine vasopressin. Over the years, it has been clinically used to manage nocturnal polyuria in children with enuresis. Various pharmaceutical formulations of desmopressin have been commercialized for this indication-nasal spray, nasal drops, oral tablet and oral lyophilizate. Despite the fact that desmopressin is a frequently prescribed drug in children, its use and posology is based on limited pediatric data. This review provides an overview of the current pediatric pharmacological data related to the different desmopressin formulations, including their pharmacokinetics, pharmacodynamics and adverse events. Regarding the pharmacokinetics, a profound food effect on the oral bioavailability was demonstrated as well as different plasma concentration-time profiles (double absorption peak) of the desmopressin lyophilizate between adults and children. Literature about maturational differences in distribution, metabolism and excretion of desmopressin is rather limited. Regarding the pharmacodynamics, formulation/dose/food effect and predictors of response were evaluated. The lyophilizate is the preferred formulation, but the claimed bioequivalence in adults (200 µg tablet and 120 µg lyophilizate), could not be readily extrapolated to children. Prescribing the standard flat-dose regimen to the entire pediatric population might be insufficient to attain response to desmopressin treatment, whereby dosing schemes based on age and weight were proposed. Moreover, response to desmopressin is variable, whereby complete-, partial- and non-responders are reported. Different reasons were enumerated that might explain the difference in response rate to desmopressin observed: different pathophysiological mechanisms, bladder capacity and other predictive factors (i.e. breast feeding, familial history, compliance, sex, etc.). Also, the relapse rate of desmopressin treatment was high, rendering it necessary to use a pragmatic approach for the treatment of enuresis, whereby careful consideration of the position of desmopressin within this treatment is required. Regarding the safety of the different desmopressin formulations, the use of desmopressin was generally considered safe, but additional measures should be taken to prevent severe hyponatremia. To conclude the review, to date, major knowledge gaps in pediatric pharmacological aspects of the different desmopressin formulations still remain. Additional information should be collected about the clinical relevance of the double absorption peak, the food effect, the bioequivalence/therapeutic equivalence, the pediatric adapted dosing regimens, the study endpoints and the difference between performing studies at daytime or at nighttime. To fill in these gaps, additional well designed pharmacokinetic and pharmacodynamic studies in children should be performed.

Pharmacologic therapies for the management of non-neurogenic urinary incontinence in children

Introduction: Non-neurogenic urinary incontinence in children is a common condition that affects the quality of life for both patients and parents. Symptoms may occur in the daytime, nighttime, or both and may be the result of structural and functional anomalies. Evaluation and management of associated co-morbidities, such as constipation is critical to management. Behavioral therapy is a fist line therapy in most cases of non-neurogenic urinary incontinence and pharmacologic therapy a second-line therapy.Areas covered: In this review, the authors cover the pharmacologic agents, FDA approved and commonly used non-FDA approved, available for the treatment of four non-structural etiologies of non-neurogenic urinary incontinence in children. These include nocturnal enuresis, overactive bladder, giggle incontinence, and dysfunctional voiding.Expert opinion: Non-neurogenic causes of urinary incontinence in children represent a complicated medical condition that requires both pharmacologic and non-pharmacologic management. Limited FDA-approved therapies as well as suboptimal results with approved therapies due to a lack in the understanding of the underlying pathophysiology and patient selection may lead to the use of alternative non-FDA approved therapies.

Constipation in nocturnal enuresis may interfere desmopressin management success

BACKGROUND

Previous studies indicated that the prevalence of constipation in enuretic patients is higher than that in the general population. Several studies have revealed that successful treatment of constipation may be helpful in resolving enuresis. However, constipation affecting the efficacy of desmopressin in treating enuresis remains to be clarified.

OBJECTIVE

This study aimed to determine whether the presence of constipation is associated with the efficacy of desmopressin in treating enuresis.

STUDY DESIGN

Patients diagnosed with nocturnal enuresis (NE) were studied prospectively. Treatment responses in different stratified groups of patients with NE were compared by Chi-squared tests or Wilcoxon rank sum test. A logistic regression model was performed to investigate the relationship between the possible factors and the effectiveness of desmopressin.

RESULTS

In children with severe enuresis, patients with constipation had significantly lower complete response rate compared with patients without constipation. The presence of constipation was always related to the effectiveness of desmopressin whether in monosymptomatic NE or non-monosymptomatic patients with NE. With stratification for dose of desmopressin, non-constipated patients who received 0.2 mg of desmopressin had significantly higher complete response rate than patients with constipation. However, in subgroups of mild to moderate NE and 0.4 mg desmopressin, constipation was not associated with treatment response of enuresis. Logistic regression analysis revealed that constipation was significantly related to the effectiveness of desmopressin.

