DDAVP for adult enuresis--a preliminary report

Failure of fixed-dose verapamil treatment in adult sleep-related enuresis

Calcium channel blockers increase the capacity of the urinary bladder. The antienuretic activity of verapamil was examined in young adult enuretics. Eleven drug-free, healthy, sleep-related enuretic males, were treated for two weeks with verapamil (240 mg, per os, at 9 pm). Verapamil failed to display an antienuretic effect.

Desmopressin for nocturnal enuresis in children

BACKGROUND

Enuresis (bedwetting) is a socially disruptive and stressful condition which affects around 15-20% of five year olds, and up to 2% of young adults. Although there is a high rate of spontaneous remission, the social, emotional and psychological costs to the children can be great.

OBJECTIVES

To assess the effects of desmopressin on nocturnal enuresis in children, and to compare desmopressin with other interventions.

SEARCH STRATEGY

The following electronic databases were searched: MEDLINE to June 1997; AMED; ASSIA; BIDS; BIOSIS Previews (1985-1996); CINAHL; DHSS Data; EMBASE (1974 to June 1997); PsycLIT and SIGLE. Organisations, manufacturers, researchers and health professionals concerned with enuresis were contacted for information. The reference sections of obtained studies were also checked for further trials. Date of the most recent search: July 1997.

SELECTION CRITERIA

All randomised trials of desmopressin for nocturnal enuresis in children were included in the review. Trials were eligible for inclusion if: children were randomised to receive desmopressin compared with placebo, other drugs or other conservative interventions for nocturnal bedwetting; participants with organic causes for their bedwetting were excluded; and baseline assessments of the level of bedwetting were reported. Trials focused solely on daytime wetting were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the quality of the eligible trials, and extracted data.

MAIN RESULTS

Twenty one randomised trials involving 948 children treated with desmopressin, met the inclusion criteria. The quality of many of the trials was poor. Desmopressin was compared with a tricyclic drug in two trials, and with alarms in one. Desmopressin was effective in reducing bedwetting in a variety of doses and forms. Each dose of desmopressin reduced bedwetting by at least one night per week during treatment (eg 20microg: 1.56 fewer wet nights per week, 95% CI -1.94 to -1.19). Participants on desmopressin were 4.6 times more likely to achieve 14 consecutive dry nights (95% CI 1.38 to 15.02) compared with placebo. However, there was no difference after treatment was finished. There was no apparent dose-related effect of desmopressin, but the evidence was limited. Data which compared oral and nasal administration were too few to be conclusive. Desmopressin and imipramine (a tricyclic drug) were equally effective in one small trial. Amitriptyline (another tricyclic) was not consistently better than desmopressin either alone or when used as a supplement. In a single trial, desmopressin was initially superior to using an alarm in reducing the number of wet nights per week: WMD -1.7 (95% CI: -2.96 to -0.45), but this result was not sustained; after three months of treatment, patients using the alarm had 1.4 fewer wet nights per week than with desmopressin: (95% CI: 0.14 to 2.65). Participants receiving the alarm intervention were also nine times less likely to relapse than those given desmopressin: RR 9.2 (95% CI: 1.28 to 65.9). Combining alarm and drug therapy was found to be superior to alarm treatment alone. The addition of desmopressin to an alarm schedule resulted in one less wet night per week: (95% CI: -1.55 to -0.45).

REVIEWER'S CONCLUSIONS

Desmopressin rapidly reduced the number of wet nights per week, but there was some evidence that this was not sustained after treatment stopped. Comparison with alternative treatments suggested that desmopressin and tricyclics had similar clinical effects, but that alarms produced more sustained benefits. However, based on the available evidence, these conclusions can only be tentative. There was some evidence of minor side effects of desmopressin in the included trials, such as nasal irritation and nose bleeds. However, the risk of water intoxication associated with over-drinking before bedtime has been reported. Patients and their families need to be warned of potential adverse effects and advise

Desmopressin in the treatment of nocturnal polyuria in the male

OBJECTIVES

To assess whether desmopressin (1-desamino 8-d-arginine vasopressin) is safe and effective in the treatment of nocturnal polyuria in elderly men.

