Adherence to antimuscarinics in children with overactive bladder

Experiencia con el uso de toxina botulínica en niños con vejiga hiperactiva neurogénica: Una serie de casos

Objetivo Describir la experiencia con la administración de inyección de toxina botulínica en niños con vejiga hiperactiva neurogénica refractaria a manejo de primera línea.

Materiales y Métodos Estudio observacional descriptivo (serie de casos) que incluyó a 14 niños con diagnóstico de vejiga hiperactiva neurogénica refractarios a tratamiento de primera línea sometidos a administración intravesical de toxina botulínica entre 2015 y 2021; se realizó el seguimiento teniendo en cuenta las variables clínicas, con evaluación de la respuesta y de los eventos adversos. Se reportaron frecuencias absolutas y porcentajes para las variables cualitativas; para las variables cuantitativas, se reportaron medidas de tendencia central y dispersión.

Resultados Se incluyeron 6 niños y 8 niñas, con una media de edad 10,1 (desviación estándar [DE]: ± 4,4) años. Todos los pacientes fueron tratados previamente con anticolinérgico y cateterismos limpios intermitentes, con una media de uso de 2,8 (DE: ± 1.0) pañales al día; 11 (78,5%) pacientes tenían antecedente de infección urinaria, 13 (92,8%), estreñimiento, y 2 (15,3%), incontinencia fecal. En la ecografía, 7 (50,0%) pacientes presentaban engrosamiento de las paredes vesicales, y 6 (42,8%), hidronefrosis. Tras el procedimiento, 1 paciente presentó infección urinaria como complicación, 6 presentaron una respuesta completa, 7, respuesta parcial, y 1 paciente no obtuvo respuesta con la primera inyección, con un tiempo promedio efectivo de la terapia 8 (DE: ± 6,3) meses. Una segunda inyección fue necesaria en 6 (42.8%) pacientes, y, de estos, 3 (50%) requirieron una tercera inyección.

Conclusión La inyección de toxina botulinica intravesical como terapia de segunda línea de manejo para vejiga hiperactiva neurogénica tiene buenos resultados, con bajas tasas de complicaciones.

Comprehensive overview of the available pharmacotherapy for the treatment of non-neurogenic overactive bladder in children

INTRODUCTION

Overactive bladder (OAB) is a chronic condition highly prevalent in children and causing bothersome symptoms. It is often associated with deterioration of quality of life and can be devastating for patients and their families. Prompt initiation of conservative measures should be the backbone of treatment. When conservative management fails, pharmacological options must be considered.

AREAS COVERED

Although antimuscarinics are considered the mainstay of pharmacological treatment for OAB, only two agents are currently approved for the pediatric population. Oxybutynin and propiverine are discussed in this review, as well as other non-approved antimuscarinic agents and β3-agonists with related literature to substantiate their use in children. Dual therapy along with medication adherence and persistence is also discussed.

EXPERT OPINION

The treatment of OAB in children is demanding and one must rely on a structured, stepwise approach to achieve success. Discussing conservative measures and prescribing medication is not enough. Clinicians should actively involve children and their families in the treatment, set realistic expectations, and closely monitor side effects and medication adherence to ensure maximal efficacy.

Transcutaneous sacral electrical stimulation versus oxibutynin for the treatment of overactive bladder in children

BACKGROUND

Nowadays there is still no ideal treatment for paediatric overactive bladder. Initial management measures (urotherapy and constipation control), resolve 40% of cases. The second line of treatment in overactive bladder is anticholinergic drugs, above all oxybutynin. Although most patients improve with these therapies, the complete resolution rate is around 30-40%. Sacral transcutaneous electrical nerve stimulation has recently emerged as a new alternative in the management of patients with refractory paediatric overactive bladder. However, only a few studies have been done to compare the effectiveness of this therapy versus conventional drugs.

OBJETIVE

The objective of the present study is to compare, in children with overactive bladder, the efficacy of the sacral transcutaneous electrical nerve stimulation versus oxybutynin therapy.

MATERIALS AND METHODS

We performed a prospective and randomized study of patients with diagnosis of overactive bladder treated with sacral transcutaneous electrical nerve stimulation versus oxybutynin, during the period July 2018-July 2020. Patients refractory to standard urotherapy and constipation management randomly received one of the therapeutic alternatives. Treatment was maintained for 6 months.

RESULTS

86 patients were included in the study: 40 patients received electrotherapy (group 1) and 46 patients received oxybutynin (group 2). Before starting the treatment assigned both groups were comparable related to the voiding symptomatology as well as the severity of the overactive bladder. Sacral transcutaneous electrical nerve stimulation was significantly more effective than oxybutynin, with a higher percentage of complete resolution of symptoms in the management of paediatric overactive bladder.

VOIDING DIARY

All the parameters obtained with the voiding calendar significantly improved in both groups at the end of the treatment. The increase in MaVV was significantly higher in group-1.

DVISS (DYSFUNCTIONAL VOIDING AND INCONTINENCE SCORING SYSTEM)

We observed a progressive decrease in the mean score obtained in the DVISS questionnaire over time in both groups. This decrease was significantly higher in group-1 compared to group-2 (p < 0.005). The mean value obtained in the DVISS questionnaire in group-1 was 6 (interquartile range: 3-9) at the end of the treatment (lower than the diagnostic cut-off point for daytime condition in the DVISS, 8.5). In group-2, the mean value obtained in the DVISS questionnaire was 10 (interquartile range: 8.75-13.25), higher than the cut-off point.

COMPLICATIONS

A greater number of adverse effects was obtained in group-2 (26.1% versus 15%, p < 0.05). Constipation (n: 6, 10.9%), and abdominal pain (n: 2,4.3%) were the most frequent adverse effects in this group. The adverse events reported in group-1 were contact dermatitis (n: 1.2%) and fecal losses [2] or urgency [5].

