Sudden death of a child treated with imipramine. Case study

Can the combined treatment of solifenacin and imipramine has a role in desmopressin refractory monosymptomatic nocturnal enuresis? A prospective double-blind randomized placebo-controlled study

BACKGROUND

Nocturnal enuresis is a common disease of childhood. It can be classified into monosymptomatic nocturnal enuresis (MNE) or nonmonosymptomatic nocturnal enuresis (NMNE). Imipramine is a tricyclic antidepressant used to treat enuresis with initial success rates are high as 50% but some studies record a high relapse rate and it has a cardiotoxic effect when overdosed. Anticholinergics may be effective in the treatment of children with bladder storage dysfunction, including daytime incontinence. However, anticholinergics monotherapy is not effective in treating MNE. In our study, we used a low dose (25 mg) of imipramine in order to avoid its potential side effects and combined it with the synergistic anticholinergic action of solifenacin. Our objective was to evaluate the efficacy and safety of the combination of solifenacin and imipramine compared with placebo in the treatment of desmopressin refractory MNE.

METHODS

One hundred children aged 6 years or more with primary MNE unresponsive to desmopressin treatment were included. The children were randomly divided into two equal groups. Group A received imipramine 25 mg and solifenacin 5-10 mg oral tablets and group B received placebo once 1 h before bedtime for 3 months. The primary end point was to investigate the efficacy of the combined treatment of solifenacin and imipramine and the secondary end point was the safety of the drugs.

RESULTS

Our study showed that the mean post treatment wet nights per month was significantly lesser in the treatment group than placebo group (p < 0.001) and cure rate was significantly higher in treatment group than placebo group (p < 0.001). The relapse rate was statistically significantly lower in treatment group than placebo group (p = 0.032). No significant side effects related to the drugs were reported.

CONCLUSION

The combination treatment of solifenacin and imipramine is a useful and safe treatment for nocturnal enuresis after failure of everything else.

Management and treatment of nocturnal enuresis-an updated standardization document from the International Children's Continence Society

BACKGROUND

Enuresis is an extremely common condition, which, although somatically benign, poses long-term psychosocial risks if untreated. There are still many misconceptions regarding the proper management of these children.

AIM

A cross-professional team of experts affiliated with the International Children's Continence Society (ICCS) undertook to update the previous guidelines for the evaluation and treatment of children with enuresis.

METHODS

The document used the globally accepted ICCS terminology. Evidence-based literature served as the basis, but in areas lacking in primary evidence, expert consensus was used. Before submission, a full draft was made available to all ICCS members for additional comments.

RESULTS

The enuretic child does, in the absence of certain warning signs (i.e., voiding difficulties, excessive thirst), not need blood tests, radiology or urodynamic assessment. Active therapy is recommended from the age of 6 years. The most important comorbid conditions to take into account are psychiatric disorders, constipation, urinary tract infections and snoring or sleep apneas. Constipation and daytime incontinence, if present, should be treated. In nonmonosymptomatic enuresis, it is recommended that basic advice regarding voiding and drinking habits be provided. In monosymptomatic enuresis, or if the above strategy did not make the child dry, the first-line treatment modalities are desmopressin or the enuresis alarm. If both these therapies fail alone or in combination, anticholinergic treatment is a possible next step. If the child is unresponsive to initial therapy, antidepressant treatment may be considered by the expert. Children with concomitant sleep disordered breathing may become dry if the airway obstruction is removed.

