Pharmacological management of interstitial cystitis /bladder pain syndrome and the role cyclosporine and other immunomodulating drugs play

Current updates relating to treatment for interstitial cystitis/bladder pain syndrome: systematic review and network meta-analysis

BACKGROUND

Despite the publication of several meta-analyses regarding the efficacy of certain therapies in helping individuals with interstitial cystitis (IC) / bladder pain syndrome (BPS), these have not provided a comprehensive review of therapeutic strategies. The study aimed to determine the efficacy of various therapies for IC/BPS and identify potential moderating factors using randomized controlled trials (RCTs).

METHODS

We queried the PubMed, Cochrane, and Embase databases to identify prospective RCTs using inclusion criteria: 1) patients diagnosed with IC, 2) interventions included relevant treatments, 3) comparisons were a specified control or placebo, 4) outcomes were mean differences for individual symptoms and structured questionnaires. The pairwise meta-analysis and network meta-analysis (NMA) were performed to compare the treatments used in IC/BPS. Hedges' g standardized mean differences (SMDs) were used for improvement in all outcomes using random-effects models. Efficacy outcomes included individual symptoms such as pain, frequency, urgency, and nocturia, as well as structured questionnaires measuring IC/BPS symptoms.

RESULTS

A comprehensive literature search was conducted which identified 70 RCTs with 3,651 patients. The analysis revealed that certain treatments, such as instillation and intravesical injection, showed statistically significant improvements in pain and urgency compared to control or placebo groups in traditional pairwise meta-analysis. However, no specific treatment demonstrated significant improvement in all outcomes measured in the NMA. The results of moderator analyses to explore influential variables indicated that increasing age was associated with increased nocturia, while longer follow-up periods were associated with decreased frequency.

CONCLUSION

This systematic review and meta-analysis provide insights into the efficacy of various treatments for IC. Current research suggests that a combination of therapies may have a positive clinical outcome for patients with IC, despite the fact that treatment for this condition is not straightforward.

TRIAL REGISTRATION

PROSPERO CRD42022384024.

Effectiveness of intravesical ozone in interstitial cystitis by the O'Leary-Sant symptom index

Introduction and hypothesis

A prospective clinical, preliminary study was performed in patients with interstitial cystitis/bladder pain syndrome (IC/BPS) who were nonresponders to conventional treatment and received intravesical ozone as a therapeutic alternative.

Methods

Sixteen patients received six applications of intravesical ozone at a concentration of 41 μg/mL. We evaluated therapeutic efficacy by the percentage reduction of Interstitial Cystitis Symptom and Problem Index scores (ICSI/ICPI—the O'Leary–Sant symptom index), recurrence rate, nonresponse, and side effects in scores collected on admission (pre-treatment), at the end of the therapeutic protocol (post-treatment), and 180 days (follow-up) after the last ozone application.

Results

The mean age of women was 52.9 years (SD: 15.5), and the duration of symptoms was 5.7 years (SD: 7.1). The median ICSI on admission was 17 (IQR: 14.25–19.5) and at follow-up was 0.5 (IQR: 0–2), with a reduction of 97.5% (CI: 85.7–100). The median ICSI/ICPI on admission was 31.5 (IQR: 29–35.2) and at follow-up was 2.0 (IQR: 0–3.75), with a reduction of 92.3% (CI: 88.8–100). The recurrence rate was only 6.25%, and no patients were nonresponders to the treatment.

Conclusions

The application of intravesical ozone was effective in the treatment of patients with IC/BPS who were nonresponders to conventional therapy, showing a progressive and safe effect, at least in the short term.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00192-022-05383-3.

Efficacy and safety comparison of pharmacotherapies for interstitial cystitis and bladder pain syndrome: a systematic review and Bayesian network meta-analysis

INTRODUCTION AND HYPOTHESIS

The objective was to compare the clinical efficacy and safety of pharmacological interventions for interstitial cystitis and bladder pain syndrome (IC/BPS) with direct and indirect evidence from randomized trials.

METHODS

We searched PubMed, the Cochrane library, and EMBASE for randomized controlled trials (RCTs) that assessed the pharmacological therapies for IC/BPS. Primary efficacy outcomes included ICSI (O'Leary Sant Interstitial Cystitis Symptom Index), ICPI (O'Leary Sant Interstitial Cystitis Problem Index), 24-h micturition frequency, visual analog scale (VAS), and Likert score for pain. Safety outcomes are total adverse events (AEs, intravesical instillation, and others), gastrointestinal symptoms, headache, pain, and urinary symptoms. A systematic review and Bayesian network meta-analysis were performed.

