Desmopressin in the treatment of nocturnal polyuria in the male

Current and Emerging Pharmacological Targets and Treatments of Urinary Incontinence and Related Disorders

Overactive bladder syndrome with and without urinary incontinence and related conditions, signs, and disorders such as detrusor overactivity, neurogenic lower urinary tract dysfunction, underactive bladder, stress urinary incontinence, and nocturia are common in the general population and have a major impact on the quality of life of the affected patients and their partners. Based on the deliberations of the subcommittee on pharmacological treatments of the 7th International Consultation on Incontinence, we present a comprehensive review of established drug targets in the treatment of overactive bladder syndrome and the aforementioned related conditions and the approved drugs used in its treatment. Investigational drug targets and compounds are also reviewed. We conclude that, despite a range of available medical treatment options, a considerable medical need continues to exist. This is largely because the existing treatments are symptomatic and have limited efficacy and/or tolerability, which leads to poor long-term adherence. SIGNIFICANCE STATEMENT: Urinary incontinence and related disorders are prevalent in the general population. While many treatments have been approved, few patients stay on long-term treatment despite none of them being curative. This paper provides a comprehensive discussion of existing and emerging treatment options for various types of incontinence and related disorders.

Oral desmopressin in nocturia with benign prostatic hyperplasia: A systematic review of the literature

Objective

To evaluate the effect of oral desmopressin in patients with nocturia associated with benign prostatic hyperplasia (BPH).

Patients and methods

With a rise of the use of oral desmopressin in the treatment of nocturia in patients with BPH, a systematic review was performed according to the Cochrane systematic reviews guidelines and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist.

Results

The literature search yielded 18 studies. The studies were published between 1980 and 2017, and included 3072 patients. Eligible patients were men aged ≥50 years with lower urinary tract symptoms (LUTS) and persistent nocturia. There was a significant 43% reduction in nocturia after using desmopressin alone. Combined α-blockers and desmopressin lead to a decrease in the frequency of night voids by 64.3% compared to 44.6% when using α-blockers only. The first sleep period, significantly increased from 82.1 to 160.0 min and from 83.2 to 123.8 min when using desmopressin + α-blocker and α-blocker only, respectively. The desmopressin dose ranged from the lowest dose (0.05 mg) to the optimum dose (0.4 mg) at bed time. The incidence of hyponatraemia associated with desmopressin use was 4.4–5.7%.

Conclusion

Low-dose oral desmopressin therapy alone is an effective treatment for nocturia associated with LUTS in patients with BPH. Oral desmopressin combined with α-blockers is well tolerated and beneficial for improving the International Prostate Symptom Score and nocturnal symptoms. All patients should be educated about the mechanism of desmopressin action to avoid treatment discontinuation due to adverse events.

[Impact of medical and surgical treatments of LUTS on nocturia]

INTRODUCTION

Nocturia is the most frequently reported lower urinary tract symptom, but the impact of medical and surgical treatments on this symptom remains poorly evaluated. The objective of this work was to carry out a systematic review of the literature on the medical and surgical management of nocturia in men with bladder outlet obstruction due to benign prostatic hyperplasia.

MATERIAL AND METHOD

A systematic review of the literature was conducted including the effects of medical and surgical treatments on nocturia. Articles were selected by 3 independent reviewers before being analyzed and synthesized.

RESULTS

Among medical treatments, the most effective on nocturia seems to be desmopressin. Nevertheless, prescribing restrictions to men under 65 years of age hinder its use in routine practice. The effect of other medical treatments remains modest, although significant compared to placebo groups. The decrease in the number of nocturia would decrease from 0.25 to 0.7 in placebo group and from 0.29 to 1.1 in active treatment groups (alpha blocker, diuretic, anti-inflammatory, IPDE-5, 5 alpha reductase inhibitor). Surgical treatments seem to be more effective on nocturia. Although persistent in half of the patients undergoing surgery, the number of nocturia episodes decreased in 70% of them.

CONCLUSION

Nocturia is one of the most common urinary symptoms and the one that responds the least to the proposed medical and surgical treatments. The information given to patients by urologists must emphasize the modest effects to be expected in this area.

Desmopressin for treating nocturia in men

OBJECTIVES

To assess the effects of desmopressin as compared to other interventions in the treatment of nocturia in men.

MATERIALS AND METHODS

We performed a comprehensive search using multiple databases and abstract proceedings with no restrictions on the language of publication or publication status, up until August 2017. We included randomised or quasi-randomised trials. Inclusion criteria were men with nocturia defined as one or more voids per night. Two review authors independently examined full-text reports, identified relevant studies, assessed the eligibility of studies for inclusion, extracted data, and assessed risk of bias. We performed statistical analyses using a random-effects model and assessed the quality of the evidence (QoE) according to Grades of Recommendation, Assessment, Development and Evaluation (GRADE).

