Tolerability and efficacy of duloxetine in a nontrial situation

Acupuncture for stress urinary incontinence in adults

BACKGROUND

The use of acupuncture for stress urinary incontinence is increasing in frequency, especially in Asian area. However, its effectiveness and side effects have not been evaluated.

OBJECTIVES

To assess the effectiveness and side effects of acupuncture for stress urinary incontinence in adults.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register (searched 28 January 2013), EMBASE, AMED, Chinese Biomedical Literature Database (CBM), Chinese Acupuncture Trials Register and China National Knowledge Infrastructure (CNKI) (all searched 20 February 2013). In addition, we searched the reference lists of relevant articles and contacted authors and trialists in the field.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of acupuncture interventions without other treatments for the management of stress urinary incontinence for adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility, trial quality and extracted data. We meta-analysed data where appropriate.

MAIN RESULTS

We identified 17 possibly eligible studies but only one small trial with 60 women met our inclusion criteria. The trial compared acupuncture versus midodrine, a drug for treating hypotension. The risk of bias was high as there was no concealment of randomised allocation, and there was no blinding of assessment of outcome. In addition, it was not possible to blind participants or health providers to the interventions. The statistical methods were not described.More women improved in the acupuncture group (73% with acupuncture versus 33% with midodrine; risk ratio (RR) 2.20, 95% confidence interval (CI) 1.27 to 3.81) but the cure rates were low and not statistically significantly different (13% versus 7%; RR 2.00, 95% CI 0.40 to 10.11). There were adverse events in the drug group only.

AUTHORS' CONCLUSIONS

The effect of acupuncture for stress urinary incontinence for adults is uncertain. There is not enough evidence to determine whether acupuncture is more effective than drug treatment.

[Stress incontinence in elderly women]

Stress incontinence is one of the major challenges in geriatric medicine. This is becoming more apparent in routine urology practice with the demographic changes in the population. A thorough diagnosis for a correct treatment of stress incontinence is as important in elderly women as it is in younger patients. This includes assessing the risk factors of incontinence and obesity, parturition, pelvic surgery and changes in hormone levels are risk factors usually found in elderly women. These are the main reasons why this patient group is most frequently affected. Treatment options do not differ significantly from these of younger women. Lifestyle modification, weight loss and supervised pelvic floor training are the mainstays of conservative therapy and surgical treatment should only be considered after these options have been exhausted. In these cases minimally invasive surgical techniques offer clear advantages especially for elderly often multimorbid women.

What do we do when a midurethral tape fails? Rediscovery of open colposuspension as a salvage continence operation

INTRODUCTION AND HYPOTHESIS

Our aim was to evaluate the outcome of open colposuspension for women with urodynamic stress incontinence who had previously undergone a failed midurethral tape.

METHODS

A retrospective study of 13 women who had undergone open colposuspension after a failed midurethral tape was conducted.

RESULTS

At a median follow-up of 12 months, subjective and objective cure rate were 85% and 77%, respectively. Thirty percent of the women developed de novo detrusor overactivity that responded to antimuscarinic treatment. Long-term voiding difficulty was observed in only one patient, who performed clean intermittent self-catheterization for 3 months. Posterior vaginal wall prolapse requiring pelvic floor repair was found in three women (23%) postoperatively.

CONCLUSIONS

Open colposuspension is an effective option for treating persistent or recurrent stress urinary incontinence after failed midurethral tape, with a high success rate.

Construct validity of a questionnaire to measure the type of fluid intake and type of urinary incontinence

OBJECTIVE

To determine the reproducibility and construct validity of the Questionnaire Based Voiding Diary (QVD) for measuring the type and volume of fluid intake and the type of urinary incontinence.

METHODS

250 women completed the QVD, a 48-hour bladder diary and underwent complete urogynecologic evaluation to determine a final clinical diagnosis. The questionnaire was re-administered after a 2-week period with no change in treatment, and 2-3 months later following treatment of urinary symptoms.

RESULTS

The reproducibility of the fluid intake, output, fluid intake behavior and urinary symptom subscales of the QVD was 0.68-0.92. Correlation of the fluid intake scale of the QVD with the 48-hour voiding diary for determining the type and volume of fluid intake was high (r = 0.65-0.83, P < 0.01). High correlations were noted between the fluid intake behavior scale and urinary frequency (r = 0.82, P < .01), urgency (r = 0.77, P < .01) and urge incontinence (r = 0.71, P < .01). The median total fluid intake and mean urinary symptom score was significantly lower in responders (2074 mL, 10.2 ± 3.3) than non-responders (2347 mL, 18.5 ± 4.6). As compared to the final clinical diagnosis, the sensitivity, specificity and positive likelihood ratio of the QVD for the diagnosis of predominant stress urinary incontinence are 86%, 66% and 2.6 and for predominant urge incontinence 82%, 79% and 4.0 respectively.

CONCLUSION

The QVD provides clinically meaningful information on the type and volume of fluid intake and the type of urinary incontinence at the initial office visit.