Management of nocturnal enuresis in Taiwan: Consensus statements of the Taiwan enuresis expert committee

Nocturnal enuresis causes significant psychological distress to affected children and their family and requires appropriate management. A 12-member expert committee of pediatric urologists and pediatric nephrologists in Taiwan with extensive experience in treating enuresis was established to develop consensus statements and a recommended treatment algorithm for the management of patients with nocturnal enuresis in Taiwan after careful consideration of current evidence, existing guidelines, and expert opinion as well as local practice and culture. The finalized consensus statements were reviewed by and have received endorsement from the Taiwan Urological Association and the Taiwan Pediatric Association. Patients with suspected enuresis should undergo a thorough initial assessment to fully evaluate urinary signs and symptoms and to rule out underlying causes of diurnal and nocturnal incontinence. Behavioral therapy is recommended throughout the course of management. Desmopressin in the fast-melting formulation is the recommended first-line pharmacological treatment. Combination therapy may be effective in patients who have failed first-line treatment. These consensus statements and a recommended treatment algorithm were created by the expert committee to provide practical support for clinical decision making by physicians in Taiwan.

Reboxetine in therapy-resistant enuresis: A randomized placebo-controlled study

INTRODUCTION

A significant minority of children with enuresis do not respond to either desmopressin or the enuresis alarm. Anticholinergics have not proven as successful as expected. The fourth evidence-based treatment, the tricyclic antidepressant imipramine, is cardiotoxic when overdosed, which has led to diminished use.

AIM

The aim was to determine whether there is a role for the noradrenergic antidepressant reboxetine, as monotherapy or combined with desmopressin, in the treatment of enuresis in children who have not responded to standard therapy, and whether there are side effects involved. We also sought prognostic factors in anamnestic data and in the voiding chart.

PATIENTS AND METHODS

The study was a randomized placebo-controlled study with a double-blind cross-over design, in which all patients underwent treatment during three 4-week periods, one with reboxetine 4 mg and placebo, one with reboxetine 4 mg and desmopressin, and one with double placebo treatment. The proportion of wet nights out of 14 was compared before treatment and during the last 2 weeks of each treatment period.

RESULTS

Eighteen patients were included. The reduction of wet nights was much better with either reboxetine in monotherapy or in combination with desmopressin than during the placebo period (p = 0.002) (Figure). However, only one patient achieved complete dryness, this during monotherapy. There were three intermediate responders to monotherapy and five to combination treatment. With reboxetine in monotherapy, six children experienced negative side effects compared with three with combination therapy, and two with placebo. All of these side effects were mild and reversible. Only one patient chose to cease treatment because of side effects. No prognostic factors were found in either the case history or in voiding chart data.

DISCUSSION

The present study, the first placebo-controlled trial, confirms that reboxetine is an evidence-based alternative to cardiotoxic antidepressant treatment in therapy-resistant enuresis. The fact that few patients achieved complete dryness may be due to the low dosage used. In our clinical practice we increase the dose to 8 mg when dryness is not achieved with the lower dose. Our experience is that this leaves more children with full response, but the evidence of this has yet to be shown.

CONCLUSION

Reboxetine seems to be an alternative in the treatment of enuretic children who have not responded to standard treatment.

Nocturnal enuresis-theoretic background and practical guidelines

Nocturnal polyuria, nocturnal detrusor overactivity and high arousal thresholds are central in the pathogenesis of enuresis. An underlying mechanism on the brainstem level is probably common to these mechanisms. Enuretic children have an increased risk for psychosocial comorbidity. The primary evaluation of the enuretic child is usually straightforward, with no radiology or invasive procedures required, and can be carried out by any adequately educated nurse or physician. The first-line treatment, once the few cases with underlying disorders, such as diabetes, kidney disease or urogenital malformations, have been ruled out, is the enuresis alarm, which has a definite curative potential but requires much work and motivation. For families not able to comply with the alarm, desmopressin should be the treatment of choice. In therapy-resistant cases, occult constipation needs to be ruled out, and then anticholinergic treatment-often combined with desmopressin-can be tried. In situations when all other treatments have failed, imipramine treatment is warranted, provided the cardiac risks are taken into account.

Reboxetine in therapy-resistant enuresis: a retrospective evaluation

OBJECTIVE

Imipramine is the only evidence-based treatment available for enuretic children resistant to standard therapy. The drug's antienuretic effect is probably due to noradrenergic facilitation. The drug is, however, potentially cardiotoxic. In this study, the non-cardiotoxic noradrenergic antidepressant reboxetine was tested as an alternative to imipramine.

