Optimizing response to desmopressin in patients with monosymptomatic nocturnal enuresis

L'évaluation et la prise en charge de l'énurésie en pédiatrie générale

Pour évaluer l'énurésie, un trouble pédiatrique courant, il faut en distinguer la forme monosymptomatique de la forme non monosymptomatique et établir la présence d'affections concomitantes. La prise en charge simultanée des facteurs cooccurrents est le meilleur moyen pour obtenir un résultat satisfaisant. Le traitement commence par l'éducation du patient et de sa famille sur l'évolution naturelle de l'énurésie et par des conseils pratiques sur le comportement. Les données probantes en appui à des interventions particulières sont limitées, et les enfants et les familles devraient participer au choix du traitement approprié. Les dispositifs d'alarme contre l'énurésie et la desmopressine représentent des possibilités thérapeutiques lorsqu'une intervention plus active est souhaitée. Des améliorations cliniques et des traitements combinés sont en voie de se dégager.

Evaluation and management of enuresis in the general paediatric setting

Assessing enuresis involves distinguishing monosymptomatic from non-monosymptomatic for this common paediatric problem, and identifying concomitant comorbidities. Addressing co-occurring factors concurrently ensures the best opportunity for a satisfactory outcome. Treatment begins with patient and family education on the natural history of enuresis and practical behavioural guidance. Evidence to support particular interventions is limited, and children and families should be involved when choosing appropriate therapy. Enuresis alarms and desmopressin are treatment options when more active intervention is desired. Clinical refinements and combined treatment modalities are emerging.

[Functional (Nonorganic) Enuresis and Daytime Urinary Incontinence in Children and Adolescents: Clinical Guideline for Assessment and Treatment]

Functional (Nonorganic) Enuresis and Daytime Urinary Incontinence in Children and Adolescents: Clinical Guideline for Assessment and Treatment Abstract: Objective: Enuresis and daytime urinary incontinence are common disorders in children and adolescents and are associated with incapacitation and a high rate of comorbid psychological disorders. This interdisciplinary guideline summarizes the current state of knowledge regarding somatic and psychiatric assessment and treatment. We formulate consensus-based, practical recommendations. Methods: The members of this guideline commission consisted of 18 professional associations. The guideline results from current literature searches, several online surveys, and consensus conferences based on standard procedures. Results: According to the International Children's Continence Society (ICCS), there are four different subtypes of nocturnal enuresis and nine subtypes of daytime urinary incontinence. Organic factors first have to be excluded. Clinical and noninvasive assessment is sufficient in most cases. Standard urotherapy is the mainstay of treatment. If indicated, one can add specific urotherapy and pharmacotherapy. Medication can be useful, especially in enuresis and urge incontinence. Psychological and somatic comorbid disorders must also be addressed. Conclusions: The recommendations of this guideline were passed with a high consensus. Interdisciplinary cooperation is especially important, as somatic factors and comorbid psychological disorders and symptoms need to be considered. More research is required especially regarding functional (nonorganic) daytime urinary incontinence.

Serum Sodium Alterations in Children with Primary Monosymptomatic Nocturnal Enuresis Using Desmopressin

Background: Hyponatremia/water intoxication has been considered a rare but serious complication of desmopressin (DDAVP) for the treatment of primary monosymptomatic nocturnal enuresis (PMNE). Objectives: This study aimed to identify the incidence and risk factors of serum sodium (Na) alterations in children with PMNE treated with oral or intranasal DDAVP. Methods: A total of 201 patients with PMNE were evaluated in 2 groups using intranasal (n = 127) or oral DDAVP (n = 74) for approximately 6 months. Treatment efficacy was defined as a more than 50% decrease in wet nights after 1 month of treatment. Serum Na was measured before, during, and after treatment in all patients. Predisposing factors of serum Na disturbance were evaluated concomitantly. Results: The mean age of patients was 8.8 ± 2.6 (5 - 17.5) years, and males outnumbered females (M/F = 1.68). Treatment efficacy was 100% in 93 (46.2%), and > 90% in 157 (78.1%) cases. Oral DDAVP had significantly more therapeutic effects than intranasal treatment (P = 0.024). However, serum Na had no significant difference between the 2 groups (P = 0.52). Hyponatremia occurred in 7 (3.5%) patients (3 in oral treatment and 4 in intranasal treatment; P = 0.73) with no significant correlation to age, gender, body weight, frequency of enuresis, and initial serum Na. However, decreased serum Na > 5 mEq/L was a significant risk factor for the prediction of hyponatremia in our patients (P < 0.001). Conclusions: Oral DDAVP had more therapeutic effects than intranasal treatment for the treatment of PMNE. Serum Na had no significant alteration in both oral and intranasal treatments, and hyponatremia was a rare complication of DDAVP, which occurred significantly in children with a > 5-mEq/L decrease of initial serum Na concentration. As a suggestion, monitoring serum Na is not an essential follow-up in asymptomatic patients in DDAVP treatment.

