Pentosan Polysulfate Maculopathy: What Urologists Should Know in 2020

Characterization of pentosan polysulfate patients for development of an alert and screening system for ophthalmic monitoring

OBJECTIVE

Pentosan polysulfate (PPS; ELMIRON, Janssen Pharmaceuticals, Titusville, NJ) is a U.S. Food and Drug Administration-approved oral medication for interstitial cystitis. Numerous reports have been published detailing retinal toxicity with the use of PPS. Studies characterizing this condition are primarily retrospective, and consequently, alert and screening systems need to be developed to actively screen for this disease. The goal of this study was to characterize ophthalmic monitoring trends of a PPS-using patient sample to construct an alert and screening system for monitoring this condition.

METHODS

A single-institution retrospective chart review was conducted between January 2005 and November 2020 to characterize PPS use. An electronic medical record (EMR) alert was constructed to trigger based on new PPS prescriptions and renewals offering ophthalmology referral.

RESULTS

A total of 1407 PPS users over 15 years was available for characterization, with 1220 (86.7%) being female, the average duration of exposure being 71.2 ± 62.6 months, and the average medication cumulative exposure being 669.7 ± 569.2 g. A total of 151 patients (10.7%) had a recorded visit with an ophthalmologist, with 71 patients (5.0%) having optical coherence tomography imaging. The EMR alert fired for 88 patients over 1 year, with 34 patients (38.6%) either already being screened by an ophthalmologist or having been referred for screening.

CONCLUSIONS

An EMR support tool can improve referral rates of PPS maculopathy screening with an ophthalmologist and may serve as an efficient method for longitudinal screening of this condition with the added benefit of informing pentosan polysulfate prescribers about this condition. Effective screening and detection may help determine which patients are at high risk for this condition.

Nationwide Usage of Pentosan Polysulfate and Practice Patterns of Pentosan Polysulfate Maculopathy Screening in South Korea

OBJECTIVE

To investigate the nationwide use of pentosan polysulfate (PPS) and screening practices for PPS maculopathy (PPM), with a focus on the timing and modalities used.

DESIGN

Population-based cohort study.

PARTICIPANTS

For evaluation of nationwide usage, 133 762 individuals who received PPS prescriptions between 2012 and 2021 were included. To investigate practice patterns, 55 487 individuals (referred to as overall users) who initiated PPS therapy between 2018 and 2020 were identified using the Health Insurance Review and Assessment database. After excluding patients with ophthalmic diseases before PPS administration, 34 857 PPS users without prior ophthalmic diseases were identified.

METHODS

Ophthalmic examinations performed after initiating PPS therapy were categorized as baseline and subsequent monitoring examinations. The timing and modalities employed for these examinations were analyzed. The annual trends in PPS utilization and maculopathy screening were evaluated by assessing the number of PPS users and determining the proportion of patients receiving retinal/macular examinations among these users.

MAIN OUTCOME MEASURES

Performance of baseline and subsequent monitoring examinations and timing and modalities used for screening.

RESULTS

The number of PPS users dramatically increased annually over the study period from 5494 in 2012 to 40 451 in 2021. However, the majority of PPS users did not undergo baseline or subsequent monitoring examinations for PPM. Only 27.2% and 12.4% of PPS users without prior ophthalmic disease underwent baseline and monitoring examinations, respectively. Funduscopy/fundus photography was the most commonly utilized, whereas OCT and fundus autofluorescence (FAF) were performed in only 45.2% and 5.3% of the PPS users without prior ophthalmic diseases for monitoring, respectively. The performance of the screening examinations differed significantly across the 3 different daily dose and duration groups (all P < 0.05).

CONCLUSIONS

This study highlights the lack of performance of baseline and monitoring examinations for maculopathy in most patients taking PPS in South Korea. The limited use of OCT and FAF suggests potential insensitivity in detecting PPM. These findings emphasize the need for improvements in screening practices, including increased awareness and referrals to ophthalmologists, utilization of more sensitive modalities, and regular monitoring to enable early detection of PPM.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Non-Surgical Management of Chronic Pelvic Pain in Females

PURPOSE OF REVIEW

The purpose of this paper is to review the most recent literature on non-surgical therapeutic options for chronic pelvic pain in females.

RECENT FINDINGS

Chronic pelvic pain can arise from virtually any organ system in the human body. If a precise etiology is identified, the management of chronic pelvic pain can be tailored accordingly. In some cases, patients with chronic pelvic pain can remain without a specific diagnosis. In these circumstances, adequate symptom control can still be achieved even if no underlying disorder is found. Although chronic pelvic pain is often a difficult disorder to manage, several non-surgical management options exist. Employing a multidisciplinary approach, most patients can achieve adequate symptom relief, usually without the need for surgical intervention.

Do medication prescription patterns follow guidelines in a cohort of women with interstitial cystitis/bladder pain syndrome?