PATIENTS AND METHODS

61 patients, aged 7-19 years, with enuresis-resistant to desmopressin, the alarm, urotherapy and anticholinergics, were given 4-8 mg reboxetine at bedtime, if necessary combined with desmopressin.

RESULTS

32 patients became dry on reboxetine treatment, although 21 of them required combination treatment with desmopressin to achieve this. Eighteen children did not respond and eight children discontinued because of side-effects before treatment could be evaluated. No serious adverse events occurred.

CONCLUSIONS

These results need to be confirmed with randomized controlled studies, but indicate that reboxetine will become a safe and efficient treatment alternative for enuretic children resistant to standard therapy.

Reboxetine in therapy-resistant enuresis: Results and pathogenetic implications

OBJECTIVE

To investigate whether the norepinephrine reuptake inhibitor reboxetine is effective as a non-cardiotoxic alternative to imipramine in the treatment of therapy-resistant enuresis.

MATERIAL AND METHODS

Twenty-two children with severely socially handicapping enuresis resistant to urotherapy, the enuresis alarm, desmopressin and anticholinergics (all children had tried all these treatments) were given reboxetine, 4-8 mg at bed-time, for compassionate reasons.

RESULTS

Thirteen of the children (59%) achieved complete dryness with reboxetine, either as monotherapy or combined with desmopressin. Side-effects were minor and did not lead to discontinuation of treatment.

CONCLUSIONS

Although the results of this study need to be confirmed in randomized, placebo-controlled trials, reboxetine may prove to be a useful treatment for therapy-resistant nocturnal enuresis.

Psychopharmacology of ADHD in pediatrics: current advances and issues

Attention deficit hyperactivity disorder (ADHD) is a neurobehavioral developmental disorder found in 3% to 8% of children and adolescents. An important part of ADHD management is psychopharmacology, which includes stimulants, norepinephrine reuptake inhibitors, alpha-2 agonists, and antidepressants. Medications with the best evidence-based support for ADHD management are the stimulants methylphenidate and amphetamine. A number of newer, long-acting stimulants are now available and a number of new medications are considered that are under current research.

Tolterodine and imipramine in refractory enuresis; a placebo-controlled crossover study

The anticholinergic drug tolterodine has been suggested to be useful in therapy-resistant enuresis. Imipramine has a proven efficiency in unselected enuretic patients, but due to its side-effect profile it is only indicated, if at all, in therapy-resistant cases. We therefore compared these two drugs to placebo. Twenty-seven children with enuresis resistant to the alarm and to desmopressin in monotherapy were given placebo, tolterodine 1-2 mg, and imipramine 25-50 mg at bedtime for 5 weeks each in a randomised, double-blind, crossover fashion. The number of wet nights during the last 2 weeks of each treatment period was compared. One patient became spontaneously dry at the start of the study, and one dropped out due to side effects. Among the remaining 25 children, the number of wet nights during placebo, tolterodine and imipramine treatment were 11.0 +/- 3.9, 10.4 +/- 3.9 and 7.8 +/- 5.1, respectively (p < 0.001). Imipramine was significantly better than both placebo (p = 0.001) and tolterodine (p = 0.006). Nine children experienced side effects on imipramine and one on tolterodine (p = 0.001). This is the first study on anticholinergics or imipramine in children with therapy-resistant enuresis. Tolterodine, in monotherapy, had no proven effect. Imipramine was better than placebo, but side effects were common.

Attention Deficit Hyperactivity Disorder Across the Lifespan: The Child, Adolescent, and Adult

Management of a child, adolescent, college student, or adult with ADD/ADHD (ADHD) is reviewed with emphasis on pharmacologic approaches in the adult. Psychological treatment includes psychotherapy, cognitive-behavior therapy, support groups, parent training, biofeedback, meditation, and social skills training. Medications are reviewed that research has revealed can improve the core symptomatology of a child or adolescent with ADHD. These medications include stimulants (psychostimulants), antidepressants, alpha-2 agonists, and a norepinephrine reuptake inhibitor. Psychopharmacology approved and/or used in pediatric patients are also used in adults with ADHD, though most are not officially FDA-approved. It is emphasized that ADHD management should include a multi-modal approach, involving appropriate educational interventions, appropriate psychological management of the patient of any age, and judicious use of medications. Such an approach is recommended to benefit those with ADHD achieve their maximum potential across the human life span.

