Desmopressin use in pediatric nocturnal enuresis patients: is there a sex difference in prescription patterns?

Validation of the "Indication for Use" (INDO) Variable in the Danish National Prescription Registry

BACKGROUND

Despite its potential value in register-based pharmacoepidemiologic research, recorded information on "indication for use" (INDO) in the Danish National Prescription Registry has rarely been used, likely because of questions about the variable's validity, which to our knowledge no study has systematically assessed.

METHODS

We extracted data on 80,814 prescriptions from the software systems (PharmaNet and C2) of five Danish community pharmacies filled between 4 and 16 February 2019 and 2020. Using the indication information recorded in the pharmacy software systems as the gold standard, we evaluated the extent and quality of the corresponding information from the Prescription Registry.

RESULTS

Of all prescriptions identified, we captured >99% in the Prescription Registry. The proportion of prescriptions with recorded indication codes in the Prescription Registry was 82% (n = 66,164) but was lower for C2 than PharmaNet. Correcting for the overrepresentation of C2 data in our sample, the estimated proportion of registration was ≈88%. Almost 100% (66,158 of 66,164) of the prescriptions with recorded indication codes in the Prescription Registry had correctly recorded indication codes. Nonspecific indication codes were present in 5.6%-36% of selected drugs and drug classes.

CONCLUSIONS

Prescriptions filled at Danish community pharmacies are accurately captured by the Danish National Prescription Registry, and the recorded information on indication is generally valid and usable in research. However, minor concerns remain about missingness, nonspecific recorded indication codes, and lower validity, and a higher proportion of missingness of recorded indication codes is expected before 2017.A supplementary digital video by the article's co-author, Hanin Harbi, is available at http://links.lww.com/EDE/C89.

Sleep-Disordered Breathing and Its Association with Nocturnal Enuresis at the Primary Schools in Saudi Arabia: A Cross-Sectional Study

The correlation between nocturnal enuresis (NE) and sleep-disordered breathing (SDB) was reported. We aim to determine whether there is an association between NE and SDB in children and to assess the prevalence of SDB and NE in primary school children aged 6-12 years in Saudi Arabia. A cross-sectional observational study was conducted among the caregivers of children aged 6-12 years in all Saudi Arabia regions. The data were gathered through a self-administered online questionnaire. It included demographic information, weight and height, and associated comorbidities, in addition to the weekly frequencies of snoring symptoms and of enuresis, as well as of unrefreshing sleep using Likert-type response scales. Counts and percentages, the mean ± standard deviation, chi-square test, independent samples t-test, and regression analysis were used in the statistical analysis using R v 3.6.3. The questionnaire was completed by 686 respondents. Most respondents did not report any comorbidities in their children (77.1%). Asthma and adenotonsillar hypertrophy were reported in 16.2% and 15.6% of children, respectively. Unrefreshing sleep, mouth breathing at night, snoring, chronic nasal obstruction, and difficulty breathing while asleep were reported once or twice per week in 38%, 34%, 28%, 18%, and 18% of children, respectively. The prevalence of NE was 22.3%, with about 36.6% of children having NE two or more times per week. Significantly, NE was reported in 26.6% of children who slept before 10 PM compared to 19% of children who slept after 10 PM; in 28.6% of children who snored or loudly snored (57.1%) three times or more per week; and in 51.2% and 27.5% of children with difficulty breathing while asleep and who breathed through their mouth at night for one or two nights per week, respectively. A multivariable regression analysis showed that male gender (OR = 1.52, p = 0.010), obesity (OR = 1.24, p = 0.028), early sleeping time (OR = 1.40, p = 0.048), loud snoring for three or more nights per week (OR = 1.54, p = 0.001), difficulty breathing for one or two nights per week (OR = 1.85, p = 0.010), and mouth breathing at night for one or two nights per week (OR = 1.55, p = 0.049) were associated with higher odds of NE. Our study revealed that 22.3% of primary school children reported suffering from NE. SDB is a common problem among children with NE. The exact mechanism that links SDB to the increase in the risk of NE is unknown. Male gender, obesity, early sleeping time, loud snoring, difficulty breathing, and mouth breathing at night are potential independent risk factors of NE in school-age children.

Evaluation of Nocturnal Enuresis After Adenotonsillectomy in Children With Obstructive Sleep Apnea: A Secondary Analysis of a Randomized Clinical Trial

Importance

Children with obstructive sleep apnea (OSA) are at increased risk for nocturnal enuresis (NE). However, randomized clinical trials assessing NE outcomes in children randomized to adenotonsillectomy (AT) vs watchful waiting are lacking.

Objective

To assess the outcomes of AT vs watchful waiting in children with nonsevere OSA who experience NE.

Design, Setting, and Participants

Secondary analysis of data from a multicenter randomized clinical trial conducted at tertiary children's hospitals was performed. Participants included 453 children aged 5.0 to 9.9 years with nonsevere OSA who were randomized to either watchful waiting or AT as part of the multicenter Childhood Adenotonsillectomy Trial. Caregivers completed the Pediatric Sleep Questionnaire, which includes a binary item on bed-wetting, at baseline and 7-month follow-up. The trial was conducted between October 2007 and June 2012. Evaluation in this secondary analysis involving NE occurred from October 2019 to March 2021.

Interventions

Adenotonsillectomy vs watchful waiting in children with NE.