A randomised, double-blind, placebo-controlled clinical trial found that a novel herbal formula Urox® (Bedtime Buddy®) assisted children for the treatment of nocturnal enuresis

BACKGROUND

Nocturnal enuresis or 'bedwetting', is a form of night-time urinary incontinence occurring in younger children. A diagnosis can be socially disruptive and psychologically stressful for a child. The most common strategies used by parents are waking the child during the night to use the bathroom and limiting the child's water intake before going to bed.

HYPOTHESIS/PURPOSE

To determine if a herbal capsule formulation taken once daily can reduce incidence and frequency of nocturnal enuresis in children.

STUDY DESIGN

This randomised double-blind placebo-controlled trial evaluated the efficacy of an herbal medicine product to reduce the symptoms of nocturnal enuresis. Participants, aged between 6 and 14 years of age, were recruited from the community in Australia. They were randomised via computerised random-number generation at study enrolment to receive one or two oral capsules in the morning of either Urox® (Bedtime Buddy®) or placebo. The Paediatric Quality of life (Pin-Q) was used as a quality-of-life measure and waking wet, fluid intake and urinary urgency per week were monitored.

RESULTS

Forty-one children completed the trial with an attrition rate of 16%. There were more males (64.6%) compared to females (35.4%) and the mean age was 8.6 years. Forty-one point seven percentages (41.7%) of participants had improvements in bed wetting by two months which was a highly clinically relevant effect (Cohen's D = 0.98). The primary outcome found that there was a statistically significant reduction in NE (p = 0.034; CI 0.086-2.095) and between groups using longitudinal analysis (p = 0.04, Coefficient -1.12, CI 95% -2.20 - -0.04). In the secondary outcomes, urinary urgency reduced statistically significantly for the intervention (p = 0.002; a reduction of 18.3% difference for Bedtime Buddy compared to an increase of 3.7% for the placebo).

CONCLUSION

Urox® (Bedtime Buddy®) may assist children in reducing nocturnal enuresis compared to placebo. In addition, it may assist in reducing daily incontinence and urinary urgency.

Evaluating nocturnal polyuria in Japanese children with nocturnal enuresis

BACKGROUND

The purpose of this study was to assess whether enuretic Japanese patients with nocturnal polyuria (NP) who met Hoashi's criteria (6-9 years: ≥200 mL; 10 years and older: ≥250 mL) met the International Children's Continence Society (ICCS; expected bladder capacity × 130%) and Rittig's criteria for nocturnal polyuria (>[age+9] × 20 mL). We also compared the effectiveness of 1-desamino-8-d-arginine vasopressin (DDAVP) with the three criteria.

METHODS

Fifty-four patients who had NP with normal bladder capacity were enrolled: 36 boys (67%); median age, 8 (interquartile range: 7-9). We compared the diagnostic differences between the Hoashi's criteria and international standards (ICCS and Rittig's) for NP and the short-term effects of DDAVP. The patients received DDAVP for 8 weeks; we evaluated the association between each evaluation method and the effects of therapy.

RESULTS

Only 17% of the patients met both Hoashi's and ICCS criteria, whereas 26% met both Hoashi's and Rittig's criteria. The therapeutic effect of DDAVP did not differ significantly between these two groups: there was an effective rate of 73% (Hoashi's criteria) versus 50% (ICCS criteria), P = 0.19, and an effective rate of 71% (Hoashi's criteria) versus 62% (Rittig's criteria), P = 0.84.

CONCLUSIONS

Hoashi's criteria are widely used but, according to both the ICCS and Rittig's criteria, approximately 80% of the patients did not fulfill the definition of NP. However, 8 weeks after the DDAVP treatment began, no significant difference was observed in the therapeutic effect of DDAVP according to each set of criteria. The definition of NP should account for the physical disparities between Japanese people and Westerners.

The Biology of Vasopressin

Vasopressins are evolutionarily conserved peptide hormones. Mammalian vasopressin functions systemically as an antidiuretic and regulator of blood and cardiac flow essential for adapting to terrestrial environments. Moreover, vasopressin acts centrally as a neurohormone involved in social and parental behavior and stress response. Vasopressin synthesis in several cell types, storage in intracellular vesicles, and release in response to physiological stimuli are highly regulated and mediated by three distinct G protein coupled receptors. Other receptors may bind or cross-bind vasopressin. Vasopressin is regulated spatially and temporally through transcriptional and post-transcriptional mechanisms, sex, tissue, and cell-specific receptor expression. Anomalies of vasopressin signaling have been observed in polycystic kidney disease, chronic heart failure, and neuropsychiatric conditions. Growing knowledge of the central biological roles of vasopressin has enabled pharmacological advances to treat these conditions by targeting defective systemic or central pathways utilizing specific agonists and antagonists.