RESULTS

A total of 23 RCTs with 1,871 participants were identified. The ICSI was significantly reduced in the amitriptyline group (MD = -4.9, 95% CI: -9.0 to -0.76), the cyclosporine A group (MD = -7.9, 95% CI: -13.0 to -3.0) and the certolizumab pegol group (MD = -3.6, 95% CI:-6.5 to -0.63) compared with placebo group. Moreover, for ICPI, cyclosporine A showed superior benefit compared to placebo (MD = -7.6, 95% CI: -13 to -2.3). VAS score improved significantly in cyclosporine A group than pentosan polysulfate sodium (MD = 3.09, 95% CI: 0.13 to 6.07). None of the agents revealed a significant alleviation of 24-h micturition frequency. In terms of safety outcomes, the incidence rate on urinary symptoms for botulinum toxin A was the only variate higher than chondroitin sulfate (MD = -2.02, 95% CI: -4.99 to 0.66) and placebo (MD = -1.60, 95% CI:-3.83 to 0.17). No significant difference was found among the other treatments.

CONCLUSIONS

Cyclosporine A might be superior to other pharmacological treatments in efficacy. Amitriptyline and certolizumab pegol were capable of lowering the ICSI as well.

Metabolic syndrome in women with and without interstitial cystitis/bladder pain syndrome

INTRODUCTION AND HYPOTHESIS

The aim of this study was to compare the frequency of metabolic syndrome (MetS) in patients with and without interstitial cystitis/bladder pain syndrome (IC/BPS).

METHODS

This case-control study evaluated the indicators of MetS in 287 females with IC/BPS and in 287 females without IC/BPS in West China Hospital between January 2010 and January 2020. Then, the number of voids per day, frequency of night urination, O'Leary-Sant Interstitial Cystitis Symptom/Problem Index, and visual analog scale were examined in the two groups.

RESULTS

Based on both the National Cholesterol Education Program Adult Treatment Panel III recommendations and the International Diabetes Federation criteria, the distribution of MetS was statistically higher in patients with IC/BPS than in the control group, with 34.8% vs 17.8% (P < 0.0001) and 34.2% vs 20.9% (P = 0.0005), respectively. Regarding symptom scores, the IC/BPS group demonstrated significantly higher scores than the control group in all aspects (P < 0.0001). More patients with anxiety (P < 0.0001), insomnia (P < 0.0001), hypertension (P = 0.0001), and diabetes mellitus (P = 0.017) were observed in the IC/BPS group. Moreover, the findings indicated that patients with IC/BPS had a higher BMI (P = 0.0001) and larger waist circumference (P = 0.0001). Blood tests presented a significantly higher level of fasting glycemia, serum cystatin-C, and triglycerides in patients with IC/BPS. Furthermore, higher ORs for the occurrence of MetS among cases were observed, although this was not statistically significant.

CONCLUSIONS

MetS frequency was relatively high in patients with IC/BPS. Further research is needed to understand the common pathophysiologic mechanism of IC/BPS and MetS.

Biomaterial-assisted drug delivery for interstitial cystitis/bladder pain syndrome treatment

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic and painful bladder condition afflicting patients with increased urinary urgency and frequency as well as incontinence. Owing to the elusive pathogenesis of IC/BPS, obtaining effective therapeutic outcomes remains challenging. Current administrational routes such as intravesical-bladder injection improve the treatment efficacy and reduce systemic side effects. However, the bladder permeability barrier hinders drug penetration into the bladder wall to meet the desired therapeutic expectation. These issues can be addressed by encapsulating drugs into biomaterials. When appropriately exploited, they would increase the drug dwelling time in the bladder, enhance the penetration of mucosa and improve the therapeutic response of IC/BPS. In this review, we first elucidate the pathogenesis and animal models of IC/BPS. Then, we highlight recent representative biomaterial-assisted drug delivery systems for IC/BPS treatment. Finally, we discuss the challenges and outlook for further developing biomaterial-based delivery systems for IC/BPS management.

Application of Adult and Pluripotent Stem Cells in Interstitial Cystitis/Bladder Pain Syndrome Therapy: Methods and Perspectives

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a multifactorial, chronic disease without definite etiology characterized by bladder-related pelvic pain. IC/BPS is associated with pain that negatively affects the quality of life. There are various therapeutic approaches against IC/BPS. However, no efficient therapeutic agent against IC/BPS has been discovered yet. Urothelium dysfunction is one of the key factors of IC/BPS-related pathogenicity. Stem cells, including adult stem cells (ASCs) and pluripotent stem cells (PSCs), such as embryonic stem cells (ESCs) and induced PSCs (iPSCs), possess the abilities of self-renewal, proliferation, and differentiation into various cell types, including urothelial and other bladder cells. Therefore, stem cells are considered robust candidates for bladder regeneration. This review provides a brief overview of the etiology, pathophysiology, diagnosis, and treatment of IC/BPS as well as a summary of ASCs and PSCs. The potential of ASCs and PSCs in bladder regeneration via differentiation into bladder cells or direct transplantation into the bladder and the possible applications in IC/BPS therapy are described in detail. A better understanding of current studies on stem cells and bladder regeneration will allow further improvement in the approaches of stem cell applications for highly efficient IC/BPS therapy.