The QT interval and psychotropic medications in children: recommendations for clinicians

The use of psychotropic medications in children has increased significantly in the last few years. There have been several case reports of sudden death in children taking specific psychotropic medications. Fears that these deaths might have been caused by ventricular arrhythmias have been enhanced by reports of electrocardiographic abnormalities, including prolongation of the QTc interval, in patients taking these medications. Several factors including genetic susceptibility, pre-existing cardiac disease, abnormalities of drug clearance and concomitant use of other medications known to affect the QTc interval can increase the susceptibility of the heart to conduction abnormalities. This article discusses the potential of particular psychotropic drugs to prolong the QTc interval in children, and examines other factors that may contribute to conduction abnormalities. We aim to provide clear clinical recommendations for the prescription of these drugs and the monitoring of children taking them.

The evaluation and treatment of therapy-resistant enuresis: a review

Children with enuresis that neither responds to the alarm or to desmopressin medication usually have nocturnal detrusor over-activity combined with high arousal thresholds as a cause for their bedwetting. The evaluation of these children is focused on 1) excluding underlying pathology such as kidney disease, urinary tract infection or neurogenic bladder, 2) looking for concomitant day-time bladder problems or constipation, and 3) detecting possible reasons for failure of alarm treatment. A bladder diary is essential, but blood tests, radiological examinations or invasive procedures are seldom informative. The non-pharmacologic treatment of these children consists of eradication of constipation, if present, and the provision of advice regarding sound drinking and toilet habits. Such treatment is essential but not uniformly sufficient by itself. The first-line pharmacologic treatment of therapy-resistant enuresis is anticholinergic medication, although this is, as yet, not evidence-based. Anticholinergics can be combined with desmopressin for better efficiency. For children failing all these measures there is still a place for tricyclic antidepressant therapy, provided that adequate safety precautions are strictly observed.

Pharmacologic treatment of attention-deficit hyperactivity disorder

Attention-deficit hyperactivity disorder (ADHD) is highly prevalent in children and adolescents. Highly effective pharmacological treatments are available that allow the child and the adolescent to function at his/her full potential. Various preparations of methylphenidate and amphetamines have been used for a long time in the treatment of ADHD. This article reviews these and some of the newer drugs used in the treatment of ADHD, including atomoxetine and bupropion.

Comparative tolerability of drug treatment for nocturnal enuresis in children

Primary nocturnal enuresis is one of the most frequent complaints in paediatric and urologic practice. Physicians face the dilemma of whether or not to treat primary nocturnal enuresis since the trend towards spontaneous remission is countered by social disadvantages and reduced self esteem of the children affected and their families. We reviewed randomised, controlled trials investigating efficacy and adverse effects of current medical treatment for primary nocturnal enuresis. Only desmopressin and imipramine displayed significant effects in reducing wet nights: when compared with baseline bedwetting or placebo controls, 30-70% of the studied children achieved therapeutic success. For drugs such as indometacin or oxybutynin, convincing studies displaying a significant positive effect are still needed. However, considering the adverse effects profiles of desmopressin and imipramine it can be seen that imipramine is associated with about twice as many unwanted reactions. More importantly, a serious adverse effect of imipramine is sudden cardiac arrest. In general, adverse effects with desmopressin are rare and mild, but there have been a number of case reports of hyponatraemic hypervolaemia associated with coma and seizures. Of these, many cases were attributed to excess water intake before taking the drug and all children recovered fully. In summary, if medical treatment is considered, preference should be given to desmopressin.

