Desmopressin Withdrawal Strategy for Pediatric Enuresis: A Meta-analysis

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

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

Evaluation and management of enuresis in the general paediatric setting

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

Does desmopressin withdrawal strategy affect relapse rates in monosymptomatic enuresis treatment?

Desmopressin plays a major role in the treatment of monosymptomatic enuresis but has the drawback of a high relapse rate after medical treatment. This study investigated the effect of the type of treatment termination on relapse in a large population of patients. A total of 1013 patients who were admitted with bedwetting to our paediatric urology clinic between October 2016 and April 2018 were evaluated retrospectively. Four hundred forty-seven monosymptomatic enuresis patients were treated with 120 μg/day oral desmopressin lyophilisate for 3 months, after which the treatment was terminated in one of two ways: immediate cessation of desmopressin (group 1; N = 209) and structured withdrawal (group 2; N = 238). In the structured withdrawal group, the patients continued to take desmopressin every other day for 15 days. All the patients were followed up 1 month after the drug was withdrawn, and the relapse rates were recorded. One month after cessation of treatment with oral desmopressin lyophilisate, the relapse rate in group 1 was 42.5% (89/209), and that in group 2 was 41.1% (98/238) (p > 0.05).Conclusion: This study, with the highest number of patients among reports in the literature, revealed that the methods used to terminate desmopressin treatment are not significantly different in monosymptomatic enuresis management. What is Known: • It is still unclear how to end the treatment in patients who are started desmopressin because of the complaint of monosymptomatic nocturnal enuresis. • Although there are papers in the literature suggesting that the drug should be discontinued gradually or by reducing the dose, there are also authors stating the opposite. What is New: • This study including vast amount of patients managed with desmopressin reveals that withdrawal strategy has no impact on relapse.

Pediatric Pharmacology of Desmopressin in Children with Enuresis: A Comprehensive Review

Desmopressin is a synthetic analogue of the natural antidiuretic hormone arginine vasopressin. Over the years, it has been clinically used to manage nocturnal polyuria in children with enuresis. Various pharmaceutical formulations of desmopressin have been commercialized for this indication-nasal spray, nasal drops, oral tablet and oral lyophilizate. Despite the fact that desmopressin is a frequently prescribed drug in children, its use and posology is based on limited pediatric data. This review provides an overview of the current pediatric pharmacological data related to the different desmopressin formulations, including their pharmacokinetics, pharmacodynamics and adverse events. Regarding the pharmacokinetics, a profound food effect on the oral bioavailability was demonstrated as well as different plasma concentration-time profiles (double absorption peak) of the desmopressin lyophilizate between adults and children. Literature about maturational differences in distribution, metabolism and excretion of desmopressin is rather limited. Regarding the pharmacodynamics, formulation/dose/food effect and predictors of response were evaluated. The lyophilizate is the preferred formulation, but the claimed bioequivalence in adults (200 µg tablet and 120 µg lyophilizate), could not be readily extrapolated to children. Prescribing the standard flat-dose regimen to the entire pediatric population might be insufficient to attain response to desmopressin treatment, whereby dosing schemes based on age and weight were proposed. Moreover, response to desmopressin is variable, whereby complete-, partial- and non-responders are reported. Different reasons were enumerated that might explain the difference in response rate to desmopressin observed: different pathophysiological mechanisms, bladder capacity and other predictive factors (i.e. breast feeding, familial history, compliance, sex, etc.). Also, the relapse rate of desmopressin treatment was high, rendering it necessary to use a pragmatic approach for the treatment of enuresis, whereby careful consideration of the position of desmopressin within this treatment is required. Regarding the safety of the different desmopressin formulations, the use of desmopressin was generally considered safe, but additional measures should be taken to prevent severe hyponatremia. To conclude the review, to date, major knowledge gaps in pediatric pharmacological aspects of the different desmopressin formulations still remain. Additional information should be collected about the clinical relevance of the double absorption peak, the food effect, the bioequivalence/therapeutic equivalence, the pediatric adapted dosing regimens, the study endpoints and the difference between performing studies at daytime or at nighttime. To fill in these gaps, additional well designed pharmacokinetic and pharmacodynamic studies in children should be performed.

Practical recommendations of the EAU-ESPU guidelines committee for monosymptomatic enuresis-Bedwetting

BACKGROUND AND AIMS

The objective of this update of the EAU-ESPU guidelines recommendations for nocturnal enuresis was to review the recent published literature of studies, reviews, guidelines regarding the etiology, diagnosis and treatment options of nocturnal enuresis and transform the information into a practical recommendation strategy for the general practitioner, pediatrician, pediatric urologist and urologist.

MATERIAL AND METHODS

Since 2012 a monthly literature search using Scopus® was performed and the relevant literature was reviewed and prospectively registered on the European Urology bedwetting enuresis resource center (http://bedwetting.europeanurology.com/). In addition, guideline papers and statements of the European Society for Paediatric Urology (ESPU), the European Association of Urology (EAU), the National Institute for Health and Care Excellence (NICE) and the International Children Continence Society (ICCS) were used to update the knowledge and evidence resulting in this practical recommendation strategy. Recommendations have been discussed and agreed within the working group of the EAU-ESPU guidelines committee members.

