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Diane Newman: Welcome. I'm Diane Newman, adult nurse practitioner at the University of Pennsylvania. My practice is urology and I'm here today with a urologist from Southern Jersey, Dr. David Sussman who also practice of course, in urology and I thought we'd discuss today a little bit about our practice and our approach to nocturia in men and women who present to us in urology practice.
Hi David. Tell us a little bit about your background and what you're doing now. 

Dr. David Sussman: Good morning Diane. I am a urologist in southern New Jersey and my practice really is centered around lower urinary tract dysfunction and certainly, that includes a lot of patients with nocturia. As you know, for years we've struggled with patients who've presented with nocturia. We've been able to treat a lot of their other urinary symptoms but that's been kind of the last thing that we've been unable to really resolve for them. I'm quite excited about some of the new opportunities to treat these patients successfully.

Diane Newman: Do you see both men and women. I see both with overactive bladder and then of course I see the men with BPH. Before I used to play around with other drugs that we had for these patients and we really weren't very successful with them, were we?

Dr. David Sussman: No. I think that's been the issue. We've learned that lots of folks will respond during the day to treatment for overactive bladder or for BPH but oftentimes the nocturia did not improve very much. We would do the things like daytime diuretics or lower extremity elevation in the afternoons, limit their fluids at night and with moderate success. I think that it's frustrating. I think a lot of people are really kind of upset with the fact that we can't improve their sleep patterns. They're tired. They're not very happy. I think right now with the advent of Noctiva to treat this, it's kind of changed the paradigm a bit.

Diane Newman: Yeah, I know. I've been actually prescribing Noctiva too in the past couple months and I've been really kind of surprised about a few things with it. Number one, patients are really accepting it. It is a nasal spray. I thought, wow was it going to be a problem. But there doesn't seem to be. I really, they talk about in the data that you have kind of a rapid response but patients tell me they saw improvement within the first night. What have you been finding?

Dr. David Sussman: Same thing. I was also a little bit concerned about the use of a nasal spray. People aren't used to using medication in that way but when they see the benefit, that concern is certainly not a problem. They do see rapid response and I think it becomes part of their routine. Patients understand that it does work overnight which is good. It really has surprisingly changed my whole approach now. I have a different discussion with patients when I see them. Whether it's with OAB or BPH. We discuss the nocturia part of it. In the past, I didn't speak much about nocturia because I had so little to offer them. I think now because of this new addition to our armamentarium, my discussions have broadened. I let them know that if I put them on a medication for OAB or we treat their BPH successfully, and the nocturia doesn't improve, we have good options for them. I think people are comfortable with that. I give them brochures, tell them why they have nocturia and explain the reasons that they may not improve with their BPH and OAB treatment.

Diane Newman: Some of my colleagues have been a little bit concerned about kind of couple the steps you do prior now. I have been, on a few of my patients, I've actually had several men with BPH who've had, getting up at night four or five times. Over two times at night has been shown to be very bothersome to patients. But you know, I think we have patients, they're not just two, three, four or five times and more at night. I started with doing a frequency volume chart on a few of them which to try to see if I can pick up that nocturnal polyuria and you really do. You see out of three days, two days where they're really getting up several times at night and those volumes are large. One of the things I think a lot of people don't understand that this really works differently doesn't it?

Dr. David Sussman: Yes.

Diane Newman: It's not working on the bladder, it's working on the kidneys.

Dr. David Sussman: Right. And that's really where the problem is with nocturia. I think over the years we finally understand now the kind of the mechanism of nocturia in lots of patients. We thought it was a bladder issue or we thought it was an outlet issue. But I think we recognize that it really is a renal issue. Kind of manifesting in the lower urinary tract. The use of a drug like Noctiva to treat that certainly makes sense along with their other symptoms. I think maybe probably only maybe 10 or 15% of patients come in with primary nocturia. I think that's not the norm. We do see some but I think the majority come in with other lower urinary tract issues. Either BPH, OAB et cetera. Again, I think if you can explain this to the patient, let them understand why this is occurring, that this is a treatment that is directed exactly to that area, it really does make sense to the patients.

Diane Newman: The other thing that what I've been doing and I don't know just seems to be who's coming to see me, is I've treated mostly patients over the age of 65. Have you done any younger patients?

Dr. David Sussman: I actually have. I've had some patients, some men actually in their late 50s, early 60s who've had a lot of nocturia. It's worked quite well. I do agree that the majority are over 65. I explain about the issues with potential sodium concerns and I let them know that it's not a common problem. We're going to follow their labs appropriately and quite frankly I haven't had a patient yet that had to stop it because of a low sodium. But I'm cautious. I watch people who are on diuretics, patients who are taking steroids, things of that nature which many kinds of confound the issue a bit. But in general, I've had very few issues with any side effects other than occasionally complaints about just that the nasal irritation.

Diane Newman: Yeah, that's true. And I try and tell them that now but I'm the same way. I've only been doing it now for a few months but prescribing Noctiva was a little concerned about, getting that sodium beforehand or making sure the patient had a recent sodium is what I've also been also looking at. And then I follow-up after seven days but I haven't seen really any drop. Any other data showed there were very, very, very few that actually had severe hyponatremia, so I'm not surprised. I've had now two on a month afterwards I've gotten their sodium but I guess in time I may just do it based on a patient by patient, what are you going to do about that over time?