RESULTS

We included 14 studies with 2 966 randomised men across five comparisons (we did not include one comparison [desmopressin vs behaviour modification] in the abstract due to a lack of data with regard to primary outcomes). Desmopressin vs placebo: based on short-term follow-up (≤3 months), desmopressin may have a similar effect on the number of nocturnal voids (mean difference [MD] -0.46, 95% confidence interval [CI] -0.94 to 0.01; low QoE). We are uncertain about the effect of desmopressin on major adverse events (risk ratio [RR] 0.97, 95% CI: 0.10-9.03; very low QoE). For intermediate-term follow-up (3-12 months), desmopressin may reduce the number of nocturnal voids in an appreciable number of men (MD -0.85, 95% CI: -1.17 to -0.53; low QoE). Desmopressin may result in little or no difference in major adverse events (RR 3.05, 95% CI: 0.13-73.39; low QoE). We found no evidence on quality of life. Desmopressin vs α-blocker (AB): based on short-term follow-up, desmopressin likely has a similar effect on the number of nocturnal voids (MD 0.30, 95% CI: -0.20 to 0.80; moderate QoE) and quality of life (MD 0.00, 95% CI: -0.35 to 0.35; moderate QoE). There were no major adverse events in either study group. Desmopressin plus AB vs AB alone: based on short-term follow-up, combined therapy likely results in a small, unimportant reduction in the number of nocturnal voids (MD -0.47, 95% CI: -0.73 to -0.21; moderate QoE) and quality of life (MD -0.29, 95% CI: -0.51 to -0.07; moderate QoE). The risk of major adverse events may be similar (RR 0.30, 95% CI: 0.01-7.32; low QoE). Desmopressin plus AB vs AB plus an anticholinergic: based on short-term follow-up, combined therapy likely results in little or no difference in the number of nocturnal voids (MD -0.43, 95% CI: -0.97 to 0.11; moderate QoE). We found no evidence on quality of life. There were no major adverse events in either study group.

CONCLUSIONS

Desmopressin may reduce the number of nocturnal voids compared to placebo up to 12 months of follow-up without increase in major adverse events. The effect on the number of nocturnal voids is likely similar to that of ABs with very infrequent major adverse events. There appears to be no added benefit in the combined use of an AB or an anticholinergic with desmopressin.

Desmopressin for treating nocturia in men

BACKGROUND

Nocturia is the bothersome symptom of awakening one or more times per night to void. Desmopressin is a commonly used medication for treating nocturia.

OBJECTIVES

To assess the effects of desmopressin as compared to other interventions in the treatment of nocturia in men.

SEARCH METHODS

We performed a comprehensive search of medical literature with no restrictions on the language of publication or publication status. The date of the latest search of all databases was August 2017.

SELECTION CRITERIA

We included randomized or quasi-randomized trials. Inclusion criteria were men with nocturia defined as one or more voids per night. Trials of children, adults with primary or secondary enuresis or underlying distinct disorders were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently classified studies and abstracted data from the included studies. We performed statistical analyses using a random-effects model and interpreted data according to the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We included 14 studies with 2966 randomized men across five comparisons. Desmopressin versus placebo: based on short-term follow-up (up to three months), desmopressin may have a similar effect on the number of nocturnal voids (mean difference (MD) -0.46, 95% confidence interval (CI) -0.94 to 0.01; low-quality evidence). We are uncertain about the effect of desmopressin on major adverse events at short-term follow-up (risk ratio (RR) 0.97, 95% CI 0.10 to 9.03; very low-quality evidence). For intermediate-term follow-up (three to 12 months), desmopressin may reduce the number of nocturnal voids in an appreciable number of participants (MD -0.85, 95% CI -1.17 to -0.53; low-quality evidence). Desmopressin may result in little or no difference in major adverse events at intermediate-term follow-up (RR 3.05, 95% CI 0.13 to 73.39; low-quality evidence). We found no evidence on quality of life. Subgroup analyses suggest a larger effect with oral, higher-dose formulations of desmopressin and in men with documented nocturnal polyuria. Desmopressin versus behavior modification: there were no data regarding the effect on the number of nocturnal voids, quality of life, or major adverse events. Desmopressin versus alpha-blocker: based on short-term follow-up, desmopressin likely has a similar effect on the number of nocturnal voids (MD 0.30, 95% CI -0.20 to 0.80; moderate-quality evidence) and quality of life (MD 0.00, 95% CI -0.35 to 0.35; moderate-quality evidence). There were no major adverse events in either study group. Desmopressin plus alpha-blocker versus alpha-blocker alone: based on short-term follow-up, combination therapy likely results in a small, unimportant reduction in the number of nocturnal voids (MD -0.47, 95% CI -0.73 to -0.21; moderate-quality evidence) and quality of life (MD -0.29, 95% CI -0.51 to -0.07; moderate-quality evidence). The risk of major adverse events may be similar (RR 0.30, 95% CI 0.01 to 7.32; low-quality evidence). Desmopressin plus alpha-blocker versus alpha-blocker plus an anticholinergic: based on short-term follow-up, combination therapy likely results in little or no difference in the number of nocturnal voids (MD -0.43, 95% CI -0.97 to 0.11; moderate-quality evidence). We found no evidence on quality of life. There were no major adverse events in either study group.