CONCLUSION

Oxybutynin and sacral transcutaneous electrical nerve stimulation are both effective therapies in the management of paediatric overactive bladder. However, electrotherapy has been shown to be a more effective therapy with a complete clinical resolution rate in a larger number of patients. Furthermore, the rate of adverse effects secondary to electrotherapy is significantly lower than those treated with oxybutynin.

Assessing the Population-Level Correlation of Medication Regimen Complexity and Adherence Indices Using Electronic Health Records and Insurance Claims

BACKGROUND

Nonadherence to medication regimens can lead to adverse health care outcomes and increasing costs.

OBJECTIVES

To (a) assess the level of medication complexity at an outpatient setting using population-level electronic health record (EHR) data and (b) evaluate its association with medication adherence measures derived from medication-dispensing claims.

METHODS

We linked EHR data with insurance claims of 70,054 patients who had an encounter with a U.S. midwestern health system between 2012 and 2013. We constructed 3 medication-derived indices: medication regimen complexity index (MRCI) using EHR data; medication possession ratio (MPR) using insurance pharmacy claims; and prescription fill rates (PFR; 7 and 30 days) using both data sources. We estimated the partial correlation between indices using Spearman's coefficient (SC) after adjusting for age and sex.

RESULTS

The mean age (SD) of 70,054 patients was 37.9 (18.0) years, with an average Charlson Comorbidity Index of 0.308 (0.778). The 2012 data showed mean (SD) MRCI, MPR, and 30-day PFR of 14.6 (17.8), 0.624 (0.310), and 81.0 (27.0), respectively. Patients with previous inpatient stays were likely to have high MRCI scores (36.3 [37.9], P < 0.001) and were less adherent to outpatient prescriptions (MPR = 50.3 [27.6%], P < 0.001; 30-day PFR = 75.7 [23.6%], P < 0.001). However, MRCI did not show a negative correlation with MPR (SC = -0.31, P < 0.001) or with 30-day PFR (SC = -0.17, P < 0.001) at significant levels.

CONCLUSIONS

Medication complexity and adherence indices can be calculated on a population level using linked EHR and claims data. Regimen complexity affects patient adherence to outpatient medication, and strength of correlations vary modestly across populations. Future studies should assess the added values of MRCI, MPR, and PFR to population health management efforts.

DISCLOSURES

No outside funding supported this study. The authors have nothing to disclose. The abstract of this work was presented at INFORMS Healthcare Conference, held on July 27-29, 2019, in Cambridge, MA.

A randomized, crossover trial comparing the efficacy and safety of fesoterodine and extended-release oxybutynin in children with overactive bladder with 12-month extension on fesoterodine: The FOXY study

INTRODUCTION

We sought to assess and compare safety and efficacy of fesoterodine and oxybutynin extended-release in the treatment of pediatric overactive bladder (OAB).

METHODS

We conducted a non-inferiority, randomized, double-blind, crossover trial comparing fesoterodine 4-8 mg and oxybutynin 10-20 mg once daily (QD) in children with OAB aged 5-14 years (2015-2018). Every child received the first medication for eight weeks, followed by crossover to the second antimuscarinic after a three-days washout. Dose up-titration was possible at mid-course. Patients could enter a fesoterodine 12-month extension. Endpoints were assessed through changes on voiding diaries, Patient's Perception of Bladder Condition score (PPBC), adverse events, vital signs, electrocardiogram, post-void residual, urinalysis, and blood tests. The Wilcoxon rank sum and Wilcoxon signed rank tests were used for statistical analysis.

RESULTS

A total of 62 patients were randomized (two early dropouts). Expected class effects (dry mouth/constipation) were present but no significant difference was observed. There was a 10.1 beats/minute increase in heart rate with fesoterodine (p<0.01) (oxybutynin-1.9 beats/min; p=non-significant [ns]). No life-threatening or serious adverse events occurred. Efficacy was similar for both drugs. Bladder capacity improved over the 16 months of the study; baseline capacity of 125 mL (44.5% expected bladder capacity for age [%EBC]) to 171 mL (53.9 %EBC) at the end of the extension phase. No clinical or statistical difference was shown between efficacy measures for fesoterodine or oxybutynin.

CONCLUSIONS

The use of fesoterodine or oxybutynin appear safe and effective for the treatment of OAB in children. Based on our study, long-term treatment to achieve the ultimate goal of urinary continence is needed in this population.

Overactive bladder in children

Overactive bladder (OAB) is a highly prevalent disorder in the pediatric population. This condition is especially troublesome for pediatric patients and their families when associated with incontinence, since it negatively affects self-esteem and impairs children's development. From the patient's perspective, urgency and urge incontinence can have a significant impact, negatively affecting their quality of life. For a therapy to have true benefit, changes must not only be statistically significant, but must also be perceived as meaningful by the patient. A stepwise approach is favoured to treat this pathology, starting with behavioural therapy, followed by medical management, and eventually more invasive procedures. Antimuscarinic agents are the mainstay of medical treatment for OAB. Oxybutynin is the most commonly used antimuscarinic in the pediatric population. However, some patients have a suboptimal response to antimuscarinics and many experience bothersome side effects, which have been documented with all antimuscarinics to a significantly higher degree than placebo. Although there have been reports about the use of tolterodine, fesoterodine, trospium, propiverine, and solifenacin in children, to date, only oxybutynin has been officially approved for pediatric use by medical authorities in North America. This review will address alternative treatment options for pediatric patients presenting with OAB, from conservative measures to more invasive therapies.