Desmopressin for nocturnal enuresis in children

  • Review
  • Intervention

Authors

  • Cathryn MA Glazener,

    Corresponding author
    1. University of Aberdeen, Health Services Research Unit, Aberdeen, Scotland, UK
    • Cathryn MA Glazener, Health Services Research Unit, University of Aberdeen, 3rd Floor, Health Sciences Building, Foresterhill, Aberdeen, Scotland, AB25 2ZD, UK. c.glazener@abdn.ac.uk.

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  • Jonathan HC Evans

    1. Nottingham University Hospitals NHS Trust, Department of Paediatric Nephrology, Nottingham, UK
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Abstract

Background

Enuresis (bed-wetting) is a socially disruptive and stressful condition which affects from 15% to 20% of five year olds, and up to 2% of young adults.

Objectives

To assess the effects of desmopressin on nocturnal enuresis in children, and to compare desmopressin with other interventions.

Search methods

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 10 May 2006). The reference list of the original version of this review was also searched.

Selection criteria

All randomised controlled trials of desmopressin for nocturnal enuresis in children were included in the review. Trials focused solely on daytime wetting were excluded.

Data collection and analysis

Two reviewers independently assessed the quality of the eligible trials and extracted data.

Main results

Forty seven randomised controlled trials involving 3448 children (of whom 2210 received desmopressin) met the inclusion criteria. The quality of many of the trials was poor.

Desmopressin was effective in reducing bed-wetting during treatment, compared with placebo (e.g. 20 µg: 1.34 fewer wet nights per week; 95% confidence interval (CI) 1.11 to 1.57), and children were more likely to become dry (e.g. 118/146, 81% versus 140/142, 98% still wet; relative risk (RR) for failure to achieve 14 dry nights with 20 µg was 0.84; 95% CI 0.79 to 0.91). However, there was no difference between the two patient groups after treatment was finished. There was no clear dose-related effect of desmopressin, but the evidence was limited. Data which compared oral and nasal administration were too few to be conclusive.

In four small trials, there were no significant differences between desmopressin and alarms during treatment when these were used separately, but the chance of failure or relapse after treatment stopped was lower after an alarm in two small trials (40/62, 65% versus 26/57, 46%; RR 1.42, 95% CI 1.05 to 1.91).

Although children had fewer wet nights during treatment when they used desmopressin combined with alarm treatment compared with alarms alone (WMD -0.83, 95% CI -1.11 to -0.55), there were no significant differences either in failure rates during treatment (RR 0.88; 95% CI 0.73 to 1.05) or for relapse after treatment stopped (105/213, 49% versus 118/214, 55%: RR 0.91, 95% CI 0.76 to 1.08).

Comparison with some tricyclic drugs (e.g. amitriptyline) suggested that they might be as effective as desmopressin, although in two trials children were less likely to achieve 14 dry nights with imipramine than desmopressin (RR 0.44, 95% CI 0.27 to 0.73) but there was not enough information about subsequent relapse. There were more side effects with the tricyclics. Desmopressin may be better than diclofenac or indomethacin.

There was not enough information to evaluate the relative effects of behavioural or complementary treatments against desmopressin.

Authors' conclusions

Desmopressin rapidly reduced the number of wet nights per week experienced by children, but the limited evidence available suggested that this was not sustained after treatment stopped. Comparison with alternative treatments suggested that desmopressin and tricyclics had similar clinical effects during treatment, but that alarms may produce more sustained benefits. However, based on the available limited evidence, these conclusions are only tentative. Children should be advised not to drink more than 240 ml (8 ounces) of fluid during the evening before desmopressin treatment in order to avoid the possible risk of water intoxication.

摘要

背景

去氨加壓素(Desmopressin)對兒童夜尿的治療效果

遺尿症(尿床)是一種受社會干擾及壓力導致的狀態,約有15%到20%的五歲孩童及2%的 年輕成人受其影響

目標

目標:評估去氨加壓素(desmopressin)對兒童夜間尿床的治療效果,並與其他療法做比較

搜尋策略

我們搜尋了考科藍尿失禁研究小組專科試驗資料庫(Cochrane Incontinence Group Specialised Trials Register)(搜尋日期為2006年5月10日). 該資料庫所列出的原始文獻亦列入搜尋範圍。

選擇標準

所有去氨加壓素(desmopressin)對兒童夜間尿床療效之隨機控制試驗(randomised controlled trials)皆列入評估,排除僅研究晨間遺尿的試驗