AUTHORS' CONCLUSIONS

Desmopressin may reduce the number of nocturnal voids in an appreciable number of participants compared to placebo in intermediate-term (three to 12 months) follow-up without increase in major adverse events. We found no evidence to compare its effects to behavior modification. The effect on the number of nocturnal voids is likely similar to that of alpha-blockers short-term with very infrequent major adverse events. There appears to be no added benefit in the combined use of desmopressin with an alpha-blocker or an anticholinergic. The findings of this review were limited by short-term follow-up, study limitations, and imprecision.

Desmopressin in adult urological disease: clinical evidences

Desmopressin is a synthetic analogue of arginine vasopressin, commercially available since 1974. Desmopressin is proven effective for the treatment primary nocturnal enuresis and polyuria. It has been considered by several investigators for the treatment of nocturia with positive results and is now an established treatment for this indication. In this review, we assessed the available clinical data on desmopressin in adult urological disease.

Efficacy of intranasal desmopressin for the treatment of nocturnal polyuria in the elderly females

Older adults often complain of nocturia as one of the most bothersome symptoms of lower urinary tract incontinence. Nocturia places such patients at risk of falling down and insomnia and increases the care burden. The causes of nocturia include various factors, such as neuropathic bladder, prostate hyperplasia and pelvic floor muscle weakness. It has also been reported that nocturia is caused by an increased renal blood flow while lying down and the loss of diurnal variation in vasopressin. The intranasal administration of desmopressin at night may improve nocturia. We experienced a case of severe nocturia that could not be controlled with fluid restriction, urethral catheterization before sleep or anticholinergic drugs. Due to frequent urination during the night, the patient was unable to sleep well and required frequent nursing care. Following the administration of nasal desmopressin before sleep, the number of episodes of nocturia considerably improved. In addition, no adverse events, such as hyponatremia, were observed with desmopressin use. Physicians should therefore consider using desmopressin in cases with treatment-resistant nocturia.

A retrospective review of the ambulatory blood pressure patterns and diurnal urine production in subgroups of spinal cord injured patients

STUDY DESIGN

Retrospective study.

OBJECTIVES

To quantify diurnal blood pressure (BP) patterns and nocturnal hypertension and to measure diurnal urine production in spinal cord injury (SCI) patients with clinically significant disorders of BP control.

SETTING

A specialist state-based spinal cord service in Victoria, Australia.

METHODS

Medical records of patients with traumatic SCI who were referred to a specialist service for management of a BP disorder were examined. Ambulatory BP and nocturnal urine production were compared between groups of patients classified according to level, completeness and chronicity of SCI. Patients with night:day systolic BP <90% were classified as dippers, 90-100% as non-dippers and >100% as reversed dippers.

RESULTS

Patients (44 tetraplegic, 10 paraplegic) were predominantly males (92.6%) aged 41±2.5 years (mean±s.e.m.). Referral was for orthostatic intolerance (n=37), autonomic dysreflexia (n=6), nocturnal polyuria (n=4), elevated BP (n=1) and peripheral oedema (n=1). The average BP was 111.1±1.4/65.0±1.2 mm Hg. In 56% of patients (n=30), BP at night was higher than during the day and another 37% (n=20) were non-dippers. Nocturnal hypertension was present in 31% (n=17) of the patients. In the tetraplegic patients, urine flow rate was greater during the night than day (121±9.5 ml h(-1) vs 89±8.2 ml h(-1), P=0.025).

CONCLUSION

Ambulatory BP monitoring in patients with SCI and clinically significant BP disorders detected a high incidence of reversed dipping and nocturnal hypertension. We postulate elevated nocturnal BP may contribute to nocturnal diuresis that might cause relative volume depletion and thereby contribute to daytime orthostatic hypotension.

Nocturia in older men

Nocturia is a common and bothersome symptom that impacts on sleep-quality and quality of life. Nocturia often has a multi-factorial etiology which makes thorough assessment of the complaint indispensable. This review summarizes the definition of nocturia, its epidemiology, clinical presentation, pathophysiology, diagnostics, and treatment options with special reference to older men. Nocturia is defined as a nocturnal voiding frequency of two or more, based on impact on quality of life. It is very prevalent in older men. Apart from the negative effects of sleep-disruption, it may be a risk-factor for hip fractures and increased mortality. Most common causes are: nocturnal polyuria, 24-h polyuria, overactive bladder (sometimes due to BPH) and sleep disturbance. A clear understanding of the etiology in the individual patient is indispensable when addressing the various possible causes and co-morbidities. Most important tool for this is the frequency-volume chart, but also patient history, physical examination and serum analysis. For treatment, lifestyle adjustments are often helpful. Medical therapy with 5-alpha reductase inhibitors, alpha-blockers, a combination of the two, or anti-muscarinics, has a limited effect. Most important medical option is desmopressin (arginine vasopressin analogue); however, treatment with this drug is limited to men under 65 years mainly due to the risk of hyponatraemia.