Imipramine for therapy resistant enuresis: a retrospective evaluation

PURPOSE

Imipramine has a proven effect in enuresis but is now seldom used. We reviewed the records of children who had been treated with imipramine to determine prognostic indicators.

MATERIALS AND METHODS

The records of all enuretic children treated with imipramine at our clinic were retrospectively evaluated, with special emphasis on history, and for most children bladder volume, renal concentrating capacity and urine production.

RESULTS

All 49 children included in the study had previously received desmopressin, alarm and anticholinergic treatment without success. Of the children 31 (64.6%) were responders (R), with at least 50% reduction in enuresis frequency (22 became completely dry) and 17 (35.4%) were nonresponders (NR). Older age (R 11.4 +/- 3.4, NR 8.7 +/-1.8 years, p = 0.004) and low spontaneous bladder capacity (R 2.6 +/- 0.9, NR 3.4 +/- 0.9 ml/kg body weight, p = 0.03) were prognostically favorable, whereas constipation (p = 0.02) and a history of daytime incontinence (p = 0.04) indicated poor prognosis. Ten children experienced nausea or other minor problems. Seven children with attention deficit and hyperactivity became more focused during treatment.

CONCLUSIONS

Imipramine is a useful treatment for enuresis when everything else has failed, especially among older children. Factors related to detrusor function provide prognostic information.

National trends in concomitant psychotropic medication with stimulants in pediatric visits: practice versus knowledge

OBJECTIVES

(1) To examine U.S. national trends in the use of concomitant pharmacotherapy with the stimulant class of psychotropic drugs in youth; and (2) to present these trends in the context of (a) extant safety and efficacy data, and (b) overall trends in concomitant pharmacotherapy with psychotropic drugs for youth.

METHODS

Prescribing data for youths under age 18 years from National Ambulatory Medical Surveys from 1993 to 1998 were analyzed. The visits were categorized into monotherapy (only one psychotropic prescribed) and concomitant pharmacotherapy (>1 psychotropic prescribed). The proportions of these groups were computed as a percentage of all visits during which a psychotropic medication was prescribed. Differences in proportions between surveys were analyzed to determine trends.

RESULTS

Between 1993--94 and 1997--98, the proportions of visits for concomitant pharmacotherapy in association with the stimulant class increased nearly five-fold. This increase paralleled an overall increase in the proportion of visits involving prescription of more than one psychotropic medication among youth.

CONCLUSIONS

The growth in concomitant pharmacotherapy with the stimulants class has out-paced the increase in safety/efficacy data to inform the use of this practice, resulting in a mismatch between trends in prescribing and growth in knowledge. A simultaneous trend of note is the overall increase in the use of concomitant pharmacotherapy with all psychotropic drugs in youth. Controlled trials are particularly needed to support commonly used combinations of stimulants with antidepressants in youth. In the absence of definitive data, clinical guidelines based on expert consensus and limited data are available and are useful.

Attention-deficit/hyperactivity disorder in children and adolescents: interventions for a complex costly clinical conundrum

Management of a child or adolescent with attention-deficit/hyperactivity disorder (ADHD) is reviewed, including psychological and pharmacologic approaches. Psychological treatment includes psychotherapy, cognitive-behavior therapy, support groups, parent training, educator/teacher training, biofeedback, meditation, and social skills training. Medications are reviewed that research has revealed can improve the core symptomatology of a child or adolescent with ADHD. These medications include stimulants, antidepressants, alpha-2 agonists, and a norepinephrine reuptake inhibitor. Management of ADHD should include a multi-modal approach, involving appropriate educational interventions, appropriate psychological management of the patient (child or adolescent), and judicious use of medications. Parents, school officials, and clinicians must work together to help all children and adolescents with ADHD achieve their maximum potential.

The relevance of prolonged QTc measurement to pediatric psychopharmacology

OBJECTIVE

To consider the relevance of prolonged QTc (QT interval corrected for rate) to pediatric psychopharmacology.