Dr. David Sussman: What I've had, like you, I've been prescribing for about I guess three months or so now. I've had patients in the initial run up. I do check their sodium about three to four days after they start and maybe a month later. If things look good, then I will probably do it maybe every six months or so. Every five to six months. Just to follow them up unless something changes. If they add medication to their regimen, particularly a diuretic, I'd be certainly a bit more cautious but in general, once I know that there, I'm comfortable with their treatment and have had acceptable labs, I think I just kind of routine. I see most of my patients who are on medication about every six months if they're stable. I think that's a reasonable timeframe to recheck some labs. Most of the patients I take care of, I do have baseline labs before I start just to be on the safe side that their electrolytes are normal. 

Dr. David Sussman: I really found it to be a very easy process.

Diane Newman: Right, I agree with you.

Dr. David Sussman:I was concerned initially. I thought it might be difficult to get people to get labs. When I explained the reason, people have been accepting of that and haven't been any real pushback on that.

Diane Newman: I agree with you. I thought it would be a couple more difficult steps or something but it hasn't been. 

Dr. David Sussman:No.

Diane Newman: Now are you doing it yourself? Or you working with a nurse practitioner? 

Dr. David Sussman: Both. 

Diane Newman: Your nurse who answers a lot of your calls probably.

Dr. David Sussman:I do. Quite frankly, I thought I would get more calls. I spend a few minutes, discuss how the medication works. How to take it. I let them know that the first time they use it they have to prime it a few time to get their medication ready to use. The instructions are fairly simple and most patients have been pretty good about it. Even the older people. We all take care of those people in their 80s that are active and are bothered by the nocturia. Even those folks have done well. I've actually been kind of pleasantly surprised that patients are happy with it, finding it easy to use and really I've had very few concerns about side effects.

Diane Newman: Yeah. One patient came back and actually the first one I prescribed who literally was so excited because it worked the first night. He'd been getting up five times at night and he said to me, "Went to bed at 11:00, got up at 3:00." And he said, "I can't believe it." And then of course, it's pretty quickly out of the system within four to six hours. It's really a great drug as far as for the nighttime. I tell patients to take about 30 minutes before.

Dr. David Sussman:30 minutes.

Diane Newman: Before bedtime and I've told them to leave it in their bathroom on their sink type of thing so they remember. And the other thing too is that a lot of people say to me, patients won't take nasal sprays, I don't find that at all. It's like not they said, oh it's not a pill. No, I say it's a nasal spray and this is how you do it. Really they don't seem to be in any way against it.

Dr. David Sussman: No. But I think what's interesting is, people are used to taking pills and what I let them know is, pills are not well absorbed in general. That this mechanism of taking it via a nasal spray is really a much more efficient way to deliver medication. The dosing is reliable. The blood levels are reliable. When I tell people that, they understand a little bit better and realize that it does make some sense. I agree with you. I've had very few patients who have said, "No, I can't do it." Some have come back and said, "It's a little irritating." But after they use it for a few weeks, they seem to get used to it and hasn't been a problem. 

I'm going to tell you, again, I was skeptical as you were, we've talked about this in the past and we've all used some of the older oral DDADP type medications and really was a last resort. You didn't want to use it because you didn't know how well it work. You didn't know the blood levels that you'd get. You were concerned about sodium issues. This has really again, pleasantly surprised at the results, how good they are. How tolerable the spray has been and how happy the patients are. This has really changed my conversation dramatically when it comes to these issues with BPH, OAB and nocturia. I'm really quite excited about it.

Diane Newman: Yeah, I agree with you. I think I did the same thing, I ordered in. And you're right, I was using DDAP on certain number of patients. At that higher dose which is what it is, you do see changes in the sodium. 

Dr. David Sussman: Absolutely.

Diane Newman: And with this new formulation, with the, it goes, the spray goes right in the nostril and it gets absorbed in the mucosa very quickly and I think that's the beauty of it is the formulation. I explain that to patients. You're right, kind of when they get it, the fact that oh my goodness, it's going to be absorbed, it's going to work very quickly. They understand why you take it that way. Yeah, I agree. I have actually couple really younger patients in their 20s and 30s that I think I'm going to try it on. Once we've gotten Noctiva and we kind of are looking for nocturia, we're finding it a lot more aren't we?

Dr. David Sussman: Absolutely.

Diane Newman: I feel like, what was I doing before? But you're right, I guess. We would take those, maybe the OAB medications and say, "Take them before bedtime, maybe it'll work." And it really wasn't doing that.

Dr. David Sussman: That's exactly right. 

Diane Newman: No, they really weren't working.

Dr. David Sussman: You're right on. I think that's you're right. Now that I'm seeing people back. I've treated for BPH and OAB and I always ask about nocturia and make a note about it but often don't treat it. Now I'm saying to the patient, "Are you still getting up three, four times a night?" And if they say, "Yes," then I bring it up and discuss these options. And it's really has been I think, as a practitioner, you're trying to the best for your patient. It's satisfying from our side of the coin as well and clearly the patients are happy but yes, you're now kind of looking for those patients, asking the questions. Before you were a little bit hesitant to ask because you didn't have much to offer but now I think that's changed and I think it's really a positive thing for patient care.

Diane Newman: Well listen, thank you very much for being with us today and I hope you enjoyed this conversation.