Efficacy and safety of desmopressin for treatment of nocturia: a systematic review and meta-analysis of double-blinded trials

PURPOSE

The purpose of this analysis was to evaluate the efficacy and safety of desmopressin for the treatment of nocturia.

METHODS

Databases including MEDLINE, EMBASE, ISI web of knowledge, the Cochrane Controlled Trial Register of Controlled Trials and Chinese Biological Medical Database were searched to identify randomized controlled trials (RCTs) that referred to the efficacy and safety of desmopressin for the treatment of nocturia. A systematic review and meta-analysis were conducted.

RESULTS

Five studies involving 619 participants were included for the meta-analysis, and 8 RCTs of cross-over design were also identified for the systematic review. The analysis revealed that desmopressin might significantly decrease the frequency of nocturnal voids, nocturnal urine volume and nocturnal diuresis, potentially resulting in an extended duration of the first sleep period and improved sleep quality. The adverse effects of desmopressin were similar to those observed in the placebo group.

CONCLUSIONS

Administered desmopressin was an effective and well-tolerated treatment for nocturia.

Vasopressin receptors in voiding dysfunction

Arginine vasopressin (AVP), also known as vasopressin or anti-diuretic hormone, is a neuropeptide produced in the hypothalamus. It is primarily responsible for osmoregulation and thus maintains body fluid homeostasis. It is also a potent vasoconstrictor, may have a role in higher cognitive functions and affects metabolism. All the biological and cellular effects of vasopressin are mediated by the interaction of this hormone with three G-protein-coupled receptors - V(1a), V(1b) and V(2).Urological applications are based on the rationale that V(2) receptors mediate water conservation and increase urine osmolality. Due to their anti-diuretic properties mediated by the V(2) receptors, synthetic vasopressin agonists, such as desmopressin, are now commonly used for the treatment of nocturnal polyuria, central diabetes insipidus and nocturnal enuresis and potentially in urinary incontinence. Desmopressin has been licenced worldwide for haematological indications of haemophilia and von Willebrand disease. Vasopressin receptor antagonists correct hyponatremia by blocking the activation of the V(2) receptor and induce a free water diuresis without an accompanying natriuresis or kaliuresis; an effect termed 'aquaresis'. Interfering with vasopressin signalling by administering vasopressin antagonists may have clinical benefits in acute and chronic heart failure.

Frequency volume charts should be used in men with lower urinary tract symptoms

A frequency volume chart is a simple, easy-to-use, non-invasive tool that is useful in the assessment of patients with lower urinary tract symptoms. Though more sophisticated techniques are now available for diagnosis, the frequency volume chart should still be considered the first line investigation. In this review we summarize the indications and value of this age old investigation. Urologists and primary care physicians should use the frequency volume chart more frequently in their practice.

Nocturnal polyuria in patients with lower urinary tract symptoms and response to alpha-blocker therapy

OBJECTIVES

To determine the prevalence of nocturnal polyuria (NP, defined as a nocturnal urine fraction exceeding one third of the daily urine output in elderly men) in patients with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) and clinical responsiveness to alpha-blocker therapy.

METHODS

Outpatients with LUTS suggestive of BPH were included. Patients filled out the International Prostate Symptom Score questionnaire and a 7-day voiding diary, and urinalysis, prostate-specific antigen measurement, uroflowmetry, and ultrasonography were performed. Patients with NP were given alpha-blocker therapy (tamsulosin 0.4 mg/day) for 6 weeks and then re-evaluated for NP and urinary symptoms.

RESULTS

A total of 58 outpatients were included in the study. Of these, 95% had NP. The mean frequency of nocturia was 2.73 +/- 1.44 per day. A significant correlation was found between NP and the duration of LUTS (r = 0.393, P = 0.035) and the amount of water intake within 3 hours before sleep (r = 0.731, P = 0.001). Of the patients with NP, 20 were given alpha-blocker therapy. After therapy, the peak urinary flow rate had increased significantly, but NP remained unchanged in 75% of the patients.

CONCLUSIONS

NP is a common symptom accompanying LUTS suggestive of BPH. Our results showed that it is significantly related to the duration of LUTS and amount of water intake before sleep. NP cannot be treated with alpha-blocker therapy, although there is improvement in LUTS suggestive of BPH.

The pharmacokinetics of 400 microg of oral desmopressin in elderly patients with nocturia, and the correlation between the absorption of desmopressin and clinical effect

OBJECTIVE

To investigate the pharmacokinetic profile of oral desmopressin in elderly patients with nocturia, and to analyse any possible correlation between the absorption and clinical effect.

PATIENTS AND METHODS

In all, 32 patients were screened to determine the baseline number of nocturnal voids and the nocturia index; of these, 24 fulfilled the inclusion criteria and were enrolled for a pharmacokinetic evaluation of oral desmopressin 400 microg. A double-blind, randomized, placebo-controlled, crossover-effect evaluation period was then used to test the association between the absorption of desmopressin and pharmacodynamic effect. Serial plasma samples were collected for 8 h for a pharmacokinetic analysis of desmopressin. The pharmacodynamics after an equivalent oral dose before bedtime were assessed by measuring changes in the number of nocturnal voids, time to first nocturnal void and nocturnal diuresis, from placebo to active treatment.

