RESUMO
OBJECTIVES: To assess the relative cost-effectiveness of two therapeutic strategies: one starting with sacral neuromodulation (SNM) versus one starting with Botulinum toxin A (BTX-A) for the management of refractory incontinent idiopathic overactive bladder (OAB) patients, from the perspective of the Italian National Health Service (INHS). METHODS: Direct medical costs (
Assuntos
Toxinas Botulínicas Tipo A/uso terapêutico , Terapia por Estimulação Elétrica/métodos , Plexo Lombossacral , Fármacos Neuromusculares/uso terapêutico , Bexiga Urinária Hiperativa/terapia , Incontinência Urinária de Urgência/terapia , Toxinas Botulínicas Tipo A/economia , Análise Custo-Benefício , Terapia por Estimulação Elétrica/economia , Humanos , Itália , Fármacos Neuromusculares/economia , Anos de Vida Ajustados por Qualidade de Vida , Bexiga Urinária Hiperativa/economia , Incontinência Urinária de Urgência/economiaRESUMO
INTRODUCTION: Erectile dysfunction (ED) is reported in a high percentage of patients with central neurological disorders (CND). AIM: An up-to-date review on oral phosphodiesterase 5 inhibitors (PDE5): sildenafil, tadalafil, and vardenafil for individuals with CND and ED. MAIN OUTCOME MEASURES: Various questionnaires on ED, such as the International Index of Erectile Function composed of 15 questions. METHODS: Internationally published clinical studies evaluating the efficacy and safety of PDE5 on subjects with CND and ED were selected. RESULTS: Overall, 28 articles on PDE5 used to treat patients with CND and ED were included. With each of the three PDE5 compared to placebo or erectile baseline, literature reported significant statistical improvement (P < 0.01; P < 0.05) only in patients with spinal cord injury (SCI). PDE5 efficacy was documented for SCI patients up to 10 years. The most frequent predicable factor for PDE5 success was the presence of upper motoneuron lesion. Each of the three clinical sildenafil studies documented statistically significant improvement on erectile function in Parkinson's patients (P < 0.01; P < 0.05). Two studies reported discordant results about sildenafil's effectiveness on multiple sclerosis (MS) patients; one on tadalafil showed significant statistical efficacy on erection versus baseline (P < 0.01; P < 0.05). The only spina bifida article determined that sildenafil remarkably improved erectile function. Overall, drawbacks were mostly slight-moderate, except in subjects with multiple system atrophy where sildenafil caused severe hypotension. CONCLUSIONS: PDE5 represent first line ED therapy only for SCI patients, though treatment results through meta-analysis were not possible. Encouraging results are reported for Parkinson's and MS patients. PDE5 use for other CND patients is limited for various reasons, such as ED and concomitant libido impairment caused by depression and/or sexual endocrinology dysfunctions, and because PDE5 may cause a worsening of neurological illness. Medical centers staffed by health professionals able to counsel patients on the possible use of PDE5 are needed.
Assuntos
Doenças do Sistema Nervoso Central/complicações , Impotência Vasculogênica/tratamento farmacológico , Inibidores da Fosfodiesterase 5/uso terapêutico , Carbolinas/efeitos adversos , Carbolinas/uso terapêutico , Ensaios Clínicos como Assunto , Humanos , Imidazóis/efeitos adversos , Imidazóis/uso terapêutico , Masculino , Esclerose Múltipla/complicações , Doença de Parkinson/complicações , Inibidores da Fosfodiesterase 5/efeitos adversos , Piperazinas/efeitos adversos , Piperazinas/uso terapêutico , Purinas/efeitos adversos , Purinas/uso terapêutico , Citrato de Sildenafila , Disrafismo Espinal/complicações , Sulfonas/efeitos adversos , Sulfonas/uso terapêutico , Tadalafila , Resultado do Tratamento , Triazinas/efeitos adversos , Triazinas/uso terapêutico , Dicloridrato de VardenafilaRESUMO
The prevalence of overactive bladder (OAB) in adult males varies from 10.2% to 17.4%, and in females from 7.7 to 31.3. 16.5% of the adult population presents symptoms consistent with OAB; of these, 37.2% are actually affected. The OAB has a significant effect on the quality of life. Initial treatment includes behavioral therapy, physiotherapy and antimuscarinic drugs. In patients where behavioral modifications fail, treatment is associated with antimuscarinics. The antimuscarinic agents used to treat OAB showed some efficacy, but adverse events too, such as dry mouth, constipation, headache and blurred vision. In selected cases unresponsive to antimuscarinic therapy, it is possible to use second-line treatments represented by sacral neuromodulation and botulinum toxin type A both for idiopathic detrusor overactivity, where it is still an experimental treatment, and for neurogenic cases with 2011 FDA approval. Surgical options represent the last choice for selected cases.