DISCUSSION

This study confirmed the negative effects of constipation in response to desmopressin in patients with NE. To the best of authors knowledge, this work is the first study to evaluate the relationship of constipation in enuretic patients and the efficacy of desmopressin.

CONCLUSIONS

The presence of constipation negatively affects the response to desmopressin in patients with NE, especially in patients with severe enuresis and in patients prescribed with low dose of desmopressin.

The adverse effects of oral desmopressin lyophilisate (MELT): personal experience on enuretic children

Objective

The aim of this study was to evaluate adverse effects of oral desmopressin lyophilisate (MELT) in enuretic children.

Material and methods

We enrolled 260 children with nocturnal enuresis (NE) referred to the Pediatric Service, 'Campus Bio-Medico' University of Rome, from April 2014 to April 2017 in the study, of these 23 were excluded. The study was characterized by 2 phases. During Phase 1 a careful patient's medical history was obtained and physical examination was performed. After 3 months of treatment with MELT (Minirin/DDAVP^®) at the dose of 120 mcg a day, a micturition diary was kept, adherence to therapy and any possible adverse effects were checked during the Phase 2. The study was carried out in compliance with the Helsinki Declaration.

Results

Among 237 patients included in the study 11 male and 6 female (n=17; 7.2%) patients with a mean age 10.06±2.49 years, reported 22 adverse effects, with an absolute risk of 7.17%. In particular, 5 neurological symptoms, 3 gastrointestinal effects, 4 sleep disturbances, 8 psycho-behavioral disorders, 2 symptoms of fatigue were reported.

Conclusion

In our study MELT with its higher bioavailability guaranteed lower frequency of adverse effects which resolved spontaneously and rapidly. The MELT formulation actually represents the first line and safe treatment for the NE.

Nocturnal Enuresis in India: Are We Diagnosing and Managing Correctly?

Nocturnal enuresis is a common problem affecting school-aged children worldwide. Although it has significant impact on child's psychology, it is always under-recognized in India and considered as a condition which will outgrow with advancing age. Nocturnal enuresis classified as primary or secondary and monosymptomatic or nonmonosymptomatic. Factors that cause enuresis include genetic factors, bladder dysfunction, psychological factors, and inappropriate antidiuretic hormone secretion, leading to nocturnal polyuria. Diagnosis consists of detailed medical history, clinical examination, frequency-volume charts, and appropriate investigations. The frequency-volume chart or voiding diary helps in establishing diagnosis and tailoring therapy. The first step in treating nocturnal enuresis is to counsel the parents and the affected child about the condition and reassure them that it can be cured. One of the effective strategies to manage enuresis is alarm therapy, but currently, it is not easily available in India. Desmopressin has been used in the treatment of nocturnal enuresis for close to 50 years. It provides an effective and safe option for the management of nocturnal enuresis. This review covers the diagnosis and management of nocturnal enuresis and introduces the concept of “bedwetting clinics” in India, which should help clinicians in the thorough investigation of bedwetting cases.

Optimizing response to desmopressin in patients with monosymptomatic nocturnal enuresis

Most patients with monosymptomatic nocturnal enuresis can be effectively treated with an enuresis alarm or antidiuretic therapy (desmopressin), depending on the pathophysiology of the condition in the individual patient. Desmopressin is first-line therapy for enuresis caused by nocturnal polyuria, an excessive urine output during the night. However, in a recent study, around one-third of patients thought to be resistant to desmopressin were subsequently treated effectively with desmopressin monotherapy in a specialist centre. The aim of this article is to review best practice in selecting patients for desmopressin treatment, as well as outline eight recommendations for maximizing the chances of treatment success in patients receiving desmopressin. The roles of formulation, dose, timing of administration, food and fluid intake, inter-individual variation in response, body weight, adherence, withdrawal strategies and combination therapies are discussed in light of the most recent research on desmopressin and enuresis. Possible reasons for suboptimal treatment response are explored and strategies to improve outcomes in patients for whom desmopressin is an appropriate therapy are presented. Through optimization of the treatment plan in primary and specialist care centres, the hope is that fewer patients with this distressing and often embarrassing condition will experience unnecessary delays in receiving appropriate care and achieving improvements.

