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Pills and Potions - Pharmacotherapy for OAB in Children — Transcript

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0:03Hello everyone. Welcome to this
0:05evening's webinar. Um for anyone in
0:08Melbourne, it's rather chilly today so
0:10or evening. So I'll let you all get
0:13settled in over the next couple of
0:15seconds and um before I introduce. So uh
0:19tonight's webinar is pills and potions
0:22uh in pediatric overactive bladder and
0:25it's hosted by continent's health
0:27Australia's pediatric special interest
0:29group.
0:33Uh firstly let's begin with an
0:35acknowledgement of country continent's
0:37health Australia would like to
0:38acknowledge the traditional owners of
0:40the lands across Australia on which we
0:43all meet today. and um that I've seen
0:46that that includes uh people across
0:48every state. So um we would like to pay
0:51our respects to elders past and present.
0:56So just some general housekeeping for
0:58those not familiar. So we will have a
1:00Q&A at the end of the presentation.
1:03However, just please feel free to ask
1:05questions via the Q&A button at the
1:07bottom of your screen. Um so there will
1:10be an upvoting mechanism that you can
1:13use. So for existing questions that
1:16you've seen that you might want to
1:18rather than asking the question again
1:20just vote vote it up and at the end of
1:22the presentation uh those questions will
1:25tend to be answered first.
1:28Um chat function will has been disabled.
1:30So um just chat can come to us but we
1:33just ask that you just send those uh any
1:35chats to us if there's a technical
1:37issue.
1:39Uh recordings will be made available um
1:41on a private YouTube channel and that
1:43should happen within a week but uh it
1:46might even happen tomorrow. So just make
1:48sure you check your junk mail or
1:51anything like that um as it might go in
1:53there um but we'll endeavor to get it
1:55out soon. And finally, there is an
1:58anonymous survey um that will take place
2:00uh during the Q&A. So, we just ask you
2:03um pop that feedback in and um pop in
2:06any ideas you'd like to see in future.
2:08Um I will also add it is a renewals
2:11period. So, for anyone who hasn't
2:13renewed their CHA membership, please
2:16please get that in. Um it does uh make
2:19my blood pressure a lot better. So if
2:23you can um participate in that that
2:25renewal, we've had something like six or
2:27seven webinars this year with the
2:29pediatric uh special interest group. So
2:33it is it's much high value for money.
2:38Uh obviously um we take uh the health
2:41and safety of children very seriously.
2:43So for anyone who may not who may find
2:47pediatrics outside of their scope of
2:49practice, we please ask that you don't
2:51take any of the learnings on board um
2:53today, but rather to contact the
2:55national continent's helpline and they
2:58can connect you with experienced
2:59pediatric uh health professionals in the
3:02continent space. So with that, let me
3:06introduce Dr. Susie Gibb. Uh so she is a
3:09general and developmental pediatrician
3:11working out of uh Royal Children's
3:13Hospital here in Melbourne and also in
3:15private practice. Uh she's done training
3:17in both Melbourne and in the UK in
3:20Sheffield and among other roles she's uh
3:23the medical lead of the complex care hub
3:25and has worked at the continent's clinic
3:27at Royal Children's Hospital since 1999.
3:31So with that I will pass over to you
3:33Susie and thank you very much for being
3:35here.
3:45Excellent. You are up and I will mute
3:48myself.
3:51>> Thank you very much for the kind
3:53introduction Crosley and um welcome
3:55everybody who is listening. Um, as
3:59Crosley said, I'm going to talk about
4:02pills and potions or pharmacotherapy in
4:05overactive bladder in children.
4:09I will also add my own acknowledgement
4:12of country. I am here on Warjurie
4:17um land and pay my respects to the old
4:20people, the elders and the ancestors who
4:22are the safekeepers and caretakers of
4:24the oldest living culture on the planet.
4:26For this is the very bedrock of this
4:28place, our shared home and our special
4:30identity in the world and the source of
4:32shared pride as Australians. For this
4:35land always was and always will be
4:37Aboriginal land.
4:41So, I think this might have been shared
4:44with you as part of the um advertising
4:48for the webinar, but I'm hoping that
4:50after tonight you will be able to
4:53identify the place of medication
4:55management in children with overactive
4:57bladder, outline some medication options
5:00and how that might need to be monitored
5:04and escalated and also how medication
5:07could be weaned with resolution of
5:09symptoms and also to understand what the
5:13potential pitfalls, side effects, and
5:15contraindications are.
