α1-Adrenoceptor blocker naftopidil improves sleep disturbance with reduction in nocturnal urine volume

Poor Sleep is Common in Treatment-Resistant Late-life Depression and Associated With Poorer Antidepressant Response: Findings From the OPTIMUM Clinical Trial

BACKGROUND

Adults with treatment-resistant late-life depression (TRLLD) have high rates of sleep problems; however, little is known about the occurrence and change in sleep during pharmacotherapy of TRLLD. This analysis examined: (1) the occurrence of insufficient sleep among adults with TRLLD; (2) how sleep changed during pharmacotherapy; and (3) whether treatment outcomes differed among participants with persistent insufficient sleep, worsened sleep, improved sleep, or persistent sufficient sleep.

METHODS

Secondary analysis of data from 634 participants age 60+ years in the OPTIMUM clinical trial for TRLLD. Sleep was assessed using the sleep item from the Montgomery-Asberg Depression Rating Scale at the beginning (week-0) and end (week-10) of treatment. The analyses examined whether treatment outcomes differed among participants with persistent insufficient sleep, worsened sleep, improved sleep, or persistent sufficient sleep during depression treatment.

RESULTS

About half (51%, n = 323) of participants reported insufficient sleep at baseline. Both persistent insufficient sleep (25%, n = 158) and worsened sleep (10%, n = 62) during treatment were associated with antidepressant nonresponse. Participants who maintained sufficient sleep (26%, n = 164) or who improved their sleep (n = 25%, n = 158) were three times more likely to experience a depression response than those with persistent insufficient sleep or worsened sleep.

CONCLUSION

Insufficient sleep is common in TRLLD and it is associated with poorer treatment response to antidepressants.

Long-term administration of alpha-1 blocker can reverse the micturition pattern in a bladder outlet obstruction murine model

OBJECTIVE

To investigate the effect of chronic administration of an alpha-1 blocker on micturition patterns in long-term partial bladder outlet obstruction.

METHODS

Mice were divided into three groups: a normal group, in which animals were fed a standard diet; a partial bladder outlet obstruction group, in which the proximal urethra was tied and animals were fed a standard diet; and a partial bladder outlet obstruction + naftopidil group, in which the proximal urethra was tied and animals were fed a standard diet containing naftopidil. Micturition behavior was evaluated in all groups for 6 months after partial bladder outlet obstruction surgery. The parameters evaluated included voided volume, time per void, urination frequency and total urine volume. Quantitative assessment of gene expression was also carried out.

RESULTS

Total urine volume, as well as total and average voided volume during night, was significantly decreased in partial bladder outlet obstruction + naftopidil mice compared with partial bladder outlet obstruction animals. The levels of transcripts encoding 5-hydroxytryptamine 2A and tissue inhibitor of metalloproteinase 2 were significantly decreased in the partial bladder outlet obstruction + naftopidil group compared with the partial bladder outlet obstruction group.

CONCLUSIONS

Long-term administration of an alpha-1 blocker seems to reverse the disturbance of the micturition pattern caused by partial bladder outlet obstruction. Mechanistically, this effect might be mediated by changes in the expression of a serotonin receptor and/or in the activity of the fibrogenesis pathway.

The role of late life depressive symptoms on the trajectories of insomnia symptoms during antidepressant treatment

OBJECTIVE

Sleep disturbances are common in late life depression; however, changes in insomnia symptoms during antidepressant treatment need to be characterized further. The objective of this study was two-fold: 1) to describe longitudinal trajectories of insomnia symptoms in older adults receiving antidepressant treatment and 2) to examine whether baseline depressive symptoms were associated with trajectories of sleep over time.

METHODS

Data was obtained from 680 older adults (aged ≥ 60) with major depression who participated in one of two protocolized open-label antidepressant treatment clinical trials (Maintenance Therapies in Late Life Depression [MTLD-3]; Incomplete Response in Late Life Depression: Getting to Remission [IRL-GRey]). Depression (total score minus sleep items) and sleep (sum of sleep items) outcomes were derived from the Hamilton Depression Rating Scale in the MLTD-3 and Montgomery-Asberg Depression Rating Scale in the IRL-GRey.

RESULTS

Both datasets identified 5 possible trajectories of insomnia symptoms with about half of the older adults having clinically significant baseline sleep disturbances and minimal improvement following a course of antidepressant treatment (i.e., sub-optimal sleep trajectory). Furthermore, across both datasets, worse baseline depression severity was associated with sub-optimal sleep trajectories.

CONCLUSION

In older adults receiving antidepressant treatment, those with clinically significant baseline sleep disturbances and greater depression severity may require adjunctive sleep-focused treatment to ameliorate sleep symptoms.

Does prostate volume affect the efficacy of α1D/A: Adrenoceptor antagonist naftopidil?

