How to increase response rate 1 Fluid restriction

How to increase response- rate 1) Fluid restriction 1 hour before desmopressin administration Evidence ? ? ? NO Rationale with indirect evidence : Yes © 2010 Universitair Ziekenhuis Gent 1

Fluid load reduces desmopressin response * * * 30% lower U osmol results in 30% higher diuresis-rate. . and bedwetting d. DAVP 2 nasal spray * p < O. O 1 EVIDENCE OF PARTIAL d. DAVP RESPONSE RELATED TO POOR PHARMACODYNAMIC EFFECTS OF d. DAVP NASAL SPRAY (De Guchtenaere J Urology, 2009) © 2010 Universitair Ziekenhuis Gent 2

How to increase response- rate 2)Diet advice Normal protein and sodium intake diet Spreading over the day Avoid highest osmotic load in the evening No food after evening meal Evidence ? ? ? NO Rationale with indirect evidence : Yes © 2010 Universitair Ziekenhuis Gent 3

Group 2: (high) Normal 24 h intake, normal 24 h excretion But high nocturnal excretion of osmol and water high osmotic load in the evening © 2010 Universitair Ziekenhuis Gent J. Dehoorne Desmopressin resistant nocturnal polyuria secundary to increased osmotic excretion J Urology 2006 4

How to increase response- rate 3) Desmopressin 1 hour before last void © 2010 Universitair Ziekenhuis Gent 5

Fast Anti-diuretic effect first hour effet anti-diuretique maximale Additional rapide effect 2 nd and 3 rd hour © 2010 Universitair Ziekenhuis Gent 6

Concentration capacity Fast effect first hour Additional increased effect 2 nd and 3 rd hour Pharmacodynamic studies © 2010 Universitair Ziekenhuis Gentof d. DAVP melt during water-load Vande Walle JG et al. BJU Int 2006; 97(3): 603– 9 7

How to increase response- rate 4) Sleep Hygiëne Last hour before bedtime No strong stimuli light or music = ipad /television/ computer / games Void just before bedtime Once in bed No light No reading No other activities © 2010 Universitair Ziekenhuis Gent 8

How to increase response- rate 5) Compliance © 2010 Universitair Ziekenhuis Gent 9

What about adherence? © 2010 Universitair Ziekenhuis Gent 10

What about adherence? © 2010 Universitair Ziekenhuis Gent 11

How to increase response- rate 6) Select the right patient © 2010 Universitair Ziekenhuis Gent 12

High nocturnal urinary volumes predict good DDAVP response Night urinary volume (m. L) 500 Full responders (N=13) Desmopressin i. n. 20 mg 40 mg Partial responders (N=19) 400 Non responders (N=84) 300 200 100 0 5 10 © 2010 Universitair Ziekenhuis Gent 15 Time (days) 20 25 30 Rittig et al. Scand J Urol Nephrol 199813

Re-analysis: Do screening parameters predict response to desmopressin? Enuretic predictors: nocturnal diuresis (p<0. 0001) © 2010 Universitair Ziekenhuis Gent 14

Enuresis is not a benign condition Results of the sleep study © 2010 Universitair Ziekenhuis Gent 15

Before and after desmopressin melt Results: Enuretic parameters Response desmopressin melt (ICCS) © 2010 Universitair Ziekenhuis Gent 16

Before and after desmopressin melt Results: enuresis / sleep Time alarm = desmopressin © 2010 Universitair Ziekenhuis Gent 17

Before and after desmopressin melt Results: Sleep PLMS index PLMSindex ↓ (p<. 001) © 2010 Universitair Ziekenhuis Gent 18

Before and after desmopressin melt Results: Sleep Cortical arousals Arousal- Arousal Awakening- index ↓ (p<. 01) (p<. 05) © 2010 Universitair Ziekenhuis Gent 19

Before and after desmopressin melt Results: Psychology Qo. L ADHD-symptoms (attention - hyperactivity/impulsivity) Internalizing problems Executive functions Self-esteem Memory © 2010 Universitair Ziekenhuis Gent 20

Before and after desmopressin melt Results: Psychology Qo. L ↑ Pin. Q Child ↓ Peds. QL Parents ↑ (p<. 01) © 2010 Universitair Ziekenhuis Gent 21

Enuresis is not a benign condition Results of the sleep study Comorbidity with Disrupted sleep Restless legs symptoms Attention deficit Poor QOL Burden toi the patie, nts Ameliorating during desmopressin trherapy © 2010 Universitair Ziekenhuis Gent 22

WAIT and SEE attitude Is not defendable © 2010 Universitair Ziekenhuis Gent 23