OBJECTIVE

To describe prescription prevalence of oral bladder pain medications among women with interstitial cystitis/bladder pain syndrome (IC/BPS) and to compare with current treatment guidelines.

METHODS

We sampled female patients with an ICD-9/10 diagnosis of IC/BPS (595.1/N30.10) by querying active users of the Veterans Health Administration. Medical records were reviewed to determine whether patients met IC/BPS diagnostic criteria. A cohort of women with other pelvic pain disorders was identified. Prescription prevalence of typical non-narcotic oral bladder pain medications was compared between the two groups and healthy controls. Prescription prevalence was also compared before and after the diagnosis of IC/BPS was made using Poisson regression.

RESULTS

There were 641 women who met criteria for IC/BPS and 197 women with "Other pelvic pain" disorders. Women with IC/BPS were prescribed a pain medication more often than those with "Other pelvic pain" (77% vs. 59%, p < 0.0001). Of the women with IC/BPS, 44% tried three or more pain medications. Of women with a diagnosis of IC/BPS, only 67% were prescribed an American Urological Association-recommended medication. Prescription prevalence increased after diagnosis for both pentosan polysulfate (10%-29%, p < 0.0001) and hydroxyzine (17%-40%, p < 0.0001), but not for amitriptyline or cimetidine. Amitriptyline was prescribed to 223 women with IC/BPS, only 125 of which (56%) had a documented history of depression.

CONCLUSIONS

Many women with IC/BPS required multiple bladder prescriptions, highlighting the difficulty in finding an effective treatment for IC/BPS. Pentosan polysulfate and hydroxyzine were preferred IC/BPS medications. Our next step will be to analyze treatment patterns in those patients who did not receive medications.

Redefining the Spectrum of Pentosan Polysulfate Retinopathy: Multimodal Imaging Findings from a Cross-Sectional Screening Study

PURPOSE

There is growing evidence of a direct association between Pentosan polysulfate (PPS) therapy and the development of macular changes. Using standardized visual acuity testing and multimodal imaging, we investigate the impact on vision and describe an expanded spectrum of imaging findings among PPS users.

DESIGN

Cross-sectional screening study.

PARTICIPANTS

Thirty-nine patients who were current or recent users of PPS.

METHODS

Participants underwent a brief eye exam and answered a comprehensive medical and ophthalmic history questionnaire. Color fundus photography, fundus autofluorescence (FAF) and spectral domain optical coherence tomography (SD-OCT) were obtained. Images were evaluated by expert graders at the Wisconsin Reading Center. Abnormalities were categorized as definitive toxicity (DT) if seen on both FAF and SD-OCT and questionable toxicity (QT) if seen on either FAF or SD-OCT.

MAIN OUTCOME MEASURES

Early Treatment Diabetic Retinopathy Study (ETDRS) and Snellen visual acuity (VA), dosage and duration of PPS exposure, prevalence of retinal toxicity on imaging.

RESULTS

Mean ETDRS and Snellen VA of the study cohort was 85 letters and 20/22, respectively. The mean PPS daily dose was 282 mg (88-400 mg), while the mean cumulative dose was 915 g (19-3650 g) over a mean period of 8.8 years (2 months-25 years). 41% of eyes evidenced retinopathy; DT was identified in 24 (31%) eyes and QT in 8 (10%) eyes. Retinal pigment epithelium (RPE) abnormalities (thickening and/or thinning) were present in all DT eyes. RPE atrophy was seen in 7 (9%) eyes. In addition to well-established findings, unique SD-OCT features of this cohort include interdigitation zone abnormalities and the presence of a flying-saucer-type defect. FAF abnormalities were seen in 24 (30.8%) of eyes, with 20 (66.7%) of these exhibiting abnormalities located outside the central subfield and extending beyond the arcades.

CONCLUSION

Findings from masked grading of multimodal imaging at a centralized reading center suggest a wider phenotypic spectrum of structural abnormalities among patients taking PPS. Macular changes selectively involve the RPE and outer retina, with a range of findings often seen beyond the arcades. The subtle and atypical findings in this cohort should prompt clinicians to consider lowering the threshold for diagnosing PPS retinopathy.

Pentosan Polysulfate Sodium-Associated Pigmentary Retinopathy: Risk Factors and Fundus Findings

Purpose

To evaluate the risk factors and fundus findings of patients with potential PPS-associated retinopathy.

Patients and Methods

A retrospective chart review was performed of patients exposed to PPS who had a dilated fundus examination at a large retina-only practice from 2018–21. Multimodal images were evaluated by masked reviewers.

Results

A total of 148 patients were included, of whom 33 (22%) had PPS-associated retinopathy, and 115 (78%) did not. The mean age was 60.3 years old, and the mean follow-up was 11.8 months. The PPS-associated retinopathy group had higher mean cumulative doses of PPS (1600g±849 vs 864g±852, P < 0.0001, Mann–Whitney test) and longer duration of PPS use (13.6 years vs 7.48, P < 0.0001). There was no statistically significant difference based on a history of kidney or liver disease or the dosage per day for the weight, body mass index, body surface area, or lean body weight. Of the patients with PPS-associated retinopathy whose genetic results were available, 15 of 16 (93%) were heterozygous for variants of uncertain significance.