5:20I acknowledge that you're probably all a
5:23very uh knowledgeable audience, but
5:27maybe not many of you are prescribers.
5:29So, I'm going to kind of dance around
5:32between um things you probably know very
5:34well and other things that maybe um will
5:38be somewhat new information to you. I
5:42think you all know what overactive
5:45bladder is, but just to um define it
5:48from my perspective, I'm talking about
5:51children who presenting with urgency.
5:55They usually have urinary incontinents
5:57but might not. And that on um
6:02investigation there is detrus
6:05overactivity with a quiet pelvic floor
6:08during voiding but eurodnamic proof is
6:12not required to make the diagnosis of
6:14overactive bladder.
6:18Before even thinking about what the
6:21pharmacotherapy might be, we obviously
6:23have to make a diagnosis and an
6:26assessment and we need lots of detailed
6:30information
6:32from the history about the urinary
6:35symptoms both the symptoms relating to
6:37storage but also to voiding and any
6:40other symptoms that might be present.
6:42I'll probably say multiple times in the
6:45next uh half an hour that it's important
6:48to understand the history of the bowel
6:53pattern and constipation in these
6:55children and that they should all at the
6:59outset at some point have a physical
7:02examination including an inspection of
7:05genitalia.
7:07Often it's also helpful to use
7:11questionnaires or symptom scores to
7:13really understand both the severity but
7:17also the impact of the symptoms at the
7:19outset.
7:23Assessing
7:25the bowel history is sometimes
7:28challenging in children's particularly
7:30school age children where their parents
7:32may not actually know the history of how
7:36often they go to the toilet and how
7:38difficult it is for them.
7:41What we're trying to find out is what's
7:43their pattern, what's their frequency.
7:45We might need a diary to really
7:48understand that, particularly when
7:52the parent is less aware of their
7:54child's symptoms. And I find that using
7:58the Bristol stool scale can be a bit of
8:02a good way to start the conversation
8:04with a child
8:07at the outset of trying to get some
8:09information.
8:12You will all be very familiar with using
8:16using diaries. But I think unless in my
8:20practice unless the history is
8:22absolutely clearcut then I would usually
8:27want to get confirmation with a with a
8:29bladder diary before starting any
8:32treatment.
8:36I think it is always
8:39useful to remind people about the
8:45the change in bladder capacity with age
8:50and also to remember that it
8:55following voiding it is important to
8:58measure postvoid residual and children
9:00with straightforward overactive bladder
9:02should empty their bladders completely.
9:08I'm sure I'm speaking to a very um
9:11familiar audience, but just as a
9:14reminder, we're talking about children
9:17with bladder overactivity tonight, and
9:20so they will likely have a tower curve
9:23on euroflammetry if that is available to
9:26you. But children can have more than one
9:31diagnosis and they can progress through
9:34different patterns over the course of
9:37the time that you're treating them.
9:42Bedside ultrasound can be
9:45incredibly helpful particularly in cases
9:50where
9:51treatment is not initially successful or
9:56uh it's unclear whether there is a
10:00contribution from constipation. I think
10:03looking at the
10:06displacement of the bladder by a field
10:10full bowel, looking at bladder wall
10:14thickness
10:16and also at measurement of the rectal
10:20cresant are all use useful pieces of
10:23information particularly
10:25if used in a followup and monitoring
10:30way.
10:34I think it's always useful also to
10:37remind people that a child who's
10:40presenting with bladder overactivity and
10:45urinary incontinents
10:47should have a formal radiology
10:52ultrasound as well. We really want to
10:54make sure that the upper tracts are
10:58normal. So we want to really look at the
11:02renal size, the renal growth, the
11:04collecting system and rule out these red
11:09flags that might send you off in a
11:11different direction. Obviously someone
11:13with a solitary kidney and a dilated
11:16collecting system. We need to be really
11:19sure that person doesn't have
11:20obstruction.
11:22We also need to be wary when there are
11:27duplex kidneys that there aren't ectopic
11:29urittors or other things and
11:33tbaculated bladders or bladders with
11:35diverticuli are red flags for a high
11:38pressure system.
11:43I'm not going to spend lots of time on
11:46physiology, but just important to
11:48remember that when we are do come on to
11:51talk about pharmacotherapy, we're
11:54talking about medications largely that
11:57act via the parasympathetic and
12:01sympathetic nervous system to
12:05in the case of treating overactive
12:07bladder. We're trying to reduce the
12:10excitation of the datusa.