RESULTS

The recommendations focus to place the child and his family in a control position. Pragmatic analysis is made of the bedwetting problem by collecting voiding and drinking habits during the day, measuring nighttime urine production and identification of possible risk factors such as high-volume evening drinking, nighttime overactive bladder, behavioral or psychological problems or sleep disordered breathing. A questionnaire will help to identify those risk factors.

CONCLUSION

Motivation of the child is important for success. Continuous involvement of the child and the family in the treatment will improve treatment compliance, success and patient satisfaction.

Pharmacologic therapies for the management of non-neurogenic urinary incontinence in children

Introduction: Non-neurogenic urinary incontinence in children is a common condition that affects the quality of life for both patients and parents. Symptoms may occur in the daytime, nighttime, or both and may be the result of structural and functional anomalies. Evaluation and management of associated co-morbidities, such as constipation is critical to management. Behavioral therapy is a fist line therapy in most cases of non-neurogenic urinary incontinence and pharmacologic therapy a second-line therapy.Areas covered: In this review, the authors cover the pharmacologic agents, FDA approved and commonly used non-FDA approved, available for the treatment of four non-structural etiologies of non-neurogenic urinary incontinence in children. These include nocturnal enuresis, overactive bladder, giggle incontinence, and dysfunctional voiding.Expert opinion: Non-neurogenic causes of urinary incontinence in children represent a complicated medical condition that requires both pharmacologic and non-pharmacologic management. Limited FDA-approved therapies as well as suboptimal results with approved therapies due to a lack in the understanding of the underlying pathophysiology and patient selection may lead to the use of alternative non-FDA approved therapies.

Systematic Review and Meta-analysis of Alarm versus Desmopressin Therapy for Pediatric Monosymptomatic Enuresis

This study is to compare the efficacy of enuresis alarm and desmopressin therapy in managing pediatric monosymptomatic enuresis. We performed systematic literature searches on different databases from inception until April 2017 without language restriction. All randomized control trials comparing an enuresis alarm and desmopressin in managing children with monosymptomatic enuresis were included. A total of 15 studies with 1502 participants (aged 5 to 16 years) were included for pooled analysis. Overall, an enuresis alarm outperformed desmopressin in achieving at least a partial response (>50% reduction in wet nights) in per-protocol analysis (OR: 1.53, 95% CI 1.05 to 2.23) but not in intention-to-treat analysis (OR: 0.97, 95% CI 0.73 to 1.30) as the alarm was hampered by a high dropout rate (OR: 2.20, 95% CI 3.41 to 4.29). However, alarm therapy yielded a better sustained response (OR: 2.89, 95% CI 1.38 to 6.04) and lower relapse rate (OR: 0.25, 95% CI 0.12 to 0.50). In the intention to treat analysis, the results revealed that alarm and desmopressin therapy are comparable in efficacy with regards to achieving >50% reduction in baseline wet nights in enuretic children. However, enuresis alarms offer a superior treatment response and a lower relapse rate in well-motivated children.

Comparison of desmopressin, alarm, desmopressin plus alarm, and desmopressin plus anticholinergic agents in the management of paediatric monosymptomatic nocturnal enuresis: a network meta-analysis

OBJECTIVE

To assess the efficacy of desmopressin, alarm, desmopressin plus alarm, and desmopressin plus anticholinergic agent (AA) therapy in the management of paediatric monosymptomatic nocturnal enuresis (MNE) using a network meta-analysis.

MATERIALS AND METHODS

We searched the electronic databases PubMed, Cochrane Library, EMBASE and Web of Science from inception to 1 March 2018. Randomized controlled trials (RCTs) that compared desmopressin, alarm, desmopressin plus alarm, and desmopressin plus AAs were identified. The network meta-analysis was conducted with software R 3.3.2 and STATA 14.0.

RESULTS

Eighteen RCTs with a total of 1 649 participants were included. The meta-analysis results showed that complete response (CR) and success rates with desmopressin plus AAs were higher than with desmopressin or alarm monotherapy. Success rates for desmopressin plus alarm therapy were higher than for alarm monotherapy. No obvious difference was observed between desmopressin plus AAs and desmopressin plus alarm therapy with regard to CR rate and success rate. The relapse rate with alarm monotherapy was much lower than with desmopressin monotherapy. Adverse events seemed to be infrequently and tolerable for all treatments. The ranking probability results were as follows: desmopressin plus AA ranked first for the outcomes of CR and success, desmopressin plus alarm therapy ranked first for mean number of wet nights per week, and alarm therapy had the lowest relapse rate.

CONCLUSIONS

The network meta-analysis showed that desmopressin had similar efficacy to alarm therapy but a higher relapse rate. Desmopressin plus AA therapy was associated with better efficacy than and a similar relapse rate to desmopressin monotherapy. Desmopressin plus alarm therapy was similar to both desmopressin and alarm monotherapy in efficacy. All treatments, including desmopressin plus AAwere associated with tolerable adverse events; however, additional high-quality studies are needed for further evaluation of these treatments.

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.