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.

Exploration of the Optimal Desmopressin Treatment in Children With Monosymptomatic Nocturnal Enuresis: Evidence From a Chinese Cohort

Objectives: Nocturnal enuresis (NE) is a common pediatric condition, and desmopressin (dDAVP) is a first-line therapy for NE. The standard initial dosage of dDAVP is 0. 2 mg/day, and most guidelines recommend that the dose should be increased at 0.2 mg increments until dryness is achieved or to the maximal recommended dose. However, previous evidence has shown that this strategy seems insufficient to further improve efficacy and results in unnecessarily high doses for some patients. Our study aimed to assess the efficacy of our modified dDAVP treatment regimen in children with MNE in China and evaluate predictive factors associated with the dDAVP response. Methods: All MNE patients at the Department of Nephrology at Children's Hospital of Fudan University from January to December 2019 were prospectively and consecutively enrolled. dDAVP treatment comprised a dose titration period and a 3-month maintenance period. The efficacy of dDAVP was assessed according to the latest International Children's Continence Society criteria at the end of the study. Predictive factors were evaluated by logistic regression analysis. Results: Overall, 322 MNE patients were enrolled in our study, and 225 (69.9%) completed the study. The intention to treat analysis showed that the overall dDAVP response rate was 69.9%: among these patients 32.3% were complete responders, and 37.6% were partial responders. At the end of the study, 194/225 (86.2%) patients received a final dose of 0.2 mg, 24/225 (10.7%) patients received a final dose of 0.3 mg, and 7/225 (3.1%) patients received a final dose of 0.4 mg. Multivariate analysis showed that patients requiring lower doses to achieve responses were significantly more likely to experience complete response during the maintenance period [odds ratio (OR)=9.683; 95% confidence interval (CI), 2.770-33.846]. Conclusions: Our results indicate that the dDAVP treatment regimen provides a comparable efficacy to the international conventional treatment regimen with a lower overall dose. Low-dose responders were likely to achieve a complete response without increasing the dose; in these cases, the maximum dose might not be necessary.

Brazilian consensus in enuresis-recomendations for clinical practice

Introduction

Enuresis, defined as an intermittent urinary incontinence that occurs during sleep, is a frequent condition, occurring in about 10% of children at 7 years of age. However, it is frequently neglected by the family and by the primary care provider, leaving many of those children without treatment. Despite of many studies in Enuresis and recent advances in scientific and technological knowledge there is still considerable heterogeneity in evaluation methods and therapeutic approaches.

Materials and Methods

The board of Pediatric Urology of the Brazilian Society of Urology joined a group of experts and reviewed all important issues on Enuresis and elaborated a draft of the document. On September 2018 the panel met to review, discuss and write a consensus document.

Results and Discussion

Enuresis is a multifactorial disease that can lead to a diversity of problems for the child and family. Children presenting with Enuresis require careful evaluation and treatment to avoid future psychological and behavioral problems. The panel addressed recommendations on up to date choice of diagnosis evaluation and therapies.

Pharmacokinetic and Pharmacodynamic Properties of a Micro-Dose Nasal Spray Formulation of Desmopressin (AV002) in Healthy Water-Loaded Subjects

Purpose

Antidiuretic therapy with desmopressin for nocturia has been hampered by formulations with high doses, low bioavailability and variable pharmacokinetics. AV002 (SER120), a novel, emulsified, microdose desmopressin nasal spray, with a permeation enhancer (cylcopentadecanolide), was developed to have pharmacokinetic characteristics suitable for nocturia treatment.

Methods

Twelve healthy subjects participated in an open-label, dose-escalating study. Water-loaded subjects were sequentially dosed every 48 h with AV002 0.5, 1.0, 2.0 μg and 0.12 μg desmopressin subcutaneous (SC) bolus injection.

Results

AV002 intranasal administration produced a time-to-maximum concentration (T_max) between 15 and 30 min and a maximum concentration (C_max) <10 pg/mL. C_max and area under the curve showed dose proportionality. Coefficient of variation for AV002 was similar to that observed for the SC dose. Bioavailability of AV002 was approximately 8% compared to SC injection. AV002 demonstrated pharmacodynamic effects within 20 min of dosing and showed increasing magnitude and duration with escalating doses. AV002 2.0 μg had maximum median urine osmolality of 629 mOsm/kg and median urine output ≤2 mL/min for 5–6 h.

