Treatment of Nocturia is Modest at Best - Benjamin Brucker
June 19, 2018
Benjamin Brucker, MD details Clinical Evaluation and Treatment of Nocturia is Modest at Best a 2018 AUA meeting presentation by Siri Drangsholt, MD, of the New York University School of Medicine. A retrospective chart review was performed to select patients who had a primary complaint of nocturia. Patients who presented with a new patient encounter were entered into this study and followed for up to two subsequent visits. Results provide valuable insights into the effectiveness of their current treatment paradigm on the reduction of nocturnal voiding episodes and patient-reported improvement.
Benjamin M. Brucker, MD
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Dr. Benjamin Brucker: I'd like to present some work that colleagues and I have put together on our cohort of patients with nocturia. The title of the work is “Nocturia Treatment is Modest at Best” and the purpose here was to characterize the current evaluation and treatment of nocturia when that's their primary complaint.
So in order to do this, we performed a retrospective chart review on patients and we use the diagnosis code ICD-9 and ICD-10 of nocturia. We had a preselected time period where we looked at patients that had a new patient encounter during that time period were enrolled in this retrospective review. They were then followed for their subsequent visits, up to two subsequent visits. We obtained data on their clinical history, whether they had bladder diary suggested, if they did their bladder diaries. The ultimate outcome of the voiding diaries or bladder diaries, and then the recommended treatments were recorded.
We excluded patients if they did not clinically have nocturia as their primary complaint. Patient outcomes were recorded based on how they perceived their improvement in nocturic episodes and reported it to the doc.
So, there were 400 patients, 403 patients in the cohort, a nice spread between men and women, about 50 to 60 percent women. And on average the patients were about 71 years old. The nocturic episodes in the cohort before treatment were four. It turns out that a lot of patients that we were seeing for nocturia had been seen by prior health healthcare providers. So about 48 percent of patients had prior care specifically for their nocturia. We wanted to look at voiding diaries and it turns out that in this cohort of patients about half of the patients, it was suggested to have a voiding diary.
Again, we're not looking at the reasons why per se, but this gives you a little snapshot of how we're managing nocturia. It turns out that 63 percent of patients completed a diary, and this was a pen and paper diary, not using any newer technologies or e-diaries. It turns out like other studies that 75 percent of patients that completed the diaries for the indication of nocturia had nocturnal polyuria.
Patients were reporting outcome improvement that was very similar in the patients that had diaries that were completed compared to those that did not. We wanted to look a little bit to see if the voiding diary or the bladder diary actually had an impact on treatment, and based on how we were treating patients in this specific cohort, there was not really a statistically meaningful difference between those two cohorts. So, in terms of the follow-up of patients, about 400 patients were in the initial visit and about 300 patients came back for a second visit.
And like many conditions of the lower urinary tract, you see a bit of a drop off. For the third visit there were only about 200 patients. So we sort of see with time perhaps the patients are not necessarily coming back to see us. We did have an improvement in nocturia from the first visit to the third visit, but it was modest. The number of voids changed from about four voids a night down to three voids a night. We got about 60 percent of patients that were not improved after that first visit, and that drops down to about 50 percent. So about 40 percent of patients actually reported an improvement, up to about 45 percent by the third visit.
We looked at what was recommended for these patients with the complaint coded as nocturia and as expected, and as has been reported by others, anticholinergics were what was used. This was continually used first visit, second visit, third visit. Alpha blockers were also used as well as beta three agonists. You can see we have all the way over at the right, DDAVP, which was used a little bit more after the second visit. But again, a very low number of patients were actually prescribed DDAVP, and these were the older off label formulations of the medication.
So what we can conclude from this is there are a lot of patients that we're going to be seeing with nocturia. The methodology doesn't necessarily allow us to make a statement about the need for voiding diaries or not, but at least in our cohort, how we're using voiding diaries, the voiding diary or the completion of the bladder diary did not actually correlate with a patient-reported improvement. We know now that anticholinergics as has been suggested, are used for the treatment of nocturia and perhaps the use of that is the reason why we're not as effective at treating patients with nocturia, and we're only having modest improvements from about four voids a night to three. The off label use of desmopressin has traditionally been pretty low in spite of a high prevalence of nocturnal polyuria. And the treatment paradigm that we're using currently is only having a modest improvement in the outcomes that patients are reporting.
Obviously, there are limitations. It's a single site study. It's retrospective. But I think it does give a little glimpse just to give us an idea that maybe this condition is something we need to do a better job at focusing on not only on the intake and diagnosis, but also the ultimate management of these patients.