Retrospective audit on tolerability and efficacy of duloxetine for stress urinary incontinence

This is an audit on medical management of patients with urinary stress incontinence (USI) with Duloxetine. The objective of this audit is to assess the efficacy & tolerability of duloxetine in patients with USI. The audit has shown good efficacy of the medication but due to poor tolerance most of the patients could not continue with it for long. Patient selection, commencing duloxetine at a lower dose and counselling about its side effects are important consideration. Although surgery is also the mode of treatment for USI, the medical treatment is reserved for patients who are elderly and not fit for surgery.

Clinical outcome and tolerability of duloxetine in the treatment of major depressive disorder: a 12-week study with plasma levels

Duloxetine (DLX) is a dual serotonin and norepinephrine reuptake inhibitor that has been recently approved for the treatment of major depressive disorder (MDD). However, little is known about the relationship between DLX plasma levels and clinical response. The aims of this open-label study were 1) to assess clinical outcome and tolerability of DLX by means of clinician and patient assessments and 2) to evaluate the value of plasma DLX levels as predictors of clinical response and tolerability. This was a naturalistic, open-label study of 45 outpatients affected with MDD (16 men and 29 women), who received DLX at doses of 30-120 mg/day and were evaluated at baseline (T0) and after 2, 4 and 12 weeks (T1-3). The assessments included the Hamilton Rating Scales for Depression (HRSD) and Anxiety (HRSA), Clinical Global Impression-Severity (CGI-S), Beck's Depression Inventory (BDI) and a mood visual analogue scale (VAS). Compared with T0, there were significant improvements in HRSD at T1, T2 and T3 (P < 0.001), in HRSA, CGI-S and the self-administered BDI at T2 and T3 (P < 0.001), and in the VAS scores shown at T3 (P = 0.01). DLX treatment was safe and well tolerated. Plasma DLX levels at T2 ranged from 5 to 135 ng/mL (mean +/- SD = 53.56 +/- 39.45) and correlated almost significantly with the DLX dose (r = 0.35; P = 0.069). There was a significant curvilinear quadratic relationship between the improvement of HRSA scores and plasma DLX levels (R(2) = 0.27; P = 0.02). The incidence of anxiety or irritability was associated with the highest plasma levels. Our findings suggest that monitoring plasma DLX levels may be helpful in predicting better treatment responses and tolerability. The present data seem to suggest an optimal anxiolytic efficacy of DLX at intermediate plasma levels.

Profile of adverse events with duloxetine treatment: a pooled analysis of placebo-controlled studies

BACKGROUND

The serotonin and noradrenaline (norepinephrine) reuptake inhibitor duloxetine has been approved in the US and elsewhere for a number of indications, including psychiatric illnesses and chronic pain conditions. Because the patient populations are diverse within these approved indications, and duloxetine is not yet approved for treatment of other conditions, we wanted to determine if adverse event profiles would differ among patients being treated for these various conditions.

OBJECTIVE

To provide detailed information on the adverse events associated with duloxetine and to identify differences in the adverse event profile between treatment indications and patient demographic subgroups.

METHODS

Data were analysed from all placebo-controlled trials of duloxetine completed as of December 2008. The 52 studies included 17,822 patients (duloxetine n = 10,326; placebo n = 7496) with major depressive disorder, generalized anxiety disorder, diabetic peripheral neuropathic pain, fibromyalgia, osteoarthritis knee pain (OAKP), chronic lower back pain and lower urinary tract disorders. The main outcome measures were rates of treatment-emergent adverse events (TEAEs) and adverse events reported as the reason for discontinuation.

RESULTS

The overall TEAE rate was 57.2% for placebo-treated patients and 72.4% for duloxetine-treated patients (p < or = 0.001). Patients with OAKP had the lowest TEAE rate (placebo 36.7% vs duloxetine 50.2%, p < or = 0.01), while patients with fibromyalgia had the highest rate (placebo 80.0% vs duloxetine 89.0%, p < or = 0.001). The most common TEAE for all indications was nausea (placebo 7.2% vs duloxetine 23.4%, p < or = 0.001), which was predominantly mild to moderate in severity. No statistically significant treatment-by-subgroup interactions for age were found between placebo and duloxetine treatment for the most common TEAEs. The rates of duloxetine-associated dry mouth and fatigue were greater in women than in men (13.1% vs 10.4%, interaction p = 0.004; and 9.4% vs 7.6%, interaction p = 0.03, respectively). Duloxetine-associated dry mouth incidence was higher in Caucasians than non-Caucasians (13.2%, 11.0%, interaction p = 0.04).

CONCLUSIONS

Duloxetine treatment is associated with significantly higher rates of common TEAEs versus placebo, regardless of indication or demographic subgroup. Differences across indications are likely to be attributable to the underlying condition rather than duloxetine, as suggested by the similar trends observed in placebo- and duloxetine-treated patients.