Introduction:

There have been reports that one of the factors affecting the efficacy of α1-adrenoceptor antagonists (α1-blocker; α1-B) was prostate volume (PV). However, there are few reports of short-term prospective trials comparing the efficacy of α1-B by PV. We examined the influence of PV on the short-term efficacy of naftopidil dose increase therapy to administration of 75 mg/day after an initial dose of 50 mg/day.

Materials and Methods:

A total of 85 patients with lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS/BPH) received 50 mg/day of naftopidil for 4 weeks. After 4 weeks, the dosage of naftopidil was increased to 75 mg/day for a further 4 weeks. We divided the patients into two groups of PV ≥40 mL at baseline (Group L) and PV <40 mL at baseline (Group S).

Results:

International Prostate Symptom Score (IPSS), IPSS storage symptoms, and IPSS quality-of-life score were significantly improved at 4 and 8 weeks compared with baseline in both Groups. IPSS voiding symptoms (IPSS-VS) were significantly improved at 4 and 8 weeks compared with baseline in Group S. IPSS and IPSS-VS were significantly improved at 8 weeks compared with 4 weeks only in Group L. IPSS-VS and intermittency at 4 weeks were significantly decreased in Group S compared with Group L. Maximum flow rate was significantly improved at 8 weeks compared with baseline in Group L.

Conclusions:

PV is a predictive factor affecting the efficacy of naftopidil 50 mg/day for IPSS-VS, and the dose increase to 75 mg/day effective for IPSS-VS. A total of 50 mg/day of naftopidil is the maintenance dose for LUTS/BPH patients with a small PV, and 75 mg/day of dose increase therapy should be chosen for patients with a large PV.

Nocturia in men is a chaotic condition dominated by nocturnal polyuria

OBJECTIVE

To characterize nocturia in men based on frequency volume chart data and symptom profiles assessed using the Core Lower Urinary Tract Symptom Score and Athens Insomnia Scale questionnaires.

METHODS

The Core Lower Urinary Tract Symptom Score and Athens Insomnia Scale questionnaires were administered to 299 consecutive treatment naïve men with nocturia (≥one time per night). Frequency volume chart data were recorded for 2 days. Correlations between nocturia and clinical characteristics including symptom scores, clinical diagnosis, Charlson Comorbidity Index, estimated glomerular filtration rate, uroflowmetry and prostate volume were analyzed.

RESULTS

Patients were divided into five groups: one time (n = 36), two times (n = 65), three times (n = 85), four times (n = 78) and five times (n = 34) of nocturia. Age, prevalence or severity of chronic kidney disease, hyperlipidemia, low bladder capacity, nocturnal polyuria, urgency, bladder pain and sleep disorders were significantly correlated with the severity of nocturia. The Spearman correlation analysis identified eight possible independent factors for nocturia: age, estimated glomerular filtration rate, urgency, bladder pain, sleep quality, sleepiness during the day, average voided volume and nocturnal volume divided by body weight. Logistic regression analysis showed that nocturnal volume divided by body weight was the strongest factor of nocturia, and ≥7, 9 and 9.7 mL/kg were practical cut-off values of three, four and five times per night of nocturia, respectively.

CONCLUSIONS

Nocturia in men is a chaotic condition dominated by nocturnal polyuria, and related to multiple factors including age, renal function, urgency, bladder pain, insomnia and bladder volume.

Naftopidil for the treatment of benign prostate hyperplasia: a systematic review

OBJECTIVES

The aim of the study was to systematically review the effects of the adrenoreceptor A1D antagonist naftopidil in the management of lower urinary tract symptoms (LUTS).

METHODS

A structured and comprehensive MEDLINE search was conducted for original articles, reviews, and metanalyses assessing the clinical pharmacology as well as the safety of naftopidil in the treatment of LUTS secondary to BPH. English-language publications dating from 1950 to 2013 were considered.

RESULTS

In the considered timeframe, 14 randomized clinical trials (RCT) were reported. Overall, the outcome measures assessed in the various reports included in the present review were changes from baseline in: International Prostate Symptom Score (IPSS), quality of life (QoL) score, maximum urinary flow rate (Qmax), residual volume (PVR), and adverse effects. Although additional well designed, worldwide, placebo-controlled and randomized studies are necessary to confirm the long-term outcomes of naftopidil pharmacotherapy, current data suggest that naftopidil administration in BPH patients provides comparable improvements in total IPSS, QoL, and urinary symptoms from baseline relative to 0.2 mg/d tamsulosin and 8 mg/d silodosin. However, improvements in Qmax are generally less with naftopidil than with tamsulosin. Reported adverse effects related to naftopidil administration are negligible and usually mild.