12:17I find this little schema can be quite
12:21helpful just at the very outset when
12:24someone's presenting with urinary
12:26incontinents. The first question is, is
12:31it structural or functional? And the
12:35really important question is, is there
12:37continuous wedding? And it's surprising
12:40that sometimes people sneak through
12:43having seen a few practitioners before
12:46and not really rec it hasn't been
12:50recognized at the outset that this child
12:53actually has continuous wedding. you
12:55know, the amount of urine from an
12:58ectopic urer draining a small moyete of
13:03a um of a duplex system might be quite
13:07small and it could sometimes be mistaken
13:10for just frequent frequent accidents. So
13:13really important to ask the question uh
13:16how long is the longest dry period and
13:20also look when you're doing an
13:25inspection of the external genitalia is
13:29is there urine partic this is
13:30particularly relevant for for girls is
13:32there urine pooling in the posterior
13:35forchet is is there something that makes
13:38you worry about a a structural
13:43That also can apply to the the children
13:47that have urethral vaginal reflux. They
13:49may have pulling of urine there and that
13:51needs to be excluded too. But then if
13:54we're not worried about the functional
13:56causes, then the structural causes my I
14:00beg beg my pardon. Um then we need to
14:05I think it's helpful to divide those
14:09with intermittent wedding into those who
14:12have overactive bladder which are by far
14:15the most common group. Those with
14:17voiding postponement who might initially
14:20look like they've got overactive bladder
14:22because they seem to rush to the toilet.
14:25But once you um ascertain that that's
14:28after a long period of not voiding that
14:30diagnosis usually becomes clear and then
14:33the other group of intermittent wedders
14:36with the dysfunctional voiding pattern
14:39or other conditions giggle and stress
14:42incontinence. So I find just kind of
14:44dividing it in that way is helpful for
14:47me.
14:50We're going to focus now though on
14:52overactive bladder. It is essentially a
14:56a condition of urgency usually with
15:00frequency nocturia and posturing and as
15:03I said before a towhaped curve or
15:05neuroplammetry. The bladder can be small
15:08or large and emptying is complete.
15:12We know that the first management is not
15:15to reach straight for medication and you
15:19will be much more expert than me in
15:21eurotherapy. But we need to make sure
15:24that the child and their parents
15:27understand what we're talking about when
15:31we talk about the urinary tract. We need
15:33them to understand what bladder
15:35overactivity is. And we need to set up a
15:40pattern of regular timed voiding,
15:45spread their fluid intake out throughout
15:48the day, talk about their posture on the
15:50toilet, and often use a bladder diary as
15:55a as a reference to how we're going to
15:57set that up for them.
16:01I found this description of eurotherapy
16:05in a paper I read recently kind of
16:08helpful. And we can think of standard
16:11eurotherapy as being those things we
16:14talked about the education, addressing
16:17intake, avoiding patterns and avoiding
16:20bladder irritants.
16:22And we
16:25research suggests that just attending to
16:27those things
16:29might be effective in almost half of
16:34those children presenting with urgency.
16:38But then we also have what this group um
16:43have termed specific eurotherapy where
16:46we're getting a bit more um doing some
16:49some more active things like using
16:52alarms or bio feedback or neurom
16:55modulation.
17:00But our focus tonight is on
17:02pharmarmacothotherapies.
17:03And the aim of medications is to reduce
17:09the urgency, increase the bladder
17:12capacity and reduce incontinence.
17:17But it's really important to emphasize
17:21that medication never comes first and we
17:25should only use it when we're sure of
17:28the diagnosis. when we think that this
17:33child and family will be able to manage
17:37taking medication at sort of the right
17:38time for them and that um we have
17:44considered carefully the side effect
17:46profile of the medicines we're going to
17:48use and how
17:51well the child and family have been able
17:54to manage the previous things we've
17:57asked of Um,
18:00and really important that it's not a set
18:02and forget. You know, we have to
18:04periodically review what we've
18:07recommended,
18:09optimize both the medicine we're using,
18:12but also its dose and thinking about
18:16combinations as well. And really trying
18:19to find what is the most efficacious and
18:22tolerable regime for that individual
18:26child.
18:30Returning to the thought about um
18:33physiology, you know, if we're attending
18:36to the datusa, we can either
18:40increase
18:42the give more of something that will
18:45relax the datus or we can block um
18:52the the nerves that will contract the
18:56data.
19:00The most common medications used
19:02initially for overactive bladder are
19:05antimuscerinics.