PATIENTS AND METHODS

Twenty men (age 52-80 years) complaining of nocturia were found to have nocturnal polyuria, determined from frequency-volume charts and defined as the production of >33% of the 24 h urine volume overnight, averaged over a 1-week period. In a double-blind study of cross-over design, a 1-week placebo run-in period was followed by two 2-week periods of placebo or 20 microg intranasal desmopressin, and ended with an open 2-week treatment period with 40 microg desmopressin.

RESULTS

Desmopressin caused a significant reduction in nocturnal urine volume and the percentage of urine passed at night, but the reduction in nocturnal frequency was only significant during treatment with 40 microg desmopressin. Four patients on desmopressin experienced side-effects, three of which were thought to be due to fluid retention.

CONCLUSION

Desmopressin is an effective treatment for nocturnal polyuria in some elderly men. However, it can cause fluid retention and should not be given to patients with cardiac failure. Those undergoing treatment must be closely monitored.

The efficacy of DDAVP is related to the circadian rhythm of urine output in patients with persisting nocturnal enuresis

OBJECTIVE

Desmopressin may be a useful treatment in some, but not all, patients with nocturnal enuresis. We have evaluated a relation between nocturnal urine output in patients with primary monosymptomatic nocturnal enuresis and the treatment response to synthetic vasopressin.

DESIGN

Adolescent or adult enuretics and normal subjects were enrolled in the study and admitted to hospital for a 24 hour investigation of the diurnal variation in urine output, plasma vasopressin (AVP) and plasma atrial natriuretic peptide (ANP). The enuretics were characterized prior to investigation as either 1-desamino-8-D-arginine vasopressin (DDAVP) responders or non-responders. During admission the fluid intake was restricted to 25 ml/kg per day.

PATIENTS

Twenty-four patients (15-37 years) with primary monosymptomatic nocturnal enuresis and 9 normal subjects (24-31 years).

MEASUREMENTS

Circulating levels of AVP, ANP, plasma electrolytes and plasma osmolality were measured (1400, 2000, 2300, 0200, 0500 and 0800 hours) together with urine volume, urine osmolality and urine electrolytes during daytime and nighttime. Tubular reabsorptive capacity for water, osmoles and creatinine were assessed as well as urinary and fractional excretion rates of sodium and potassium.

RESULTS

Controls and DDAVP non-responders had a significant decrease in urine output at night concomitant with a significant plasma AVP amplitude in peak/nadir values although both groups lacked a significant nocturnal increase in AVP. In contrast, in DDAVP responders there was no circadian variation in urine output and thus a nocturnal polyuria together with no oscillation in plasma AVP. The DDAVP responding group had a nocturnal urine production significantly larger than the two other groups. However, the mean 24 hour AVP levels were similar in all groups. The excessive urine production at night in DDAVP responders was accompanied by nocturnal natriuresis due to an increased fractional excretion of sodium. In contrast, nocturnal antidiuresis in controls and DDAVP non-responding enuretics coincided with diminished sodium excretion. Average ANP levels were elevated in both enuretic groups compared to normals, whereas a circadian variation was detected only in the latter.

CONCLUSION

It is concluded that DDAVP responsiveness is linked to the nocturnal urine production and that no pathophysiological role can be ascribed to AVP or ANP in DDAVP refractory adolescent and adult enuretics. Moreover, it is suggested that an abnormal tubular handling of sodium may contribute to the nocturnal polyuria seen in DDAVP responders.

Long-term treatment with desmopressin in children with primary monosymptomatic nocturnal enuresis: an open multicentre study. Swedish Enuresis Trial (SWEET) Group

OBJECTIVE

To study the long-term efficacy and safety of desmopressin treatment in children with primary monosymptomatic nocturnal enuresis.

PATIENTS AND METHODS

Children (aged 6-12 years) with nocturnal enuresis were recruited into an open multicentre trial. All children underwent an observation period of 4 weeks before starting a 6-week dose-titration period with desmopressin. If the number of wet nights decreased by more than half during medication, they began long-term treatment on 20-40 microg desmopressin. To test for cure and avoid overtreatment, the medication was interrupted for one week every third month.