CONCLUSION

It remains unknown whether the data reported on naftopidil in the Japanese population are applicable in symptomatic BPH patients from western countries given that: (1) no English-language clinical trials have compared naftopidil to placebo in Western countries; (2) all clinical trials available were carried out in Japan; (3) in the comparative studies with tamsulosin, the dose of this drug was lower than the recommended dose in Western countries; (4) no data from long-term clinical trials evaluating drug safety beyond 18 weeks.

Imidafenacin, an antimuscarinic agent, improves nocturia and reduces nocturnal urine volume

OBJECTIVE

To evaluate the efficacy of imidafenacin for nocturia and nocturnal polyuria in patients with overactive bladder.

MATERIALS AND METHODS

A stratified analysis was conducted on data from a phase III randomized, double-blind, controlled trial of imidafenacin performed at 158 centers in Japan. The subjects received imidafenacin (0.1 mg) twice daily (group I) or placebo twice daily (group P). The 24-hour urine volume, daytime and nighttime voiding frequency, and volume voided/micturition were evaluated from 3-day voiding diaries recorded every 4 weeks during the 12-week study period. Longitudinal data analysis was performed, with all values expressed as the least squares mean ± standard error.

RESULTS

A total of 46 patients (mean age 66.54 ± 9.38 years, 9 men and 37 women) with nocturia and nocturnal polyuria (>33% of urine production at night) were enrolled. Group I (n = 35) and group P (n = 11) showed no baseline differences in the daily voided volume, concomitant diseases, age, or body weight. However, the average daily number of micturitions differed (11.22 ± 2.17 vs 14.45 ± 2.85). Therefore, longitudinal data analysis was performed for each micturition pattern. After 12 weeks of treatment, nighttime micturition was significantly less frequent in group I than in group P (P = .0292), and the nocturnal percentage of 24-hour production was significantly smaller (P = .0053). The interval to the first nighttime void was significantly longer in group I than in group P, but no difference was found in the first nighttime voided volume.

CONCLUSION

The novel antimuscarinic agent, imidafenacin, decreases the number of urinations and reduces nocturnal urine production, thereby improving both nocturia and nocturnal polyuria.

Nocturia Potentially Influences Maintenance of Sexual Function in Elderly Men with Benign Prostatic Hyperplasia

OBJECTIVE

This study examined the relationship between bothersome symptoms of nocturia and erectile function.

METHODS

Subjects comprised patients with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH). Patients were prospectively followed on treatment with the alpha-1 blocker naftopidil for 8 weeks. Patient backgrounds and efficacy of naftopidil associated with LUTS and sexual activity were evaluated.

RESULTS

The percentage of patients who identified nocturia as the most bothersome symptom was 30.2% (n = 135), representing the highest percentage among International Prostate Symptom Score (IPSS) items. The number of patients with nocturia as the most bothersome symptom plateaued at an IPSS for nocturia of two or three points. In contrast, the number of patients with slow stream as the most bothersome symptom increased with symptom severity according to IPSS for slow stream. Logistic regression analysis on association between nocturia and erectile function confirmed that the odds ratio was 1.41 (P < 0.05). Naftopidil showed excellent efficacy related to male LUTS, but International Index of Erectile Function 5 (IIEF5) total score was almost unchanged. Among patients with nocturia improved by naftopidil, IIEF5 total score was significantly changed in the group with IPSS nocturia score ≤1 as compared to the group with IPSS nocturia score ≥2 per night (P = 0.038).

CONCLUSION

Nocturia the most bothersome symptom correlated with aging. Nocturia could associate erectile dysfunction, and keeping the frequency of nocturia at ≤1 episode might be meaningful for maintaining quality of life in elderly men.

Antidiuretic effect of antimuscarinic agents in rat model depends on C-fibre afferent nerves in the bladder

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Antichollnergic agents are anticipated to diminish storage symptoms, as well as nocturia. Nevertheless, the effect of this treatment on polyuria related to nocturia is not clear. By subgroup analysis of the data set from a phase III clinical trial of antimuscarinic agent for OAB patients in Japan, imidafenacin was found to improve nocturia with a reduction in nocturnal polyuria. This study adds the effects and underlying mechanism of antimuscarinic agents decreasing urine production through inhibition of C-fibre in the bladder of water-leaded rats.

OBJECTIVE

To evaluate the effects and underlying mechanisms of antimuscarinic agents used to decrease in urine production in water-loaded rats.

SUBJECTS AND METHODS

Urine production was measured using a cystostomy catheter in female Sprague-Dawley rats every 2 h. The effect of the antimuscarinic agents atropine, tolterodine and imidafenacin on urine production was investigated under water-loaded conditions, which were induced by i.p. injection of 15 mL saline. Blood samples were collected to determine the levels of antidiuretic hormone (ADH), aldosterone (ALD), atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) before, and 2 and 8 h after, antimuscarinic agent administration. To induce desensitization of C-fibre afferent nerves, resiniferatoxin (RTX)was injected s.c. or intravesically 2 days before experiments.