Main Outcomes and Measures

Prevalence of NE as defined by parental response to the Pediatric Sleep Questionnaire bed-wetting item at baseline and 7-month follow-up.

Results

Of the 453 children enrolled, 393 were included in analysis; of these, 201 were girls (51.1%). Mean (SD) age at baseline was 6.54 (1.40) years. At baseline, the number of children with NE was similar (2.6%; 95% CI, -0.12% to 0.07%) between the AT (59 [30.7%]) and watchful-waiting (67 [33.3%]) groups. The odds of NE in the watchful-waiting group were approximately 2 times higher than the AT group after 7 months (odds ratio, 2.0; 95% CI, 1.3 to 3.1). Following AT, there was a decrease (-11.0%; 95% CI, -16.3% to -5.7%) in the number of children with NE (n = 38). The prevalence of NE did not change significantly (-0.5%; 95% CI, -5.4% to 6.4%) in the watchful-waiting group (n = 66) at follow-up. Although NE was less frequent in girls (adjusted odds ratio, 0.53; 95% CI, 0.33-0.85), other clinical factors, such as age, race and ethnicity, obesity, and apnea-hypopnea index, were not associated with improvement of NE.

Conclusions and Relevance

In this secondary analysis of a randomized clinical trial, AT for the treatment of pediatric OSA appears to result in improvement in NE. Further research is needed to assess whether AT is associated with long-term benefits for NE compared with watchful waiting.

Trial Registration

ClinicalTrials.gov Identifier: NCT00560859.

Let's talk about sex: Differences in drug therapy in males and females

Professor Henry Higgins in My Fair Lady said, 'Why can't a woman be more like a man?' Perhaps unintended, such narration extends to the reality of current drug development. A clear sex-gap exists in pharmaceutical research spanning from preclinical studies, clinical trials to post-marketing surveillance with a bias towards males. Consequently, women experience adverse drug reactions from approved drug products more often than men. Distinct differences in pharmaceutical response across drug classes and the lack of understanding of disease pathophysiology also exists between the sexes, often leading to suboptimal drug therapy in women. This review explores the influence of sex as a biological variable in drug delivery, pharmacokinetic response and overall efficacy in the context of pharmaceutical research and practice in the clinic. Prospective recommendations are provided to guide researchers towards the consideration of sex differences in methodologies and analyses. The promotion of disaggregating data according to sex to strengthen scientific rigour, encouraging innovation through the personalisation of medicines and adopting machine learning algorithms is vital for optimised drug development in the sexes and population health equity.

Nocturnal enuresis in children: The role of arginine-vasopressin

Nocturnal enuresis is the involuntary pass of urine during sleep beyond the age of 5 years. It is a common condition in childhood and has an impact on the child's well-being. Research into the pathophysiology of the condition in the last decades has led to a paradigm shift, and enuresis is no longer considered a psychiatric disorder but rather a maturation defect with a somatic background. An excess urine production during sleep is a common finding in children with enuresis and disturbances in the circadian rhythm of arginine-vasopressin (AVP) is found in the majority of children with nocturnal polyuria. Children with enuresis and nocturnal polyuria lack the physiologic increase in AVP levels during sleep and treatment with the AVP analogue desmopressin can restore this rhythm and lead to dry nights. The reasons for this aberrant circadian AVP rhythm are not established. Furthermore, not all children with enuresis and nocturnal polyuria can be successfully treated with desmopressin suggesting that factors beyond renal water handling can be implicated such as natriuresis, hypercalciuria, and sleep-disordered breathing. The advances in the research of the genetic background of the condition may shed further light on the enuresis pathophysiology.

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.

Nocturnal enuresis and sleep disordered breathing in primary school children: Potential implications

INTRODUCTION

The association between nocturnal enuresis (NE) and sleep disordered breathing (SDB) has been repeatedly reported, but has primarily been focused on clinical cohorts. The purpose of this study, was to assess whether SDB-related symptoms such as snoring and unrefreshing sleep in the morning are associated with NE in a large-scale community school-based survey.

METHODS

A cross-sectional assessment using a standard questionnaire was conducted on nearly 20 000 primary school children (5-12 years old) in Matsuyama, Japan. Associations between NE and the frequencies of snoring and unrefreshing sleep were evaluated using multivariate logistic and regression analyses.

RESULTS

Multivariate adjusted odds ratios (95% confidence intervals) for enuresis were 1.21 (1.04 to 1.40) and 1.36 (1.07 to 1.73) in boys who snored 1 or 2 nights per week and ≥3 nights per week, respectively (P for trend <0.0001). Those for enuresis were 1.67 (1.41 to 1.99) and 1.96 (1.63 to 2.36) in boys who showed unrefreshing sleep 1 or 2 nights per week and ≥3 nights per week, respectively (P for trend <0.0001). Significant associations between NE and snoring frequency emerged among children who did not report unrefreshing sleep (P-trend for boys and girls were <0.0001 and <0.01, respectively), while significant associations between NE and frequency of unrefreshing sleep were detected among children who snored ≥1 nights per week (P for trend >0.1).

CONCLUSIONS

The pathogenic mechanisms linking snoring and unrefreshing sleep to increased risk of NE are unknown. However, snoring, a surrogate reporter of SDB, is associated with increased urine production, while unrefreshing sleep may result from disrupted sleep facilitating increased sleep pressure and elevated arousal thresholds. Thus, both SDB and unrefreshing sleep are potential independent risk factors of NE in school age children.