19:06And the other thing that's um perhaps
19:10not always well remembered or recognized
19:14about them is that they actually work
19:17not just on the motor um nerves but also
19:21on the sensory nerves and actually have
19:23better affinity for the sensory nerves.
19:29Having
19:31given you a very simplistic kind of
19:34overview of overactive bladder, it is
19:37important to say that this is a sort of
19:40a schematic simple thing. And overactive
19:43bladder is actually much more
19:44complicated than just um related to the
19:48detrusa. But I think we keep it simple
19:53when we're explaining it to families and
19:56we and that makes just the understanding
20:01of how the medications work um
20:04best best communicated to them.
20:09So I'm going to in the next part just um
20:14talk um about some individual
20:17medications that
20:20are commonly used in bladder
20:23overactivity and some of the evidence
20:25and some of the
20:29things we need to be worried about. So
20:32oxybutin marketed in Australia as
20:35detropan is the most common medication
20:39used in pediatric overactive bladder.
20:42It's on the PBS. It's widely available.
20:45It's been used for many years. But
20:48despite that, interestingly, has never
20:50been tested in a randomized control
20:52trial against placebo in children.
20:56But it certainly seems effective in many
21:00children. It binds to both M2 and M3
21:04receptors.
21:05It has been shown
21:09in
21:10um open trials to increase bladder
21:13capacity, increase the volume to first
21:17detected
21:19to treat a contraction and to reduce
21:21incontinents both during the day and at
21:24night.
21:26The main [sighs] challenge with oxybutin
21:30is that its metabolites
21:34act on all of the other subreceptors. So
21:36there are side effects on gut, saliva,
21:40skin, and brain.
21:44Dry mouth is really common and usually
21:47not a barrier to ongoing treatment, but
21:51constipation can limit the value that we
21:56get from oxybutin. And there are
21:59definitely a small number of children
22:02who get really marked central nervous
22:04system side effects with irritability
22:08and real that can be quite extreme. I
22:12always warn parents that that might
22:14happen because if they don't, it may
22:17take them too long to put two and two
22:19together and they might wonder what else
22:20is wrong. So that's a really important
22:23side effect to warn them about
22:28it. The um it comes as 5 mgram tablets.
22:33They're tiny. there. They can be chewed
22:36or crushed and usually tolerability in
22:40terms of actually getting the medication
22:41in is not an issue. The starting dose is
22:442.5 milligrams twice a day and we can
22:48give up to 5 milligrams three times a
22:50day in childhood.
22:56If there are difficulties with tolerance
22:59or adherence with oxybutin but we think
23:04it's effective changing to using the
23:07transdermal
23:08preparation is a useful
23:12uh alternative. It avoids the first pass
23:15metabolism. There is much less incidence
23:18of constipation,
23:20but
23:22some children get significant skin
23:25reaction to the adhesive and that can be
23:29limiting for them. Oxyrol patches are
23:33available on the PBS in Australia, but
23:35the PBS recommendation is for adults,
23:40as long as you disclose to uh families
23:45that you're using it um
23:49and and it's been well tested. And in
23:52other countries, there are guidelines
23:54that um allow its use. in in the US the
23:59um recommendation is is for children
24:01over five. So I think it's a useful
24:05adjunct as long as the skin um side
24:09effects are not a problem. And I find
24:12particularly useful for adolescents who
24:17find it really hard to take three
24:19tablets a day and to to stick to the
24:22regime. just having to change your patch
24:24twice a week can be really valuable for
24:27them.
24:31The other medication in this class that
24:34has gets quite a lot of use in
24:37pediatrics is toleradine which acts more
24:41specifically just on the M2 receptors.
24:44So there are less side effects in other
24:49systems in particular less constipation.
24:54It's useful if you if oxybutin is not
24:59tolerated. It's definitely um safe and
25:03has similar efficacy to oxybutin in most
25:08trials but in some trials didn't seem to
25:10be as effective. The downside in
25:14Australia is that this is a nonPBS
25:16medicine and is more expensive.
25:21Solenosin
25:24similarly is a more specific
25:27anticolinergic
25:29with again a lower incidence of side
25:33effects than oxybutin. The advantage of
25:36solenisonin is it's once daily dosing.
25:40So again that can be useful in older
25:43adolescents.
25:46It's definitely in open label studies
25:49safe and efficacious.
25:52It um
25:57and has proven um benefits
26:03in reducing um bladder contractions and
26:07increasing bladder capacity. And
26:12there is a small amount of evidence that
26:14it's worth trying solenisonin
26:17if there's an incomplete response to
26:20oxybutin or toleradine.