METHOD

The authors reviewed publications on QTc prolongation and publications on sudden death in Medline from 1968 to November 2002.

RESULTS

The search yielded more than 20,000 publications. Review manuscripts with clinical recommendations outnumber the few pediatric studies of QTc duration during treatment. Most reviews have been published in the past 5 years, during a time when the Food and Drug Administration restricted five psychotropic medications because of QTc prolongation (sertindole: not approved; thioridazine, mesoridazine, and droperidol: black-box warning; and ziprasidone: bolded warning) and nine somatic medications because of QTc prolongation.

CONCLUSION

Pretreatment screening, careful selection of psychotropic and/or somatic medication combinations, and recognition of QTc prolongation in electrocardiographic tracings during treatment with medications that prolong QTc are important components of clinical practice.

Depression in children and adolescents. When "moodiness" merits special attention

Depression does occur in children and adolescents and can result in significant morbidity and mortality. Therefore, identification and treatment of depression are essential. Referral to a mental health clinician, preferably a child and adolescent psychiatrist, is important for suicide evaluation, psychotherapy, and management of complicated medication treatment regimens. The SSRIs are most often used in youngsters because of their favorable side effect profiles and their efficacy as documented in some double-blind, placebo-controlled studies.

Imipramine, mianserine and maprotiline block delayed rectifier potassium current in ventricular myocytes

Imipramine, mianserine and maprotiline are three widely used antidepressant drugs with different chemical structure. In the present work we have studied the effects of these drugs on the delayed rectifier potassium current (I(K)) in myocytes isolated from rat ventricle. The delayed rectifier potassium current, responsible for action potential termination, is blocked by all of the three drugs I(K)studied in a state-independent manner. Imipramine and mianserine block I(K)in a 1 : 1 drug-receptor interaction, whereas maprotiline shows a negative cooperativity in the interaction between the channel complex and drug molecules.

Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults

This practice parameter describes treatment with stimulant medication. It uses an evidence-based medicine approach derived from a detailed literature review and expert consultation. Stimulant medications in clinical use include methylphenidate, dextroamphetamine, mixed-salts amphetamine, and pemoline. It carries FDA indications for treatment of attention-deficit/hyperactivity disorder and narcolepsy.

Sudden death related to selected tricyclic antidepressants in children: epidemiology, mechanisms and clinical implications

The association between tricyclic antidepressant (TCA) use in children and increased risk of sudden death is unclear, but still possible. There are suitable alternatives to TCAs for all of the indications in which they have shown efficacy. A prudent practice model for the utilisation of TCAs has been developed. This includes initial utilisation of alternative agents, with TCAs as secondary or tertiary choices; informed consent from patient and family, including mention of the possible relationship of TCA with sudden death; vigilance of the emerging literature; and finally, systematic monitoring of patients, including electrocardiograms, drug serum concentrations and vital signs. This protocol needs to be validated with regard to utility and the degree of assistance it provides in the management of children treated with TCAs.

Management of Depression in Children and Adolescents

Depression is increasingly recognized as an illness that causes functional impairment and diminished quality of life for all age groups, including children. One to two percent of children and between 4% and 8% of adolescents meet Diagnostic Statistical Manual of Mental Disorders(4th ed.) (DSM-IV-TR) criteria for major depression. Psychotherapy, particularly cognitive-behavioral therapy, is effective, with 70% response rates. Antidepressants are effective according to limited controlled trials; however, concern exists over the gap between research and clinical practice, as most antidepressants are not well-studied in youth. Nevertheless, pharmacotherapy has gained greater acceptance in pediatric psychiatry, and prescriptions for antidepressants in youth have increased dramatically over the past 5 to 10 years. In 1995, 1.08 million selective serotonin reuptake inhibitor prescriptions were written for children and adolescents. Scientific evidence for the safety and effectiveness of antidepressants in youth is reviewed along with data on nondrug interventions such as cognitive-behavioral therapy. Recommendations for promoting the safe and effective management of depression in children and adolescents is provided.