RESULTS

There was a linear relationship between plasma desmopressin at 2 h after dosing and the area under the plasma concentration curve from 0 to infinity (Pearson's rho 0.923, P < 0.001). Women had a significantly higher plasma desmopressin concentration than men (P = 0.0012) and more adverse events. There was no correlation between plasma desmopressin at 2 h after dosing and the within-patient response in any of the effect variables. Generally, the number of nocturnal voids and nocturnal diuresis were half that with placebo. The time to the first nocturnal void was almost doubled compared with placebo.

CONCLUSIONS

There seems to be a relationship between gender, plasma level of desmopressin and the incidence of adverse events. Plasma desmopressin at 2 h after dosing cannot be used to predict the pharmacodynamic response, although desmopressin lowers the nocturnal diuresis and the number of nocturnal voids.

Nocturnal polyuria in women with overactive bladder symptoms and nocturia

OBJECTIVE

This study was undertaken to determine the prevalence of nocturnal polyuria in women complaining of nocturia and overactive bladder (OAB) symptoms and to identify clinical and health characteristics associated with nocturnal polyuria.

STUDY DESIGN

Women presenting to a urogynecology clinic with complaints of nocturia and OAB symptoms were asked to participate. They completed a health characteristic summary, 3-day voiding diary, Nordic sleep questionnaire, urinary distress inventory (UDI), and a nocturia distress visual log (NDVL). The 24-hour urine production, nighttime urine volume, and maximum bladder capacity were calculated from the bladder diary. Nocturnal polyuria was defined as production of greater than 33% of the 24-hour urine volume during an 8-hour sleep period. A histogram was performed to analyze at what age the prevalence of nocturnal polyuria increased. Women were then divided by presence or absence of nocturnal polyuria and compared by the health and clinical characteristics.

RESULTS

Fifty-five women met the qualifications and participated in the study. Average age of the cohort was 65.8 +/- 13.5 years. The risk of nocturnal polyuria increased with age 65 years or older (prevalence for age 65-74 = 0.86 [0.62-1.00]) and with white race. On the basis of the mean population values for UDI, NDVL, sleepiness scores, and insomnia scores, all women were bothered by their nocturia. Median number of nighttime voids, 24-hour urine production, maximum bladder capacity, nocturnal index, UDI, NDVL, sleepiness scores, and insomnia scores did not differ, based on presence or absence of nocturnal polyuria.

CONCLUSION

Among women complaining of nocturia and overactive bladder symptoms, age 65 years or older and white race appear to be risk factors for nocturnal polyuria.

Nocturnal polyuria with abnormal circadian rhythm of plasma arginine vasopressin in post-stroke patients

OBJECTIVE

Nocturia is a common reason for interrupted sleep in post-stroke patients. These patients often have neurogenic bladder overactivity. However, little is known about the possible contribution of nocturnal polyuria in the patients.

METHODS

We measured the number of nocturia, the circadian plasma arginine vasopressin (AVP) level and urinary excretion in 4 patients with stroke.

RESULTS

All patients had nocturnal urinary frequency (three times in one and twice in 3). All patients were revealed to have nocturnal polyuria, and the ratio of nocturnal urinary output to 24 hour volume ranged from 36% to 63%. Measurement of daily plasma AVP variation showed that all patients lost normal nocturnal rise of the plasma AVP concentration. Two patients were successfully treated with 5 mug of intranasal desmopressin once a night, a potent analogue of AVP, without hypertension particularly in the night, signs of congestive cardiac failure or any electrolyte abnormality such as hyponatremia.

CONCLUSION

Our post-stroke patients had nocturnal polyuria with abnormal circadian rhythm of plasma AVP secretion. Desmopressin reduced nocturnal waking in urination. It also ameliorated nocturnal dehydration that might trigger a stroke recurrence in the patients.

Pharmacokinetics and renal excretion of desmopressin after intravenous administration to healthy subjects and renally impaired patients

OBJECTIVE

To evaluate the influence of renal impairment on the pharmacokinetics of desmopressin.

METHODS

Twenty-four subjects were enrolled in the study, 18 with varying degrees of renal impairment and six healthy volunteers. Each subject received a single intravenous dose of 2 microg desmopressin. Blood and urine samples were collected for 24 h and assayed for desmopressin by radioimmunoassay. Plasma concentrations and the amounts of desmopressin excreted in the urine were analysed simultaneously by use of mixed effects modelling.