26:26All of these anticolinergics
26:29probably have the same
26:32contra indications and the same
26:36uh side effect profile just to different
26:39degrees. I think there are a couple of
26:44contraindications.
26:45can't use them in active urinary
26:47retention. And you do need to be mindful
26:50that
26:52anticolinergic therapy can lead to
26:56incomplete bladder emptying and increase
26:58the risk of UTI. And all of them can
27:01cause constipation. And I think we've
27:03probably all seen kids that have a
27:06really what seems like a really good
27:09initial response to an anticolinergic
27:11medication and then the wheels fall off
27:14and that's often because of
27:17occult constipation
27:21and like everything
27:25sticking to it, continuing to take it
27:29staying taking
27:31consistent dosing can interfere with
27:34efficacy.
27:39The other
27:42increasingly
27:44used and really valuable addition to our
27:48armamentarium for pharmarmacotherapy for
27:50overactive bladder is miragron.
27:54This is a beta3 adronergic agonist. So
27:59it is stimulating the relaxation
28:04pathway to the bladder.
28:07It comes in 25 and 50 mgram tablets. It
28:13only has to be given once a day.
28:17There are some potential drug
28:19interactions but not with the kind of
28:21medications that children are usually
28:23on. It is
28:27in
28:29um it's been shown to be mod mo
28:32moderately efficacious but it definitely
28:36reduces frequency and increases bladder
28:39volume and
28:42the pediatric studies have definitely
28:45confirmed safety and efficacy and in um
28:51a head-to-head trial mirac and
28:55solenisonin were equally effective in
28:58reducing symptoms but miragron has less
29:02side effects and I think that is the uh
29:06the value of miragron
29:09it
29:12the the side effects that are reported
29:14in adults are tend to be cardiovascular
29:17side effects and they are really rare in
29:19children who have otherwise very healthy
29:23cardiovascular systems normally, but it
29:26is important to monitor blood pressure
29:29both prior to and during therapy with
29:32Miraberon.
29:37What is clear is that there is some
29:42synergistic
29:43uh benefit of using more than one
29:48medication.
29:50If monotherapy is not effective or you
29:54can't push the dose up of your
29:57anticolinergic due to side effects, it
30:01can you can optimize treatment by either
30:05using two different antimuscerinics at
30:09um lower doses. So a combination of a
30:12low dose of ditropan with a low dose of
30:15solenisonin or a low dose of ditropan
30:17with a low dose of tolterine
30:20but I think actually even better
30:23combining an antimuscerinic
30:25with mirac and there are some studies uh
30:31confirming that that combination is more
30:35effective than monotherapy and well
30:39tolerated.
30:40You can see those references there on
30:43the slide. So I think the only downside
30:49of meron is cost. If it weren't um
30:53expensive, I think it it would
30:56potentially replace
30:59oxybutin as the medication of first
31:02choice in pediatrics because of the
31:03tolerability.
31:08It's probably important also just to
31:10briefly touch on
31:13placebo effect.
31:16Um, in
31:19all of the
31:21placebo control trials, there is always
31:24some improvement in the placebo group.
31:27And it there's twoing and throwing about
31:30what that what that means. But is it uh
31:37a central effect? Is it a result of you
31:40know just being in the trial and the
31:42attention and the fact that that means
31:43that you stick to your eurotherapy
31:46recommendations better and
31:50we know that
31:53there is you know there's a a big
31:56influence of the central nervous system
31:57on bladder function. So is it patient
32:00expectation that um is responsible for
32:04that placebo effect that is really
32:07common?
32:12So
32:14people always ask me patients and other
32:18practitioners, how long do you need to
32:20treat overactive bladder with medication
32:22for? And I don't think that there's a
32:24simple answer, but the longer the better
32:29is kind of is [snorts] kind of my
32:32mantra. It definitely need if you've got
32:35to the point of needing
32:36pharmarmacotherapy, you need to treat
32:38for at least 6 months. And you then if
32:41you've had a really good response and
32:44and great symptom control,
32:47you can start to wean at that point. But
32:50you should wean really slowly. I think
32:52if you wean fast, you are often back
32:55where you started from not straight away
32:59but within five or six weeks and that
33:02can be really frustrating for everybody.
33:08It is important to keep an eye out
33:11during treatment. I talked about
33:13monitoring blood pressure with miragron.
33:17think also important to think about all
33:19of the side effects of anticolinergics.