Conclusion

A longer duration of PPS use and higher cumulative dosage of PPS were associated with an increased risk of developing PPS-associated pigmentary retinopathy. The role of genetic mutations in patients exposed to PPS is still to be determined.

Update on Retinal Drug Toxicities

Purpose of Review

This review aims to provide an update on the clinical presentations and diagnostic findings of drug-induced retinal toxicities.

Recent Findings

Several newly FDA-approved medications have been associated with acute retinal toxicities, including brolucizumab, MEK inhibitors, ulixertinib, and FGFR inhibitors. Additionally, as previously believed-to-be well-tolerated medications, such as pentosan sulfate sodium, anti-retroviral therapies, and certain intraoperative ocular medications, are used more frequently or for longer periods of time, associated toxic retinopathies and inflammatory reactions have been reported. Finally, advances in ocular imaging have revealed novel findings in hydroxychloroquine and tamoxifen maculopathies.

Summary

Discovery of new medications, increased frequency of use, and longer-term use have led to increased reports of retinal toxicities. Advances in retinal imaging have allowed for earlier detection of subclinical changes associated with these medications, which may help prevent progression of disease. However, more research is needed to determine the point at which vision loss becomes irreversible. Risks and benefits must be assessed prior to discontinuation of the offending, but potentially lifesaving, therapy.

Treatment of cystoid macular oedema secondary to pentosan polysulfate maculopathy using anti-VEGF and intravitreal steroid injections

BACKGROUND

Pentosan polysulfate-related maculopathy is a recently described clinical entity, related to dose and long term use of this medication, and may progress despite drug cessation. Cystoid macular oedema (CMO) has been reported in some cases, but there are few reports of treatment outcomes in the literature.

AIMS

We present the case of a 55 year old female, with CMO secondary to pentosan polysulfate maculopathy, that was responsive to treatment with both intravitreal anti-VEGF and steroid injections, stabilising vision over a four year follow up period.

CONCLUSIONS

This is the first report, to our knowledge, of CMO related to pentosan polysulfate maculopathy responding to intravitreal steroid injections, broadening the therapeutic options for preserving vision in these patients.

Association of Elmiron (pentosanpolysulphate sodium) with pigmented maculopathy: An update for urologists and patients

Introduction:

Bladder pain syndrome (BPS) is a difficult disorder to diagnose and manage with a limited number of treatment options that have a good evidence base. Elmiron (pentosanpolysulphate sodium (PPS)) is recognised as a main second-line treatment option in many international guidelines. Recently published retrospective studies suggest that there is an association between Elmiron and pigmented maculopathy, a rare disease associated with visual impairment.

Objectives:

To review the known literature on Elmiron and pigmented maculopathy and alternative oral pharmacotherapy options for BPS. To promote awareness on this topic and aid urologists in managing Elmiron prescription.

Methods:

We reviewed the most commonly used oral treatments for BPS, in particular Elmiron, the current evidence to support this association with eye disease and its position in the management pathway of this complex condition.

Conclusions:

Recent retrospective longitudinal studies have demonstrated an association of Elmiron with pigmented maculopathy. However, as yet the exact nature of this relationship is unknown. Nevertheless, Elmiron remains an important part of the treatment pathway for BPS. We suggest clinicians should fully inform patients of this association, including patients who have been previously comenced on Elmiron. There should be ongoing and continuing reviews of all treatments to review its efficacy in indiviual patients.

Level of evidence:

Not applicable

Update on maculopathy secondary to pentosan polysulfate toxicity

PURPOSE OF REVIEW

The aim of the present review is to provide a comprehensive summary of available knowledge regarding toxic maculopathy secondary to pentosan polysulfate sodium (PPS).

RECENT FINDINGS

PPS toxicity was described in 2018, and additional studies characterize it as dysfunction of the retinal pigment epithelium centered on the posterior pole, which can progress despite drug cessation. Requisite exposure can be as little as 0.325 kg and 2.25 years but averages closer to 1-2 kg and 10-15 years. Multimodal imaging should include near-infrared reflectance, optical coherence tomography, and fundus autofluorescence. Cross-sectional studies demonstrate evidence correlating cumulative dosing and the likelihood/severity of maculopathy. Early estimates of prevalence range from 12.7 to 41.7% depending on dosing, with overall rates around 20%.

SUMMARY

Reasonable evidence associates maculopathy with extended exposure to PPS, with an average reported incidence of around 20% in patients with long-term exposures. Patients with unexplained retinal pigment epithelium changes and difficulty with dark adaptation should be questioned regarding PPS exposure, and patients with known exposure to PPS should be examined. Further research is needed to refine screening protocols. Currently, providers should consider baseline examination and examination at 5 years and/or 500 g of exposure followed by yearly screening.