From the Desk of the Editor - “It Works Like Clockwork”

This was a quote from a patient who was treated for bothersome nocturia with a new formulation of desmopressin acetate (Noctiva).  Nocturia - awakening to urinate - is an all too common symptom reported by both men and women.  This is a commonly reported symptom in patients who report other lower urinary tract symptoms, such as incontinence, urgency and daytime frequency, but I also hear it from male patients who have benign prostatic hyperplasia (BPH).  It can be part of the overactive bladder (OAB) syndrome but unlike other symptoms, I have not been very successful in my behavioral or drug treatments.  Daytime symptoms seem to respond to these interventions but nighttime voiding- nocturia - is an outlier.  

The recent release of a new formulation of desmopressin, Noctiva, has given me hope.  I recently prescribed Noctiva in an 83 yo male who had been treated for BPH but persisted with complaints of urgency and frequency.  At initial visit, patient-reported voiding 2 to 3 times in the morning, 2 to 4 times in the afternoon, 2 to 3 times in the evening hours with nocturia 4 to 5 times.  Prostate size was WNL and PVR was < 50 cc.  The patient’s report of nighttime awakenings was significant but all too common a complaint in his age group as nocturia increases with age with up to 59% of men and 62% of women awakening at least twice per night by the age of 70 years.  For patient’s overactive bladder symptoms, a previous provider had tried several medications.  I prescribed a 6-week program of bladder training and urge suppression strategies and daytime frequency improved but nocturia persisted.  I educated the patient on ways to decrease nocturia including elimination of ingestion of caffeine with dinner, decreasing fluid intake after 7 PM, and other sleep hygiene strategies (dark room, cold sleeping temperature, etc.) but these were only marginally effective.  Nocturia became patient’s most bothersome problem, reporting sleepiness during the day and not feeling “well-rested.”  I decided to try Noctiva nasal spray which is approved for the treatment of nocturia due to nocturnal polyuria (NP) in adults who awaken at least twice nightly.  It has been shown to reduce nocturnal voids by >50% in up to 49% of patients in clinical trials. Per drug recommendations, I obtained a pre-drug sodium level.  I also decided to have the patient complete a 2-day frequency-volume chart (FVC).  As per AUA Guidelines, in patients with >2 nocturia episodes, a FVC will help identify 24-hour polyuria and nocturnal polyuria (NP) as causes of nocturia.   Nocturnal polyuria is defined as nighttime urine production >20% for younger adults and >33% of the total urine output for older adults and > 20% for younger adults. The 2 FVC completed charts on this patient met the criteria for NP.  With a normal range blood sodium, the patient was prescribed Noctiva 0.83 mg.

After 5 days, I received this message from the patient “The Noctiva is working great. I go to bed around 23:30 and wake up to go like clockwork every night once around 03:00 and not again until 06:00. “ Per drug instructions, the blood sodium after 7 days on Noctiva was WNL and has stayed unchanged.  It has been 6 weeks and efficacy persists.  So I plan to address the illusive nocturia in more of my patients.

Frequency-Volume Charts: 
frequency_volume_charts.png

Written by: Diane K. Newman, DNP, ANP-BC, FAAN

References: 
1. Bosch JLHR, Weiss JP. The prevalence and causes of nocturia. J Urol. 2013;189:S86-S92. 
2. McVary KT, Roehrborn CG, Alvins AL, et al. Update on AUA guideline on the management of benign prostatic hyperplasia. J Urol. 2011;185:1793-1803 
3. Van Kerrebroeck P, Abrams P, Chaikin D, et al. The standardization of terminology in nocturia: report from the standardization subcommittee of the International Continence Society. BJU Int. 2002;90(suppl. 3): 11-15.
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