Medline ® Abstracts for References 35,36
Does structured withdrawal of desmopressin improve relapse rates in patients with monosymptomatic enuresis?
Gökçe Mİ, Hajıyev P, Süer E, Kibar Y, Sılay MS, Gürocak S, Doğan HS, Irkılata HC, Oktar T, Onal B, Erdem E, Aygün YC, BalcıC, Arslan AR, Kaya C, Soygür T, Sarıkaya S, Tekgül S, Burgu B
J Urol. 2014 Aug;192(2):530-4. Epub 2014 Feb 8.
PURPOSE: Relapse after cessation of desmopressin is an important problem in treating patients with enuresis. Structured withdrawal of desmopressin tablets has been shown to decrease relapse rates. However, scientific data are lacking on the structured withdrawal of the fast melting oral formulation of desmopressin. We compared relapse rates of structured withdrawal using placebo and direct cessation in a population of patients with enuresis who were desmopressin responders.
MATERIALS AND METHODS: Patients diagnosed with enuresis and responding to desmopressin from 13 different centers were involved in the study. Patients were randomized into 4 groups. Two different structured withdrawal strategies were compared to placebo and direct withdrawal. Sample size was estimated as 240 (60 patients in each group), with a power of 0.80 and an effect size of 30%. Randomization was performed using NCSS statistical software (NCSS, Kaysville, Utah) from a single center. The relapse rates of the groups were compared using chi-square testing. Logistic regression analysis was performed to define the independent factors having an effect on relapse rates.
RESULTS: Desmopressin treatment was initiated in 421 patients, and 259 patients were eligible for randomization. Relapse rates were 39 (1%) and 42 (4%) for the structured withdrawal groups, which were significantly less than for direct withdrawal (55, 3%) and placebo (53, 1%). Logistic regression analysis revealed that initial effective dose of 240μcg, greater number of wet nights before treatment and nonstructured withdrawal were associated with higher relapse rates.
CONCLUSIONS: We found that structured withdrawal with the fast melting oral formulation of desmopressin results in decreased relapse rates. Application of a structured withdrawal program was also an independent factor associated with reduced relapse rates, together with lower initial effective dose and number of wet nights per week. Relapse after cessation of desmopressin is an important problem, and in this study structured withdrawal was observed to be associated with decreased relapse rates compared to placebo and direct withdrawal.
Department of Urology, Ankara University School of Medicine, Ankara, Turkey. Electronic address: email@example.com.
Desmopressin Withdrawal Strategy for Pediatric Enuresis: A Meta-analysis.
Chua ME, Silangcruz JM, Chang SJ, Williams K, Saunders M, Lopes RI, Farhat WA, Yang SS
CONTEXT: A high relapse rate after discontinuation of desmopressin treatment of pediatric enuresis is consistently reported. Structured withdrawal strategies have been used to prevent relapse.
OBJECTIVE: To assess the efficacy of a structured withdrawal strategy of desmopressin on the relapse-free rate for desmopressin responder pediatric enuresis.
DATA SOURCES: Systematic literature search up to November 2015 on Medline, Embase, Ovid, Science Direct, Google Scholar, Wiley Online Library databases, and related references without language restriction.
STUDY SELECTION: Related clinical trials were summarized for systematic review. Randomized controlled trials on the efficacy of structured versus abrupt withdrawal of desmopressin in sustaining relapse-freestatus in pediatric enuresis were included for meta-analysis.
DATA EXTRACTION: Eligible studies were evaluated according to Cochrane Collaboration recommendations. Relapse-free rate was extracted for relative risk (RR) and 95% confidence interval (CI). Effect estimates were pooled via the Mantel-Haenszel method with random effect model.
RESULTS: Six hundred one abstracts were reviewed. Four randomized controlled trials (total 500 subjects) of adequate methodological quality were included for meta-analysis. Pooled effect estimates compared with the abrupt withdrawal, structured withdrawal results to a significantly better relapse-free rate (pooled RR: 1.38; 95% CI, 1.17-1.63; P = .0001). Subgroup analysis for a dose-dependent structured withdrawal regimen showed a significantly better relapse-free rate (pooled RR: 1.48; 95% CI, 1.21-1.80; P = .0001).
LIMITATIONS: The small number of studies included in meta-analysis represents a major limitation.
CONCLUSIONS: Structured withdrawal of desmopressin results in better relapse-free rates. Specifically, the dose-dependent structured withdrawal regimen showed significantly better outcomes.
Institute of Urology, St Luke's Medical Center, National Capital Region, Philippines; Division of Urology, Taipei Tzu Chi Hospital, Medical Foundation, New Taipei, Taiwan and Buddhist Tzu Chi University, Hualien, Taiwan; Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, Canada firstname.lastname@example.org.