RESULTS

Only mild adverse events were observed. Both the renal and the nonrenal clearance of desmopressin were found to vary with the creatinine clearance (CrCL). A decrease of 1.67% in the CrCL (corresponding to 1 ml min(-1) from 60 ml min(-1)) was found to cause a 1.74% decrease in the renal clearance and a 0.93% decrease in the nonrenal clearance. The fall in renal clearance caused the amount of desmopressin excreted in urine to decrease from 47% in healthy subjects to 21% in the patients with severe renal impairment. The mean systemic clearance of desmopressin was 10 litres h(-1) in healthy subjects and 2.9 litres h(-1) in patients with severe renal impairment (difference -7.5 litres h(-1), 95% CI [-11; -4.3] litres h(-1)). Correspondingly, the mean terminal half-life, was 3.7 h in healthy subjects and 10 h in patients with severe renal impairment (difference 6.7 h, 95% CI [4.0; 9.4] h).

CONCLUSION

Although desmopressin appears to be safe and well-tolerated by patients with impaired renal function, great caution should be exercised when titrating towards an efficient dosage regimen if patients with moderately or severely impaired renal function are to be treated with desmopressin at all.

Pharmacokinetics and pharmacodynamics of desmopressin administered orally versus intravenously at daytime versus night-time in healthy men aged 55-70 years

OBJECTIVE

To investigate (1) the pharmacokinetic and pharmacodynamic profiles of desmopressin in men from an age group with a high incidence of nocturia; and (2) circadian variation in the pharmacokinetic parameters.

METHODS

The study had an open, randomised, four-way cross-over design. Desmopressin was administered orally (0.2 mg) and intravenously (2 microg), daytime and night-time, yielding four in-hospital sessions, separated by at least 2 days. Blood samples were taken before and at predetermined time points up to 12 h after dosing. Pharmacokinetic parameters were derived using a two-compartmental model except for AUC(0-->t), which was derived using non-compartmental analysis. Bioavailability was estimated using AUC(0-->t) for the oral and the intravenous periods. Urine, for measurements of volume and osmolality, was collected in predetermined intervals before and until 12 h after dosing.

RESULTS

Fifteen healthy men aged 55-70 years were included in the analysis. The concentration-time curve after 2 microg intravenous desmopressin was best described using a biexponential term. The mean (95% CI) AUC at night was 302 (272-335) pg x h/ml and in the day was 281 (253-312) pg x h/ml. No statistically significant differences were detected between night and day except for terminal half-life, which was 3.1 h at night and 2.8 h in the daytime (P=0.02). After oral desmopressin, concentrations above the limit of quantification (2.5 pg/ml) were only detected in 51% of the samples. Peak plasma concentration (Cmax) was 6.2 (5.1-7.5) pg/ml at night and 6.6 (5.5-7.9) pg/ml in the daytime. Median time to reach Cmax (tmax) was 1.5 (range 1.0-4.1) h at night and 1.5 (range 0.5-3.0) h in the day. The bioavailability was 0.08%. The pharmacodynamic effects of oral and intravenous desmopressin given in the daytime were similar during the first 6 h after dosing. The night-time dosing and daytime intravenous dose resulted in antidiuresis throughout the measuring period, while the effect of the daytime peroral dose receded after 6 h.

CONCLUSION

The pharmacokinetic profile of desmopressin is biexponential. Terminal half-life was longer at night than in the daytime, but the difference is considered too small to be of clinical importance. The plasma levels given by the intravenous dose resulted in a duration of action of 12 h or more. Despite low bioavailability, the pharmacodynamic effects of oral desmopressin were similar in magnitude to those after intravenous dose at night and during the first 6 h after daytime administration.

Nocturia in older people: a review of causes, consequences, assessment and management

Nocturia is common in older people and it may be bothersome for both patients and carers. It is most commonly related to bladder storage difficulties and nocturnal polyuria. The former results most frequently from an uninhibited overactive bladder. The latter occurs as a consequence of age-associated changes in the circadian rhythm of urine excretion. The management of an overactive bladder includes both behavioural and drug treatment. The management options for nocturnal polyuria include an afternoon diuretic and desmopressin, but caution is required, particularly with the latter, as it can cause significant hyponatraemia.

The risk of hyponatremia in older adults using desmopressin for nocturia: A systematic review and meta-analysis

AIMS

To estimate the incidence of hyponatremia in older adults who use nasal or oral desmopressin to treat nocturia.

MATERIALS AND METHODS

A systematic review and meta-analysis of cohort studies and randomised controlled trials of the use of nasal or oral desmopressin for older adults with nocturia. The incidence of hyponatremia was estimated by a random effects model for binomial data.

RESULTS

Seventy-five papers were identified by the literature review of which 14 were reports of randomised trials or cohort studies. Seven studies reported the incidence of hyponatremia. The pooled estimate for the incidence of hyponatremia was 7.6% (95% CI 3.7-15.1).

CONCLUSIONS

Hyponatremia is a relatively common adverse effect of the use of desmopressin for the treatment of nocturia and caution and regular monitoring should be part of the use of this management option for nocturia in older adults.