RESULTS

Urine production increased and reached its maximum 2 h after 15 mL saline injection. Imidafenacin and tolterodine decreased urine production in water-loaded rats, but ADH, ALD, ANP and BNP levels were not different between imidafenacin-treated and vehicle-treated rats. The inhibitory effect on urine production was not found in RTX-treated rats. Atropine did not reduce urine production.

CONCLUSION

These results suggest that antimuscarinic agents decrease urine volume through C-fibres in the bladder; thus, antimuscarinics with inhibitory effects on C-fibres could be beneficial for nocturia with nocturnal polyuria.

Male lower urinary tract symptoms and α1D-adrenoceptors

Historically, α(1)-adrenoceptors have been classified into three subtypes (α(1)(A), α(1)(B) and α(1)(D)) that are widely distributed in various organs. Research on the α(1)(D)-adrenoceptors in the bladder, urethra and prostate has focused on the relationship between expression levels and symptoms of bladder outlet obstruction, and the implications and functional roles of α(1)(D)-adrenoceptors subtypes in these organs. The α(1)(D)-adrenoceptor messenger ribonucleic acid and protein seem to be increased in obstructed bladders or small capacity bladders. In contrast, α(1)(D)-adrenoceptor subtype knock-out mice have been found to have a prolonged voiding interval. Interestingly, an α(1)(D)-adrenoceptor antagonist was found to inhibit the facilitation of afferent nerve activity for the micturition reflex induced by intravesical infusion of acetic acid. Clinically, patients who felt urgency at low filling volumes and had a small bladder capacity were found to have more α(1)(D)-adrenoceptor messenger ribonucleic acid in their bladder mucosa than patients who felt urgency at high filling volumes and had a large bladder capacity. An α(1)(D)-adrenoceptor antagonist was found to increase the first desired volume and the maximum desired volume while decreasing detrusor overactivity in pressure flow studies. Thus, α(1)(D)-adrenoceptors in the lower urinary tract might play an important role in the pathophysiology of lower urinary tract disorders.

α1D/A-adrenoceptor antagonist naftopidil for the male lower urinary tract symptoms associated with benign prostatic hyperplasia: efficacy of dose increase therapy

OBJECTIVES

To examine the efficacy of dose increase therapy in patients with lower urinary tract symptoms associated with benign prostatic hyperplasia who responded poorly to 50 mg/day of naftopidil.

METHODS

A total of 95 patients received 50 mg/day of naftopidil for 8 weeks. After this treatment period, they were divided into two groups: the poor responders were defined as those who either had an International Prostate Symptom Score-Quality of Life ≥ 4 or with an International Prostate Symptom Score-Quality of Life of 3 whose International Prostate Symptom Score-Quality of Life improved <2 points (group A). All other patients were defined as responders to naftopidil 50 mg/day (group B). The dose of naftopidil was increased to 75 mg/day in group A, and maintained at 50 mg/day in group B. The treatment was continued for a further 8 weeks.

RESULTS

The prostate volume at the baseline was significantly larger in group A than group B. The improvement of International Prostate Symptom Score total score, International Prostate Symptom Score-Quality of Life, and voided volume after 8 weeks was significantly better in group B than in group A. However, there was no significant difference in the changes of all parameters between the two groups after 16 weeks.

CONCLUSIONS

A dose increase to 75 mg/day is an effective treatment strategy in patients with lower urinary tract symptoms associated with benign prostatic hyperplasia who responded poorly to an initial dose of 50 mg/day of naftopidil. Furthermore, a starting dose of 75 mg/day should be considered in patients with a large prostate volume, as this is a predictive factor for dose increase.

Naftopidil for the treatment of urinary symptoms in patients with benign prostatic hyperplasia

Naftopidil, approved only in Japan, is an α1-adrenergic receptor antagonist (α1-blocker) used to treat lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH). Different from tamsulosin hydrochloride and silodosin, in that it has higher and extremely higher affinity respectively, for the α1A-adrenergic receptor subtype than for the α1D type, naftopidil has distinct characteristics because it has a three times greater affinity for the α1D-adrenergic receptor subtype than for the α1A subtype. Although well-designed large-scale randomized controlled studies are lacking and the optimal dosage of naftopidil is not always completely determined, previous reports from Japan have shown that naftopidil has superior efficacy to a placebo and comparable efficacy to other α1-blockers such as tamsulosin. On the other hand, the incidences of ejaculatory disorders and intraoperative floppy iris syndrome induced by naftopidil may be lower than for tamsulosin and silodosin having high affinity for the α1A-adrenergic receptor subtype. However, it remains unknown if the efficacy and safety of naftopidil in Japanese is applicable to white, black and Hispanic men having LUTS/BPH in western countries.