33:22And this um very old-fashioned but
33:25lovely kind of pneumonic is quite
33:28helpful to remember. You know that
33:30someone who is toxic from an
33:32anticolinergic will be hot as a hair,
33:34red as a beat, blind as a bat, dry as a
33:37bone, mad as a hatter, and full as a
33:39flask. Um that just helps you remember
33:42all the things you should ask about and
33:44and look out for. And then in my
33:48practice, everybody who is on
33:51anticolinergic
33:53therapy for overactive bladder has an
33:56annual formal ultrasound to keep an eye
34:00on their bladder emptying, their bladder
34:03volume, and their upper tracts.
34:09So what do we do if people don't respond
34:12to eurotherapy and then
34:15pharmacothotherapy?
34:17I think anyone who's not responding
34:19needs a kind of re-evaluation.
34:22Did we have the diagnosis right? Do we
34:24need to do some more investigations?
34:26What else is going on? What other things
34:28are going on in the child's life in the
34:31family? Do they have an undiagnosed
34:34neurodedevelopmental disorder? Is there
34:36something else that we need to manage as
34:39well?
34:41There are various other novel therapies
34:44and adjuncts that might help support
34:46adherence. We need to think about the
34:50things that were on that first slide for
34:53kind of special eurotherapy, alarms,
34:56neurom modulation.
34:58there are
35:00more
35:03uh selective anticolinergics coming onto
35:05the market. There may be other agonists
35:09coming as well. I'm not going to talk
35:12about intracycle
35:14Botox, but it is definitely in the mix
35:18for intractable overactive bladder and
35:23remains an option.
35:29So, I think just to put this all in
35:31context,
35:33treating children with overactive
35:35bladder is is hard. It's demanding. Um,
35:39it needs people hanging in there,
35:42continuing to support children and
35:45families. We need to kind of have a good
35:47structure and a stepwise individual
35:50approach so that we can hopefully
35:53achieve success and actively involve the
35:58children and their families in the
35:59treatment. Make sure that the
36:01expectations are realistic and they know
36:05we're hanging in for a a long time. It's
36:07not a quick fix and that we're going to
36:10closely monitor for side effects.
36:16So if I could summarize my suggested
36:19approach is that the main stay of
36:22treatment isn't the pharmacological
36:25treatment and we need to get those
36:26things right and the diagnosis right and
36:29the co-orbidities identified and managed
36:33and the constipation identified and
36:35managed before thinking about
36:38prescribing.
36:40and make sure everyone has had an
36:42ultrasound and only then if there are no
36:45contraindications
36:47start treatment. And my approach would
36:50be to start with oxybutin but to
36:54consider other agents if it's poorly
36:56tolerated and to not be too slow to
37:00think about combination therapy if the
37:03response is imperfect.
37:07There are a few references on the slide
37:10if you want to read some more. And at
37:15this stage we um are done with the
37:18dactic part and very happy to um address
37:22any questions that you might have.
37:32>> Thank you. Um
37:34>> Crosley, do you want me to stop sharing?
37:36>> Oh, yeah. On with Yeah, if you'd like.
37:38Um that's fine. Um we've got a couple of
37:40questions coming through. So, um
37:43firstly, uh do you recommend postvoid
37:45residual scans in certain time within a
37:48certain time frame after starting
37:50anticolagenics?
37:53Sorry.
37:54>> Uh I think if you have access to easily
38:00do postfoid scans, then yes. um it's
38:04good to to do it at the at the first
38:06review after starting treatment. But if
38:09you're if that's not something that is
38:12easily available to you, then it would
38:16depend on symptoms. If things were going
38:19well, you weren't worried about it, then
38:22and there wasn't
38:24infection or anything else, then I think
38:26you wouldn't have to rescan and just do
38:30it at the 12 months with a formal scan.
38:33So, a bit individualized.
38:36>> Fantastic.
38:38Um, so
38:40no easy access would need to use formal
38:43ultrasound.
38:44>> That's Yeah. Okay, great. Um so how long
38:48do you recommend eurotherapy should be
38:50used alone before starting an
38:52anticolinage colonergic?