資料收集與分析

資料收集與分析:由兩位研究者獨立審核合乎資格的研究品質以並擷取當中的數據

主要結論

主要結論:47個隨機控制試驗符合搜尋的準則,包含3448名受試兒童符合,(其中2210名接受去氨加壓素治療)其中許多試驗的品質不佳. 去氨加壓素在受試期間減少尿床的效果優於使用安慰劑的對照組. (例如,使用20毫克去氨加壓素的組別,平均每周減少1.34個夜晚尿床,95%信賴區間為1.11到1.57), 且使較多兒童在受試期間完全沒有尿床(例如,實驗組146人中118人仍有尿床,佔81%;對照組142人中140人仍有尿床,佔98%;使用每天20毫克去氨加壓素治療但無法達到14個夜晚沒有尿床的相對危險性(relative risk, RR)為0.84,95%信賴區間為0.79到0.91). 然而,實驗組與對照組在試驗結束後,尿床的情形並沒有差別. 去氨加壓素對尿床的療效,與使用劑量沒有明顯相關性, 不過關於此的證據有限. 比較經口與經鼻給藥的數據太少,無法做出有效結論. 在四個小型臨床試驗中,單獨使用去氨加壓素治或鬧鈴治療的組別的治療結果大約相當,但兩個小型試驗中顯示鬧鈴療法治療失敗或在治療後恢復尿床的機率較小(去氨加壓素組:40/62人次,65%比較鬧鈴治療組:26/57人次,46%;相對風險RR:1.42,95%信賴區間:1.05到1.91). 雖然孩童在合併使用去氨加壓素及鬧鈴治療的期間比起單純使用鬧鈴組尿床夜數較少(加權平均差:WMD −0.83, 95%信賴區間: −1.11到−0.55), 但在試驗期間治療失敗機率(相對風險RR 0.88; 95%信賴區間: 0.73到1.05)及治療結束後復發機率105/213人次,49%比較 118/214人次,55%: 相對風險 0.91, 95%信賴區間: 0.76到1.08)沒有顯著差別. 有兩個臨床試驗比較去氨加壓素及一些被認為與去氨加壓素有一樣療效的三環類藥物(例如amitriptyline),結果發現服用imipramine此種三環類藥物的兒童較難在試驗期間達到14個未尿床夜晚(相對風險RR 0.44, 95%信賴區間:0.27到0.73),但是沒有關於後續復發的足夠資訊. 使用三環類藥物會產生較多副作用. 去氨加壓素的效果比diclofenac以及indomethacin較好. 此外,並沒有足夠資訊可供將行為療法或其他輔助療法療效與去氨加壓素作比較

作者結論

去氨加壓素能快速減少兒童每週尿床的夜晚數,但有限可獲得的資料顯示:治療效果在停藥後無法維持. 跟其他替代療法相比的結果顯示:去氨加壓素與三環類藥物在治療期間達到相似的臨床療效,但鬧鈴能提供較持續的效果. 然而,在所能獲得的有限證據之下,僅屬暫時性的結論. 試驗中建議受試的孩童每晚在服用去氨加壓素前不應飲用超過240毫升(8盎司)的液體,避免提高水中毒的風險

翻譯人

本摘要由中國醫藥大學附設醫院郭純恩翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

尿床給孩童以及其父母很大的壓力及挫折感,有些孩童需要較長的時間才能停止尿床的發生. 五歲兒童族群中,有多達20%的人會尿床, 到16歲的時候, 只剩下約2%的人仍因此所苦. 去氨加壓素能夠減少夜晚產生的尿量, 進而減少尿床的機會. 治療方式為在睡前服用, 同時建議孩童在晚間不要飲用多於240毫升(8盎司)的液體. 然而,去氨加壓素僅在有服藥的夜晚有作用, 所以並無法對尿床有長期療效. 使用去氨加壓素期間, 大部分兒童的尿床夜晚數減少(平均一週減少一晚尿床),與使用安慰劑相比, 較多孩童達到在用藥期間沒有尿床情形 (包括288名受試兒童的五項臨床試驗結果顯示服用去氨加壓素:19%,安慰劑:2%在受試期沒有尿床,). 然而,停止用藥後,許多兒童又回復尿床情形. 另一方面, 接受鬧鈴提醒治療的兒童, 有較高比例能在停止治療後維持不尿床.(包含119名兒童的兩項臨床試驗中,接受鬧鈴提醒治療:54%, 接受去氨加壓素治療:35%在治療後維持不尿床). 兩者合併治療並沒有比單純鬧鈴治療有更佳的治療結果(兩者合併治療:51%,單純鬧鈴治療: 45%在治療結束後維持不尿床). 受試兒童及家屬應注意:在受試過程中,孩童不應在就寢前飲用太多液體,以免造成嚴重但少見的副作用. 三環類藥物較便宜,且跟去氨加壓素對兒童尿床有差不多的療效,但有較多的副作用. 除了短期家庭分裂的狀態,鬧鈴提醒療法鮮少有副作用,. 總結來說:鬧鈴提醒需要較長的時間才能改善兒童尿床問題,但是較之去氨加壓素,其能夠維持較長的治療作用

Plain language summary

Desmopressin for bedwetting in children

Bedwetting is a distressing and stressful condition for children and their families. Some children take longer than others to stop bedwetting. Up to 20% still wet at the age of five years, but by the age of 16 only 2% or less do so. Desmopressin is a drug which reduces bedwetting by reducing the amount of urine produced at night. It is taken before bedtime, and the children are also advised not to drink more than 240 ml (8 ounces) of fluid in the evening. However, it only works on the nights when it is used, so does not cure the problem in the long term.

When desmopressin is used, most of the children have fewer wet nights (one night less on average per week) and more become dry (19% compared with only 2% using dummy treatment in five trials involving 288 children). However, many children start wetting again when treatment stops. On the other hand, more children remain dry when alarm treatment is finished (54% after alarm compared with 35% after desmopressin in two trials involving 119 children). Adding desmopressin to alarm treatment did not result in better cure rates after the end of treatment (51% remained dry after combination treatment compared with 45% after alarm alone).

Those using desmopressin (or their parents) should be warned that over-drinking before bedtime should be avoided as this may lead to serious, but rare, adverse effects. Drugs called tricyclic antidepressants have a similar effect to desmopressin and are cheaper, but have more adverse effects. There are few adverse effects with alarms, other than short-term disruption for the family. In summary, alarms take longer to reduce bed-wetting, but their effect may persist longer than desmopressin.

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