RESULTS

Of the 399 children forming the intention-to-treat cohort, 245 halved their number of wet nights and started long-term treatment. During the periods off medication, 77 children were dry and at the end of the study another 73 (still on medication) reduced the number of wet nights to < or =10% of that during the observation period. A further 51 children halved the number of wet nights compared with the observation period. No serious adverse events occurred.

CONCLUSION

Long-term treatment with nasal desmopressin at a main dose of 40 microg is an effective and safe treatment for monosymptomatic nocturnal enuresis.

Hyponatremia in patients with nocturnal enuresis treated with DDAVP

Treatment of nocturnal enuresis with DDAVP is associated with a low incidence of adverse effects. The only reported serious adverse effect is seizure or altered level of consciousness due to water intoxication. We reviewed 14 articles that reported data on serum sodium in patients treated with DDAVP for nocturnal enuresis and 11 articles that reported patients who developed a seizure or altered level of consciousness during treatment with DDAVP for nocturnal enuresis. Excess fluid intake was identified as a contributing factor in 6 of the 11 case reports.

CONCLUSION

Hyponatremia is a potential adverse effect in patients with nocturnal enuresis who are treated with DDAVP. To prevent this adverse effect we recommend that the patients prescribed DDAVP for nocturnal enuresis should be counseled not to ingest more than 240 ml (8 ounces) of fluid on any night that DDAVP is administered.

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.

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.

Combined treatment with enuresis alarm and desmopressin for nocturnal enuresis

Seventy-one children with nocturnal enuresis were enrolled in a controlled trial. The children were allocated to two matched groups. Children in both groups used an enuresis alarm until the end of treatment. Children in the first group were treated with 40 micrograms of intranasal desmopressin (Desmospray) for up to 6 weeks at the start of treatment with the alarm. During the observation period treatment there were 2.3 dry nights per week in both groups. At the end of treatment there was a significant difference in the mean number of dry nights per week between the two groups (6.3 in the alarm and desmopressin group and 4.8 in the alarm group) and also in the number of children becoming reliably dry. The combination of desmopressin and alarm was particularly helpful for children with severe wetting and those with family and behavioural problems.

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.

Efficacy, safety, and dosing of desmopressin for nocturnal enuresis in Europe

Desmopressin is a potent antidiuretic for nocturnal enuresis with few and mostly insignificant adverse reactions. Almost 80 years ago, the antidiuretic effects of extracts of the posterior pituitary were first reported. The molecular structure of the peptide vasopressin arginine vasopressin (AVP) became known in 1956, and by 1967, a synthesized modification of AVP, known as DDAVP, or desmopressin, was introduced. Toxicity studies performed on experimental animals support the conclusion that desmopressin is considerably more potent as an antidiuretic than AVP and has an exceptional safety margin. Further, clinical experience reveals that from 1974 to June 1992 only 21 patients using desmopressin had serious adverse reactions (water intoxication), and no fatalities occurred. Seven of 10 children with nocturnal enuresis who receive desmopressin stop their bedwetting completely or reduce it significantly, with best results noted in children over 10 years of age. Given these results, the preferred treatment in Europe for children with nocturnal enuresis is the sequential combination of desmopressin and the enuresis alarm.

Desmopressin for bed wetting: length of treatment, vasopressin secretion, and response

Fifty five children with nocturnal enuresis referred to a hospital enuresis clinic entered a controlled trial to compare the efficacy of one month and three month courses of intranasal desmopressin (Desmospray). There was no significant difference in outcome between the two groups. Overall 36% improved by at least two dry nights/week during treatment, but only five children (18%) in the one month group and three (11%) in the three month group became completely dry and only one in each group remained dry after treatment. To determine whether nocturnal polyuria was associated with a therapeutic response to desmopressin, the nocturnal urine volume, osmolality, and vasopressin concentration were measured in desmopressin responsive enuretics, desmopressin non-responders, and non-enuretic control children. There were no significant differences between the three groups. A three month course of desmopressin is no more effective than a one month course. Although many children will improve during treatment, only a small number become dry and most will relapse when treatment is stopped.