Effects of OPC-51803, a Novel, Nonpeptide Vasopressin V2-Receptor Agonist, on Micturition Frequency in Brattleboro and Aged Rats

We assessed the effects of OPC-51803 ((5R)-2-[1-(2-chloro-4-(1-pyrrolidinyl)benzoyl)-2,3,4,5-tetrahydro-1H-1-benzazepin-5-yl]-N-isopropylacetamide), a nonpeptide vasopressin V(2)-receptor agonist, on micturition frequency in female homozygous Brattleboro rats (strain carries hereditary diabetes insipidus) and aged male Sprague-Dawley rats with polyuria. Female homozygous Brattleboro rats exhibited more diuresis and a larger micturition frequency over a 24-h period than did the heterozygous controls. In Brattleboro rats, an oral administration of OPC-51803 at 0.03 and 0.3 mg/kg significantly decreased urinary frequency and was accompanied by decreased urine volume. However, little effect was seen in the mean and maximal micturition volume. Aged male Sprague-Dawley rats (25-month-old) showed a significant increase in urine volume throughout a 0- to 24-h period compared with mature (6-month-old) rats. Orally administered OPC-51803 at 0.3 mg/kg decreased not only urine volume but also urinary frequency in aged rats. Furthermore, OPC-51803 prolonged the time prior to the first micturition. Therefore, OPC-51803 decreased micturition frequency in both rat species by reducing urine outflow. This suggests that the compound will be useful for treating micturition disorders that result in frequent micturition, such as that from polyuria, nocturnal polyuria, and some kinds of urinary incontinence.

Relation between nocturnal voiding frequency and nocturnal urine production in older men:a population-based study

OBJECTIVES

To describe the normal values for nocturnal urine production and its determinants, as well as the relation between nocturnal urine production and voiding frequency.

METHODS

Data were collected from 1688 men aged 50 to 78 years without bladder or prostate cancer, radical prostatectomy, neurogenic bladder dysfunction, or negative advice from their general practitioner. Measurements included self-administered questionnaires, a 3-day frequency-volume chart, transrectal ultrasonography of the prostate, uroflowmetry, and postvoid residual urine volume measurement. The mean nocturnal urine production was computed from the frequency-volume charts. Linear regression analyses were performed to determine associated factors for nocturnal urine production. Areas under the receiver operating characteristic curves were used to describe the discriminative value of nocturnal urine production on nocturnal voiding frequency. A cutoff value for "increased" nocturnal urine production was defined using logistic regression analysis.

RESULTS

The nocturnal urine production was 60.6 mL/hr for the total study population; it increased with age and was significantly higher in men with 24-hour polyuria. Nocturnal urine production was on average higher in men with increased nocturnal voiding frequency, but had only a reasonable discriminative value on nocturnal voiding frequency (areas under receiver operating characteristic curve of 0.71 and 0.76). Nocturnal urine production exceeding 90 mL/hr is suggested as abnormal.

CONCLUSIONS

On average, nocturnal voiding frequency is indicative of nocturnal urine production. However, nocturnal urine production is only a modest discriminator for increased nocturnal voiding frequency. Therefore, the use of nocturnal urine production as an explanatory variable for nocturnal voiding frequency in daily practice is of little value.

Efficacy of desmopressin in treatment of refractory nocturia in patients older than 65 years

OBJECTIVES

To evaluate the efficacy of desmopressin treatment in patients 65 years old and older with nocturia and to determine whether baseline urodynamic characteristics influenced the outcome of treatment.

METHODS

Patients with nocturia three or more times a night and nocturnal polyuria refractory to medication were treated with oral desmopressin 0.1 mg at bedtime for 4 weeks. Data from urodynamic studies and a voiding diary, nocturnal urine volume, urine specific gravity, serum sodium and potassium level, and quality of life index were measured at baseline, 4 weeks, and 4 weeks after discontinuation of treatment.

RESULTS

A total of 30 patients (25 men and 5 women) were enrolled in the study. The mean age was 75.4 +/- 6.6 years. Five patients (16.7%) reported side effects, including hyponatremia in one. Twenty patients (66.7%) reported a good response with both reduced nocturnal frequency (5.2 +/- 1.16 times versus 2.24 +/- 1.12 times a night, P = 0.000) and urine volume (955.6 +/- 255.9 mL versus 522.8 +/- 210.5 mL, P <0.0001). Two patients (6.7%) had improved nocturnal frequency, and 3 patients (10%) reported no effect at all. After discontinuing the medication for 4 weeks, 13 patients (52%) had improved symptoms compared with baseline and 6 (24%) remained at their post-treatment frequency of nocturia. Urodynamic studies revealed that 15 patients had detrusor instability and 17 had a cystometric capacity of 250 mL or less. No significant difference was found in the success rate relative to the urodynamic results.

CONCLUSIONS

Desmopressin is safe and effective in the treatment of severe nocturia in patients 65 years old and older.

Human atrial natriuretic peptide is a useful criterion in treatment of nocturia

BACKGROUND

Nocturia is one of the major problems of elderly people. The possible causes of nocturia include irritation of lower urinary tract obstruction, disturbance of the fluid balance, and sleep disturbance. In a significant proportion of patients, the mechanism of nocturia is still unclear and a definitive method of treatment has yet to be determined. This study investigated how to treat nocturia.