Application of water-insoluble polymers to orally disintegrating tablets treated by high-pressure carbon dioxide gas

The phase transition of pharmaceutical excipients that can be induced by humidifying or heating is well-known to increase the hardness of orally disintegrating tablets (ODTs). However, these conditions are not applicable to drug substances that are chemically unstable against such stressors. Here, we describe a system which enhances the hardness of tablets containing water-insoluble polymers by using high-pressure carbon dioxide (CO2). On screening of 26 polymeric excipients, aminoalkyl methacrylate copolymer E (AMCE) markedly increased tablet hardness (+155N) when maintained in a high-pressure CO2 environment. ODTs containing 10% AMCE were prepared and treatment with 4.0MPa CO2 gas at 25°C for 10min increased the hardness to +30N, whose level corresponded to heating at 70°C for 720min. In addition, we confirmed the effects of CO2 pressure, temperature, treatment time, and AMCE content on the physical properties of ODTs. Optimal pressure of CO2 gas was considered to be approximately 3.5MPa for an AMCE formula, as excessive pressure delayed the disintegration of ODTs. Combination of high-pressure CO2 gas and AMCE is a prospective approach for increasing the tablet hardness for ODTs, and can be conducted without additional heat or moisture stress using a simple apparatus.

Advances in the management of primary monosymptomatic nocturnal enuresis in children

Intermittent incontinence of urine in a sleeping child who has previously been dry for less than 6 months without any other lower urinary tract symptoms is considered to be primary monosymptomatic nocturnal enuresis (PMNE). Although, most children outgrow PMNE with age, the psychological impact on the child warrants parental education and patient motivation and treatment. Motivational therapy, alarm therapy and drug therapy are the mainstay of treatment. Motivational and alarm therapy have better success rates than drug therapy alone. Desmopressin is the commonly used first-line drug and is best for short-term relief. Other drugs such as anti-cholinergics, imipramine and sertraline are used in resistant cases. This review focuses on the assessment and treatment of PMNE.

Advances in the management of enuresis

There are still many undiscovered facts about enuresis, even though it is a very old "symptom". It is a significant health problem with a high prevalence among children and a lower prevalence in adulthood. Many treatment guidelines have been proposed for the management of this problem. The improvement of diagnostic tools, and also treatment modalities, have had a significant impact on success rates; however, the long-term success rates need to be higher, especially in resistant cases. In this report, we summarize the advances made in the diagnosis and treatment of enuresis.

National Surveillance of Central Diabetes Insipidus (CDI) in Denmark: results from 5 years registration of 9309 prescriptions of desmopressin to 1285 CDI patients

CONTEXT

Epidemiological data for central diabetes insipidus (CDI) are sparse.

OBJECTIVE

The purpose of this study was to provide accurate epidemiological data on CDI on a national level.

DESIGN AND SETTING

This was a drug utilization and patient registry study during a 5-year period from 2007 to 2011.

METHODS

We used the Danish National Prescription Registry data linked with the Danish National Patient Registry to study the epidemiology of CDI using waiting time distribution and other pharmacoepidemiological methods.

PATIENTS

A total of 1285 patients with CDI were recorded in the observation period and given 9309 prescriptions for desmopressin in the nasal formulation, orodispersible tablet, or conventional tablet.

RESULTS

The period prevalence rate of CDI in Denmark over the 5-year period investigated was 23 CDI patients per 100 000 inhabitants, with a higher prevalence in children and older adults (>80 years of age). The 1-year period prevalence rate of CDI decreased in Denmark over the 5 years from approximately 10 to 7 CDI patients per 100 000 inhabitants. The yearly incidence rate of new cases of CDI was found to be 3 to 4 patients per 100 000. The incidence of (presumable) congenital CDI was found to be 2 infants per 100 000 infants. Half of the patients with CDI prescribed as oral treatment were provided dosing instructions to only administer the drug before bedtime, and one third of the CDI patients either had no specific instructions or were instructed to use the drug as needed. Hospital admissions due to severe hyponatremia occurred in 0.9% of patients over a 5-year period, predominantly in females with an incidence ratio of women to men of 1.8:1.

CONCLUSION

Half of the cases of CDI are acquired later in life. At least half of the patients with CDI are instructed to prevent nocturnal polyuria, but it is not clear whether their CDI remains uncontrolled during the daytime or, alternatively, whether they use desmopressin only as needed. Female patients with CDI had approximately twice the number of hospital admissions due to severe hyponatremia than male patients with CDI.