Urinary incontinence in women: part 1 of a series of articles on incontinence

BACKGROUND

Urinary incontinence can arise in a woman of any age. Its prevalence is between 10% and 40%. The main clinical problems in urogynecology are stress urinary incontinence (involuntary leakage of urine on exertion, sneezing, or coughing) and the overactive bladder syndrome (nycturia, pollakisuria, and urinary urgency with or without incontinence).

METHOD

Selective literature search, with special attention to large-scale studies and to the guidelines of the German Society of Obstetrics and Gynecology (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG) and its Task Force on Urogynecology and Pelvic Floor Reconstruction (Arbeitsgemeinschaft Urogynäkologie und Beckenbodenrekonstruktion).

RESULTS

There are many diagnostic and therapeutic options, whose use should be based on the degree of the patient's suffering and on her motivation to be treated. Anticholinergic drugs are of established value in the treatment of overactive bladder. They are used in combination with possible lifestyle changes and bladder training. In some circum-stances, botulinum toxin injections can be considered as well. Stress incontinence should be treated conservatively (with pelvic floor training) before any surgical treatment is provided. The new tension-free vaginal tapes are just as effective as classic treatments, such as colposuspension, while being less invasive and enabling a more rapid recovery.

CONCLUSION

All women with urinary incontinence should undergo appropriate, specialized diagnostic evaluation and well-founded counseling in order to benefit from individualized treatment.

The predictive value of pre-treatment cystometry in the outcome of women with mixed incontinence treated with duloxetine

OBJECTIVES

Whilst auditing the results of women treated with duloxetine, it was noted that some women with mixed urodynamic stress incontinence (USI) and detrusor overactivity (DO) reported worsening of their incontinence. Duloxetine works by increasing urethral resistance and may alter voiding function. Worsening voiding may result in worsening irritative symptoms. The aim of our study was to assess whether pre-treatment pressure flow studies predicted which women with mixed USI and DO became worse after treatment with duloxetine.

STUDY DESIGN

Women were recruited from our one-stop urogynaecology clinic. All women complained of troublesome mixed urinary symptoms with moderate or severe stress incontinence. Their initial assessment included a detailed history, a physical examination, a 3-day urinary diary, King's Quality of Life questionnaire and filling cystometry.

RESULTS

Fifty seven women were recruited. Thirty (52%) women recorded an improvement in their patient global impression of improvement (PGI-I) score; 18 (32%) recorded no change and nine (16%) women reported worsening bladder symptoms. Pressure flow studies of women who recorded a worsening of their incontinence were compared to those women who recorded no change or an improvement of their incontinence. The maximum flow rate (p=0.78), average flow rate (p=0.61), bladder capacity (p=0.14), detrusor pressure at maximum flow (p=0.68) and volume voided (0.66) showed no statistical difference when the two groups were compared. The pre-treatment voiding time (p=0.04) was statistically longer in women who got worse following treatment with duloxetine.

CONCLUSION

Pre-treatment pressure flow studies may be useful in predicting the outcome of treatment with duloxetine. Women who report worsening of their incontinence are more likely to have a longer voiding time compared to women who do not report worsening. Hence a prolonged voiding time may predict a poorer outcome for women treated with duloxetine.

The market lifecycle of duloxetine for urinary incontinence in Norway

OBJECTIVE

To investigate the epidemiology of prescriptions for duloxetine for the treatment of stress urinary incontinence during its entire lifecycle in Norway (October 2004-May 2007), including the persistence of use of the drug and the prescribers.

DESIGN AND SETTING

Observational study in Norway.

SAMPLE

All prescriptions on duloxetine filled in Norwegian pharmacies.

METHODS

Data from the Norwegian Prescription Database.

MAIN OUTCOME MEASURE

Patient's age, unique identification, date of dispensing, data on specialty of the prescribing doctor, and number of packages purchased. Persistence of use of duloxetine was analyzed by grouping the months of first prescription filled into quarters of a year, from the fourth quarter of 2004 to the third quarter of 2007.

RESULTS

A total of 3,024 filled prescriptions were recorded of which 2,903 (96%) could be further analyzed, corresponding to 37 users per 100,000 women in the population. Each patient filled a mean of 3.4 prescriptions. The persistence of use was very low from the second quarter itself, and after 1 year only 12.5% of the patients still purchased the drug. Most prescriptions were written by GPs and gynecologists. A prescription database like ours consists of dispensed prescriptions and not drugs taken. We believe that these biases are of little importance for the main results.

CONCLUSIONS

Analyses from the national prescription database show that duloxetine had a low uptake on the market and a low persistence rate among the patients during its full lifecycle on the Norwegian market.

The treatment of urinary incontinence with Duloxetine

Duloxetine is a Serotonin and Noradrenaline reuptake inhibitor, and is the first drug licensed for medical treatment of urodynamic stress incontinence. In this paper, we will briefly review the pharmacology, current evidence and controversies in relation to the use of duloxetine.