Transplant immunosuppressive drugs in urology

Immunosuppressive drugs are used in renal transplantation to prevent and treat rejection and their use has traditionally been limited to urologists trained in transplant surgery. However, there are other urologic conditions for which these drugs have proven efficacy. Since transplant surgery has become a small niche subspecialty within urology, most urologists are unfamiliar and uncomfortable with their use. This review will focus on the use of Cyclosporine (CyA), mycophenolate mofetil (MMF), and mammalian target of rapamycin (mTOR) inhibitors in urology outside of solid organ transplant. This includes the treatment of interstitial cystitis/bladder pain syndrome (IC/BPS) with CyA as well as the role of CyA in eosinophilic cystitis (EC) and the treatment of retroperitoneal fibrosis (RF) with MMF. Also included is the utilization of mTOR inhibitors in both advanced renal cell carcinoma (RCC) and in patients with tuberous sclerosis complex (TSC) associated angiomyolipoma (AML). Available clinical data on mTOR inhibition in autosomal dominant polycystic kidney disease (ADPKD) is also briefly presented. Specific attention is given to the indications for each agent, the available evidence surrounding their use, and the most common adverse events (AEs) and their subsequent management.

Modulatory effects of intravesical P2X2/3 purinergic receptor inhibition on lower urinary tract electromyographic properties and voiding function of female rats with moderate or severe spinal cord injury

OBJECTIVES

To evaluate the role that intravesical P2X2/3 purinergic receptors (P2X2/3Rs) play in early and advanced neurogenic lower urinary tract (LUT) dysfunction after contusion spinal cord injury (SCI) in female rats.

MATERIALS AND METHODS

Female Sprague-Dawley rats received a thoracic Th8/Th9 spinal cord contusion with either force of 100 kDy (cN); moderate) or 150 kDy (cN; severe); Sham rats had no injury. Evaluations on urethane-anesthetised rats were conducted at either 2 or 4 weeks after SCI. LUT electrical signals and changes in bladder pressure were simultaneously recorded using cystometry and a set of custom-made flexible microelectrodes, before and after intravesical application of the P2X2/3R antagonist AF-353 (10 μM), to determine the contribution of P2X2/3R-mediated LUT modulation.

RESULTS

Severe SCI significantly increased bladder contraction frequency, and reduced both bladder pressure amplitude and intraluminal-pressure high-frequency oscillations (IPHFO). Intravesical P2X2/3R inhibition did not modify bladder pressure or IPHFO in the Sham and moderate-SCI rats, although did increase the intercontractile interval (ICI). At 2 weeks after SCI, the Sham and moderate-SCI rats had significant LUT electromyographic activity during voiding, with a noticeable reduction in LUT electrical signals seen at 4 weeks after SCI. Intravesical inhibition of P2X2/3R increased the ICI in the Sham and moderate-SCI rats at both time-points, but had no effect on rats with severe SCI. The external urethral sphincter (EUS) showed strong and P2X2/3R-independent electrical signals in the Sham and moderate-SCI rats in the early SCI stage. At 4 weeks after SCI, the responsiveness of the EUS was significantly attenuated, independently of SCI intensity.

CONCLUSIONS

This study shows that electrophysiological properties of the LUT are progressively impaired depending on SCI intensity and that intravesical P2X2/3R inhibition can attenuate electrical activity in the neurogenic LUT at early, but not at semi-chronic SCI. This translational study should be useful for planning clinical evaluations.

Bridging pharmacotherapy and minimally invasive surgery in interstitial cystitis/bladder pain syndrome treatment

INTRODUCTION

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a painful and debilitating clinical entity which is challenging to diagnose and even more difficult to treat. Unfortunately, none of the existing oral and intravesical medications have been established as effective and therefore relevant research is ongoing. Areas covered: In this review, the authors present established and emerging treatment options for IC/BPS in terms of medication and minimal invasive procedures. Both American and European Urological Association Guidelines recommend multimodal behavioral techniques alongside oral (e.g. amitriptyline and pentosan polysulfate sodium) or minimally invasive treatments (e.g. dimethyl sulfoxide, botulinum toxin, chondroitin sulfate, triamcinolone, hyaluronic acid, and lidocaine). Novel treatment modalities include immunomodulating drugs, stem cell therapy, nerve growth factor, and ASP6294. Expert opinion: IC/BPS is still a pathophysiological enigma with multifactorial etiopathogenesis that may be controlled but not completely cured. Patient-tailored phenotype-directed multimodal therapy is the most promising treatment strategy. Combined phenotypic categorization with specific biomarkers could help toward better treatment.