38:57Again, I don't think there is one right
39:00answer to that question because it's
39:02probably dependent a little bit on the
39:05severity of the symptoms, the age of the
39:08child, the amount of impact that the
39:12symptoms are having, and I guess yeah,
39:16how
39:18how what what your uh how really what
39:23the symptoms have shown you. If
39:24someone's got an incredibly
39:28severe bladder overactivity with very
39:32frequent wedding and a very small um
39:37functional bladder capacity and you have
39:40had no impact with urtherapy and
39:43addressing constipation after a month I
39:47would start treatment but if someone is
39:50you know their symptoms are less
39:51bothersome they're less severe you think
39:54you're making some small gains, it would
39:57be reasonable to wait several months,
40:00particularly in at the younger end of
40:03the spectrum. But if you've got an
40:05adolescent, I'd be jumping in faster
40:08because the impact of the symptoms will
40:11be so much greater.
40:13>> Fantastic.
40:14Um,
40:16we've got Thank you. Excellent
40:18presentation. Uh do you ever prescribe
40:20these medications for children with
40:22bedwedding and not uh daytime urinary
40:25incontinents?
40:27>> Yes. Yes. Absolutely. So if someone has
40:30bladder overactivity as the cause of
40:34their uh enureesis and they haven't
40:38responded to firstline treatment which
40:41would be the pattern bell conditioning
40:43alarm then definitely using
40:45anticolinergics either alone or as an
40:48adjunct to other multimodal treatment
40:51for renuresis is is really common. think
40:55um just to expand on that a little bit,
40:58children who are still wetting over 10
41:02are more likely to have nocturnal
41:05bladder overactivity as their underlying
41:08pathology
41:10rather than
41:12nocturnal polyurea. So I'd be more
41:15suspicious in the overtens who are still
41:17wetting particularly those who are
41:19wetting multiple times each night.
41:23Um I might just quickly go back to the
41:25eurotherapy because the next two
41:27questions are a little bit about neurode
41:28diverency but um with the eurotherapy in
41:32the circumstance that a child has
41:33significant frequency and that's
41:36interrupting schooling would that be a
41:38trigger for the the urther theapy um
41:44before the uh anticolinergic
41:48>> sorry if I'm not quite sure about the
41:50question so if
41:53symptom was really disruptive at school
41:55and they couldn't they were going in and
41:58out of the classroom the whole time cuz
42:01there were their bladder capacity was
42:03not sufficient to get through an hour of
42:07school. I they're the sort of children
42:10that I would maybe treat earlier for
42:13sure. Is that was that the gist of the
42:15question?
42:15>> It was it was linked to that question.
42:17Yeah. So yeah. Um okay. So um does your
42:21prescription practice change for kids
42:23with neurodeiversity?
42:27Um no um not not for
42:32um managing the actual bladder
42:35overactivity component
42:38but um I think you know sometimes making
42:43the diagnosis is harder in that group of
42:46children and whether it's bladder
42:50overactivity or um difficulties with um
42:56routine or awareness of bladder filling
43:00or other things that are contributing to
43:02the symptom needs is sometimes a bit
43:05harder to tease out in the neurodeiverse
43:08group. But if your evidence is all
43:11pointing to
43:14real bladder overactivity and urgency
43:17and frequency and small bladder
43:20capacity, then I would still use the
43:22same medication approach.
43:24You have to be a little bit more careful
43:27to make sure you've taken a good
43:28medication history. You need to know
43:31what other medication they're on. Some
43:33of these kids might be on a number of
43:35psychotropic medications that will have
43:38additional anticolinergic
43:41side effects as part of their side
43:43effect profile. So you might it might
43:46influence your dosing but not the drug
43:49that you chose.
43:52Um well there's just a sort of a a
43:55question just in regards to the what is
43:57the incidence of um OAB in childhood and
44:00then is there a higher incidence amongst
44:02children with neurodeiversity?
44:08>> Good question. Um I don't think that we
44:11have really good epidemiological
44:14data. We know how common
44:18wetting is in in young children and we
44:22know that the most common cause of
44:25wedding
44:26is bladder overactivity.
44:29But we don't know how many people have
44:34bladder overactivity that don't come to
44:36attention in childhood because they've
44:39just got a bit of frequency and they
44:41don't wet. We probably don't actually
44:44have really good data about that. In the
44:47neurodeiverse group, I think
44:52they come to attention more because
44:55managing their continents is is so much
44:59more problematic and kind of
45:02multifaceted. So, we probably know more
45:04about them. think we know that they are
45:09they have a higher incidence of bowel
45:11dysfunction and withholding and anxiety
45:15and that that may drive um bladder
45:18overactivity. So I think it probably is
45:22more common but I don't think I am not
45:26aware of a any good sort of solid
45:28epidemiological data that would answer
45:31that question.
45:33>> Okay. Um, can diagnosis of overactive
45:36bladder be based on tower shaped curve
45:40flow rate only?