Conclusions

AV002 demonstrated rapid absorption, high bioavailability, limited duration of action, and low coefficient of variation, suggesting it may be a suitable formulation for nocturia treatment.

Trial registration not required (single-center, phase 1).

'Frequently recurring' nocturnal polyuria is predictive of response to desmopressin in monosymptomatic nocturnal enuresis in childhood

INTRODUCTION

The nocturnal polyuria is considered a significant predictive value for response to desmopressin. The cutoff value useful to define nocturnal polyuria is still a matter of debate. Moreover, it is current notion that maximal voided volume (MVV) could be used as a predictor for desmopressin response.

OBJECTIVE

The objective of this study was to assess the impact of different definitions of nocturnal polyuria (and of its frequency) and MVV in predicting the response to desmopressin.

STUDY DESIGN

A total of 103 patients with frequent monosymptomatic nocturnal enuresis (≥4 wet nights/week) were enrolled. A bladder diary over a 4-day period was collected. The MVV was defined as the highest micturition volume detected at bladder diary. Nocturnal diuresis was measured in 5 wet nights. Then, patients were administered with 120 mcg of sublingual desmopressin. After 2 months, if there was no complete response, the dose was increased to 240 mcg. Nocturnal polyuria was defined as follows: 1.Definition 1: nocturnal urine production >130% of the expected bladder capacity (EBC). 2. Definition 2: >100% EBC. 3. Definition 3: > 20×(age + 9) mL. The primary outcome was 'response to desmopressin' after 3 months of treatment.

RESULTS

Fifty-three patients responded to desmopressin. Comparing the responses to desmopressin on the basis of the three definitions of nocturnal polyuria, no significant difference was found. There was no cutoff value of nocturnal polyuria expressed as %EBC useful in providing a significant receiver-operating characteristic (ROC) curve. The area under the ROC curve for MVV expressed as %EBC was 0.67 (95% confidence interval [CI], 0.54-0.80; p = 0.01). A MVV >103.1% of EBC had 78.8% (95% CI, 61.1-91.0) sensitivity and 47.5% (95% CI, 31.5-63.9) specificity for predicting response to desmopressin. Among the patients with nocturnal polyuria according to definition 1, a higher percentage of subjects with nocturnal polyuria in 4 out of 5 or 5 out of 5 nights responded to desmopressin, compared with other patients. Patients presenting with nocturnal polyuria according to definition 3 in 5 out of 5 nights showed a 100% of response to desmopressin. At multivariate analysis, the only significant odds ratio (OR) to respond to desmopressin was that of patients with nocturnal polyuria according to definition 1 in >3 nights (OR = 7.1, 95% CI, 1.3-40.3).

DISCUSSION AND CONCLUSIONS

The presence or absence of nocturnal polyuria-according to all three definitions-in at least one night was not effective in predicting the response to desmopressin. Predictors of desmopressin response were nocturnal polyuria in >3 out of 5 wet nights according to definition 1 and in 5 out of 5 wet nights according to definition 3.

Oral Desmopressin Lyophilisate Formulation (MELT): Efficacy and Safety in Children and Adults

Nocturnal enuresis (NE) is a common disorder in childhood and desmopressin is one of the most widely and well-tolerated medications for NE. The recent oral lyophilisate formulation of desmopressin (MELT) is effective in the treatment of NE in children and nocturia in adults. A MEDLINE literature search MEDLINE (2000-July 2017) was performed using the search terms MELT enuresis, MELT desmopressin, sublingual desmopressin, lyophilisate desmopressin. Twenty articles were analyzed with a number of patients of 3448. In 12 articles were reported 1275 pediatric patients (<18 years old), and in 8 articles 2213 adult patients. In pediatric population the indication was enuresis in 1269 patients and central diabetes insipidus in 6 patients. In adult population the indication was nocturia in 1941 patients, renal colic in 259 patients, healthy volunteers 13 patients. In 17 studies desmopressin was administered alone while in 3 studies in association respectively with Tolterodina, Ketorolac and Tamsulosin. In 7 studies were reported side effects in only 81 patients, 60 in pediatric population and 21 in adult population. The reported side effects in pediatric population were nausea, lethargy, lower limb weakness, headache, diarrhea, viral gastroenteritis. The reported side effects in adult population were asymptomatic hyponatriemia, nausea, diarrhea, dizziness, symptomatic hyponatriemia. Our review confirm that the MELT formulation of desmopressin guarantee the same response of other formulations with a lower doses and a lowest number of side effects. We believe according with the literature that this formulation is actually the first line and safety treatment for nocturnal enuresis and nocturia.