Urinary incontinence in women: have we anything new to offer?

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Sleep cystometries in children with nocturnal enuresis

A combined analysis was done of sleep and bladder filling during sleep. Cystometry did not specifically affect sleep, since most of the cystometry studies in cases of enuresis did not lead to sleep stage changes on electroencephalography. Bladder instability was not accompanied by lighter sleep. Increasing patient age did not appear to have any influence on sleep or bladder behavior. We conclude that it is possible to provoke enuresis at any sleep stage and that sleep is unaffected by bladder filling in enuretic patients.

Assessment of the safety of regular DDAVP therapy in primary nocturnal enuresis

A group of 7 patients with refractory primary nocturnal enuresis on long-term DDAVP therapy (mean 13 months) were submitted to a standard water deprivation test in conjunction with a hormone profile and routine haematological and biochemical investigations. No abnormalities were demonstrated, which suggests that the drug is safe in this clinical situation.

Prophylactic treatment of adult nocturia with bumetanide

The efficacy of 1 mg bumetanide on nocturia was compared with placebo in a randomised double-blind cross-over study in general practice. Twenty-eight patients, 13 females and 15 males, completed two treatment periods of 2 weeks' duration. During the placebo period the weekly number of nocturia episodes was 13.8 and during bumetanide treatment the number was reduced by 3.8. Ten males had a history of prostatic hypertrophy and in these patients treatment with bumetanide was not beneficial. In the remaining 18 patients the weekly number of nocturia episodes was reduced by 4 during bumetanide treatment compared with the placebo period. Of these patients, 3 preferred treatment with placebo, 11 preferred bumetanide and 4 gave no preference. These results suggest that bumetanide offers an alternative in the treatment of adult nocturia not connected with enlargement of the prostate.

Comparison of intranasal and oral desmopressin for nocturnal enuresis

A single blind dose response study of the effects of treatment with tablets containing 50-400 micrograms of desmopressin was conducted in 15 children with primary nocturnal enuresis. A dose response effect was seen, with the 100, 200, and 400 micrograms doses resulting in significantly more dry nights than when a placebo was used. The response after 200 micrograms was significantly different from that after 100 micrograms (p less than 0.02) but not from that after 400 micrograms. A randomised, double blind, double dummy, cross over study was then carried out in 30 children to compare the effects of a 20 micrograms dose given through a nasal pipette, a 200 micrograms tablet, and a placebo. The numbers of dry nights were significantly greater during both periods of treatment with desmopressin when compared with that using placebo, but there were no differences between the methods of taking the drug. After oral and nasal treatment 41% and 52%, respectively, of the patients improved by more than 50%. Nine children (31%) remained completely dry after treatment.

Use of three specific radioimmunoassays in measuring neurohypophysial hormone content and plasma concentrations of vasopressin, oxytocin and DDAVP in rats after prolonged infusion of DDAVP

Specific radioimmunoassays (RIA) were employed for measuring plasma and neurohypophysial concentrations of oxytocin (OT) and vasopressin (AVP) after administration of 1-deamino-8-D-Arg-vasopressin (DDAVP). DDAVP concentrations were measured by a newly-developed specific RIA. Through the use of minipumps, DDAVP was infused i.p. over a period of 3 days in normally hydrated rats. Despite decreased urine production and increased urine osmolality no changes could be observed in neurohypophysial and plasma hormone concentrations.

Mazindol for nocturnal enuresis

Sixteen adult enuretics who had failed to respond to simple conventional treatment of their symptoms have been investigated and treated with mazindol. Sixty-three per cent have been made dry and improvement achieved in a further 31%.

DDAVP in young enuretic patients: a double-blind trial

A double-blind cross-over trial of DDAVP was carried out in 22 patients aged between 9 and 16 years. The patients had previously failed to respond to other treatments for enuresis. While DDAVP resulted in fewer wet nights during the 14-day period of active treatment, the results did not achieve statistical significance. This is in contrast to previous reports. The dose in this study was 20 micrograms intranasally. Further studies may be valuable, possibly relating dosage to body weight.