45:44>> Uh,
45:47I think I might have Yeah,
45:48>> I think no. Like you need the you need a
45:52compatible history. You need to have had
45:55an examination to exclude other things.
45:58And I think you need an ultrasound.
46:00Yeah.
46:02Um, do children respond to eurotherapy
46:06differently to adults
46:09maybe and expand on that too or how
46:13[laughter]
46:14>> I Well, I think yes. I mean, eurotherapy
46:17needs to be kind of different for
46:18children as well. And I guess the thing
46:21that some of the aspects of
46:25eurotherapy
46:26in adults is hard to apply to children
46:31and there is not the evidence
46:34and forgive me if I don't know this
46:37absolutely but I think in adults there
46:39is some evidence that you can um
46:43increase bladder capacity by um teaching
46:47voiding postponement. There is no
46:49evidence that you can achieve that in
46:52childhood. And so we don't teach
46:54children to try to hold on and not go.
46:59We we want children to go if they if
47:02they have the urge. And we're focused
47:04very much on trying to avoid wedding,
47:08treat all of the other factors that
47:10might be contributing to urgency or
47:14small bladder capacity. But we don't
47:16teach holding as a mechanism to
47:21expand the bladder capacity.
47:25>> Okay. And uh it looks like this might be
47:27the last one. So with recent uh research
47:29linking anticolinergic use with dementia
47:32risk in adults, how does this apply to
47:34children? Is there any increased risk?
47:40It's a really good question and not only
47:42you but many um families are asking
47:45asking that same question at the moment.
47:49I think there is no evidence in
47:53childhood that um anticolinergics
47:56uh cause long-term change in the CNS.
48:01we
48:03but I think it's one of the factors that
48:07is making me
48:09keener and keener on the idea of um
48:13miragron as a as a good um a you know a
48:17good agent for overactive bladder in
48:20children. I think
48:23I'm, you know, I always talk about the
48:27CNS side effects of oxyben and
48:33make sure that that parents know about
48:35them and really look out for them and if
48:38any child is experiencing irritability
48:41on oxybutin, I would always stop it. I
48:45think I think that the other sort of
48:51point to make about that though is that
48:53the children usually have normal renal
48:58and liver function and clear um
49:01medications much better than the elderly
49:04do. know there's a lot of and and
49:07perhaps a lot some of the side effects
49:10and the impacts in the elderly might
49:13relate to relative toxicity too. So I
49:19think we're less likely to see high
49:22blood and brain levels of medication and
49:26accumulation in children that probably
49:29can happen in the adult population with
49:31multi-system disease.
49:34>> Great. And uh we did get one more. So is
49:38it a preference for pediatricians to uh
49:42to ask a child to prescribe medication
49:46or is it reasonable for a GP to
49:48prescribe?
49:52>> I think that's a really good question.
49:54Many GPS will not feel
49:59comfortable to prescribe at least
50:02initially for a a young child in
50:06particular. Um it depends totally on
50:09their experience. So some some in some
50:12general practices they actually will
50:15have seen very few children with
50:19incontinents and might feel quite
50:21uncomfortable to prescribe. But, you
50:24know, depending on where you work and if
50:27you have, you know, if you have a good
50:29ongoing working relationship with a GP
50:31who's very, you know, well across the
50:35the issues and you're working with them
50:38and giving them good information about
50:41the the work that you've already been
50:44doing with them, some GPS would
50:46definitely be happy to at least
50:48prescribe firstline treatment.
50:51We wrote um some of guidelines for um
50:58primary, secondary and tertiary care a
51:01few years ago. And the guidelines did
51:06sort of go as far as initial
51:08prescription in primary care if the GP
51:12felt comfortable to do that.
51:16>> Fantastic.
51:18Okay. Um well with that it's all just
51:21the thank yous and great presentations
51:23coming through now. So um with that I
51:26we'll probably end it there. Um thank
51:29you once again for a very informative
51:32presentation and uh uh there's yeah the
51:35feedback is coming through very
51:37positively. So um um on behalf of all
51:41the attendees here, thank you for the
51:42presentation and um thank you for coming
51:45in on a chilly evening and giving us
51:48your time. Hope you have a great evening
51:50and uh for everyone else remember to
51:53renew your CHA membership and renew with
51:57uh the pediatric special interest group
52:00uh where you get one free special
52:01interest group with your renewal.
52:04Thank you again and have a great
52:06evening. Thanks.
52:08>> Thanks everyone. Good night.

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