1. How to increase response- rate 1) Fluid restriction
1 hour before desmopressin administration
Evidence ??? NO
Rationale with indirect evidence : Yes

2. Fluid load reduces desmopressin response
* * *
30% lower U osmol results
in 30% higher diuresis-rate
.. and bedwetting
dDAVP
2 nasal spray
* p < O.O1
EVIDENCE OF PARTIAL dDAVP RESPONSE RELATED TO POOR PHARMACODYNAMIC EFFECTS OF dDAVP NASAL SPRAY (De Guchtenaere J Urology,2009)

3. 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

4. But high nocturnal excretion of osmol and water
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
J.Dehoorne Desmopressin resistant nocturnal polyuria
secundary to increased osmotic excretion J Urology 2006

5. How to increase response- rate
3) Desmopressin 1 hour before last void

6. effet anti-diuretique maximale
rapide
Fast Anti-diuretic effect first hour
Additional effect 2nd and 3rd hour
Vermindering van diurese van 0,05 ml/kg/min naar 0,02 gedurende 2 uur lijkt niet veel….doch voor een kind van 30 kg betekent dit een afname van 0,03*120*30 wat betekent een winst van een volume van 108 ml, hetgeen natuurlijk wel het verschil kan maken tussen nat of droog….

7. Concentration capacity Fast effect first hour
Additional increased effect 2nd and 3rd hour
Zelfde voor osmolaliteit, een stijging van 650 naar 900 in uur 2 en uur 3 na medicatie-inname
Pharmacodynamic studies of dDAVP melt during water-load Vande Walle JG et al. BJU Int 2006;97(3):603–9

8. 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

9. How to increase response- rate
5) Compliance

10. What about adherence?
The study clearly demonstrated that a high adherence is associated with a high response rate. Low adherence is associated with a low response rate. This study demonstrates the importance of non-adherence as a possible reason for therapyresistance.

11. What about adherence?
The study also demonstrates that even when patients know that adherence will be measured, the group with the 100% adherence decreases over time, to 77% after 3 months and even to 71% of the patients after 6 months who are fully adherent.

12. How to increase response- rate
6) Select the right patient

13. High nocturnal urinary volumes predict good DDAVP response
500
Full responders
(N=13)
Desmopressin i.n.
20 mg
40 mg
Partial responders
(N=19)
400
Non responders
(N=84)
Night urinary volume (mL)
300
200
100 5 10 15 20 25 30
Time (days)
Rittig et al. Scand J Urol Nephrol 1998

14. Re-analysis: Do screening parameters predict response to desmopressin?
Enuretic predictors: nocturnal diuresis (p<0.0001)

15. Enuresis is not a benign condition
Results of the sleep study

16. Before and after desmopressin melt Results: Enuretic parameters
Response desmopressin melt (ICCS)

17. Before and after desmopressin melt Results: enuresis / sleep
Time alarm
Response volgens ICCS criteria: 25/30 minstens 50% reductie in aantal natte nachten
= desmopressin 17

18. Before and after desmopressin melt Results: Sleep
PLMS index
PLMS-index ↓
(p<.001)

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

20. Before and after desmopressin melt Results: Psychology
QoL
ADHD-symptoms (attention - hyperactivity/impulsivity)
Internalizing problems
Externalizing problems
Executive functions
Self-esteem
Memory

21. Before and after desmopressin melt Results: Psychology
QoL ↑
PinQ Child ↓ (p<.01)
PedsQL Parents ↑ (p<.01)

22. 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

23. WAIT and SEE attitude
Is not defendable