Use of desmopressin and concomitant use of potentially interacting drugs in elderly patients in Sweden

A better understanding of basic science may help our management of LUTS/LUTD in older persons with nocturnal polyuria and nocturia: ICI-RS 2024

AIMS

To discuss the role of autocrine/paracrine signaling of urothelial arginine vasopressin (AVP) on mammalian bladder capacities and micturition thresholds, impact of distension on water/urea reabsorption from the bladder, review of the literature to better characterize the central/peripheral effects of AVP, desmopressin (dAVP) toxicity, and urine biomarkers of nocturia.

METHODS

This review summarizes discussions during an International Consultation on Incontinence-Research Society 2024 think tank with respect to the role of urothelial AVP in aged individuals with nocturnal polyuria, impact of solute and water reabsorption by the bladder on uninterrupted sleep, central effects of AVP, pharmacological basis of dAVP toxicity, and biomarkers in nocturia/lower urinary tract dysfunction (LUTD) with neurological diseases.

RESULTS

Consensus recognized AVP function and pathways in the central nervous system (CNS), pre-proAVP localized using immunohistochemistry in bladder sections from adult/aged noncancerous human punch biopsies and rodent bladder sections is likely to accelerate the systemic uptake of water and urea from the bladder of anesthetized mice instilled with 3H-water and 14C-urea. Mechanisms for charged and uncharged solutes and water transport across the bladder, mechanism of dAVP toxicity, and utility of urine biomarkers in those with neurological diseases/nocturia were determined from literature reviews.

CONCLUSION

Pre-proAVP is present in human/rodent bladders and may be involved in water reabsorption from bladder that prevents the sensation of fullness for uninterrupted sleep in healthy adults. The mechanism of action of AVP in the CNS was discussed, as was electrolyte/water transport across the bladder, the basis for dAVP toxicity, and feasibility of urine biomarkers to identify nocturia/LUTD with neurological diseases.

Severe water intoxication secondary to the concomitant intake of non-steroidal anti-inflammatory drugs and desmopressin: a case report and review of the literature

Most of the clinical data on the safety profile of desmopressin (DDAVP), which is an effective treatment for both polyuric conditions and bleeding disorders, originate from studies on the tailoring of drug treatment, whereas few reports exist describing severe side effects secondary to drug-drug interaction. We herein describe a case of severe hyponatremia complicated by seizure and coma due to the intake of non-steroidal anti-inflammatory drugs (NSAIDs) in a patient on DDAVP replacement therapy for central diabetes insipidus (DI). A 50-yr-old Caucasian man, with congenital central DI, developed an episode of generalized tonic-clonic seizure, resulting in coma immediately after being admitted to the Emergency Unit for weakness and emesis. Based on his medical history and clinical findings, water intoxication secondary to ketoprofen intake (200 mg/day for the last 3 days) concomitant with DDAVP replacement therapy (Minirin(®) 60 mcg 4 tablets a day) was hypothesized as being the cause of the severe euvolemic hypotonic hyponatremia (natremia 113 mEq/l, plasma osmolality 238 mOsm/Kg). After standard emergency procedures, appropriate gradual restoration of serum sodium levels to the normal range was achieved in 72 hours. Hydratation was maintained according to water excretion and desmopressin therapy was re-introduced. We discuss this case report in the context of the published literature. The present report first highlights the potentially life-threatening side effects associated with over-the-counter NSAIDs during DDAVP replacement therapy for central DI. Risks and benefits of co-treatment should be carefully considered and therapeutic alternatives to NSAIDs should be recommended to patients with central DI in order to improve DDAVP safety.

High concomitant use of interacting drugs and low use of gastroprotective drugs among NSAID users in an unselected elderly population: a nationwide register-based study

BACKGROUND

NSAIDs are commonly used in the elderly and carry significant risks of adverse events when used concomitantly with potentially interacting drugs.

OBJECTIVE

The aim of this study was to provide a valid estimate of concomitant use of potentially interacting drugs and gastroprotective agents among elderly NSAID users.

METHODS

This was a nationwide Swedish register-based study of drug prescriptions for 1 529 267 persons aged ≥65 years in 2008, using the Swedish Prescribed Drug Register. The proportions of concomitant use of potentially interacting drugs and gastroprotective agents were analysed among NSAID users, categorized by age group, sex and NSAID use, defined as: non-users, people with 0-30 days of treatment, people with >30-180 days of treatment and people with >180 days of treatment. Use of the following concomitant drugs was evaluated: potentially harmful interacting drugs, i.e. antithrombotic drugs, antihypertensive drugs or drugs for congestive heart failure (digitalis glycosides, thiazide diuretics, loop diuretics, β-adrenoceptor antagonists, calcium channel antagonists, ACE inhibitors and angiotensin II type 1 receptor antagonists [angiotensin receptor blockers]) and other drugs (systemic corticosteroids, selective serotonin reuptake inhibitors [SSRIs], methotrexate and lithium); and gastroprotective drugs.

RESULTS

In the study cohort, 257 963 (16.9%) people had collected at least one prescription for an NSAID in 2008. This use was higher in females than in males and decreased in older age groups in both sexes. In the age groups 65-69, 70-74, 75-79, 80-84 and ≥85 years, the frequencies of NSAID users were 20.6%, 20.5%, 18.9%, 15.6% and 11.6% among women, and 16.8%, 16.7%, 15.2%, 13.5% and 11.1% among men, respectively. NSAID users often concomitantly used potentially interacting drugs, e.g. over 30% used antithrombotic agents, and women had higher concomitant use of SSRIs, i.e. 12% compared with 6% in men in the youngest age group. Concomitant use of potentially harmful interacting drugs generally increased with age and with increasing use of NSAIDs. Among the eldest (age ≥85 years), concomitant drug use was stable over NSAID groups. Only 40% of regular NSAID users (i.e. those prescribed NSAIDs for >180 days) were prescribed any gastroprotective medication.

CONCLUSIONS

Prescribers should be alert to the possibility of potentially harmful interactions between NSAIDs and commonly prescribed drugs in the elderly. Increased use of gastroprotective medication might be justified in this context.