MATERIALS AND METHODS

We analyzed 51 patients who visited Kobe City General Hospital between January 1998 and June 1999 with nocturia (three or more nocturnal voidings) and no daytime urological problems. Twenty-two of these patients were given daytime diuretic therapy (azosemide 60 mg), while 29 other patients received a minor tranquilizer. The method of treatment was selected randomly. Correlations between the plasma level of atrial natriuretic peptide (hANP) and the effect of treatment were analyzed.

RESULTS

Daytime diuretics decreased the nocturnal frequency of voiding in 10 out of 22 patients. The plasma hANP level at the first visit was significantly higher in the patients with improvement (p = 0.0026). Furthermore, the plasma hANP level was significantly decreased after daytime diuretic therapy in patients who showed improvement of nocturia with diuretic therapy (p = 0.0180). Minor tranquilizer administration decreased nocturia in 22 out of 29 patients. The plasma hANP level at the first visit was significantly lower in the patients who improved (p = 0.0021).

CONCLUSIONS

These findings suggest that patients with higher plasma hANP levels should be treated as having subclinical heart failure, while nocturia in patients with a normal plasma hANP level might be caused by sleep disturbance.

Nocturia in women

Frequent episodes of nocturnal voiding disturb the sleep and well-being of women. The prevalence of nocturia is more common in parous women and shows a linear increase with age, occurring in more than 50% of women > or =80 years old. Nocturia has a multifactorial origin that develops through a pathophysiologic mechanism of nocturnal polyuria or low functional bladder capacity or through a combination of both. Nocturia is also one of the most bothersome lower urinary tract symptoms and has a significant impact on quality of life. However, most women accept symptoms of nocturia as part of the aging process and few seek medical help. Treatments for nocturia (behavior modification and pharmacologic treatment) are effective in many cases, although it is important to tailor treatment to the underlying pathophysiology. This review discusses the impact of nocturia on women and reviews the current situation regarding the definition, prevalence, diagnosis, and treatment of this condition in this patient population.

Nocturnal polyuria in older people: pathophysiology and clinical implications

OBJECTIVES

To review the physiological changes of aging which affect the systems involved in urine formation and to consider how these changes interact with changes in bladder function, thereby leading to the onset of nocturnal polyuria with associated urinary frequency, nocturia, and incontinence. Based on this information, data are presented on the effectiveness of pharmacological interventions which reduce the rate of urine formation and, thus, can be of benefit in reducing symptoms, especially during the nighttime.

METHODS

Peer-reviewed journal articles were identified by MEDLINE Search and by review of the literature.

CONCLUSIONS

As a consequence of age-associated diminished renal concentrating capacity, diminished sodium conserving ability, loss of the circadian rhythm of antidiuretic hormone secretion, decreased secretion of renin-angiotensin-aldosterone, and increased secretion of atrial natriuretic hormone, there is an age-related alteration in the circadian rhythm of water excretion leading to increased nighttime urine production in older people. The interaction of nocturnal polyuria with age-related diminution in functional bladder volume and detrusor instability results in the symptoms of urinary frequency, nocturia and, in some persons, incontinence. The additional impact of Alzheimer's disease on these physiological and aging changes, as well as on a diminished perception of bladder fullness, leads to an even greater risk of urinary incontinence in these patients. Treatment of nocturnal polyuria with the antidiuretic hormone analog, DDAVP (desmopressin), can result in decreased nocturnal urine production with improvement in symptoms of frequency, nocturia, and incontinence.

Relation of nocturnal polyuria of the elderly to essential hypertension

Nocturnal polyuria is common in the elderly. In this condition the normal circadian rhythm of urine production is reversed so that urine flow is higher at night than during the day. Elderly men with nocturnal polyuria are commonly referred for prostate surgery, which, not surprisingly, fails to relieve their symptoms. Compared with controls, patients with nocturnal polyuria have higher nocturnal sodium excretion but not higher nocturnal free-water clearance. Similar results have been obtained in children with nocturnal enuresis. Use of vasopressin analogues to induce water retention in elderly patients with nocturnal polyuria is illogical and potentially hazardous; nocturia can be more safely alleviated by diuretic therapy. Nocturnal polyuria in the elderly is associated with hypertension: this is consistent with studies in younger age groups that show that essential hypertension is associated with nocturia and with increased night/day ratios for sodium excretion. We propose that nocturnal polyuria and essential hypertension share some of the same pathophysiological determinants. Specifically, we suggest that a defect in the nitric-oxide pathway may lead to resetting of the pressure-natriuresis relation in the kidney, sodium retention, and compensatory nocturnal natriuresis. This suggestion is consistent with evidence that ageing and essential hypertension are both associated with defects in the nitric-oxide pathway. Our hypothesis has obvious therapeutic implications. More generally, studying the pathogenesis of nocturnal polyuria in the elderly may advance our understanding of the pathogenesis of essential hypertension.