Reduction in Bladder-Related Autonomic Dysreflexia after OnabotulinumtoxinA Treatment in Spinal Cord Injury

Abstract

Bladder-related events, including neurogenic detrusor overactivity, are the leading cause of autonomic dysreflexia in spinal cord injured individuals. Self-reported autonomic dysreflexia is reduced following onabotulinumtoxinA treatment for neurogenic detrusor overactivity; however, none of these trials have assessed autonomic dysreflexia events using the clinical cutoff of an increase in systolic blood pressure ≥20 mm Hg. This study used a prospective, open-labelled design from 2013 to 2014 to quantitatively assess the efficacy of one cycle 200 U intradetrusor-injected onabotulinumtoxinA (20 sites) on reducing the severity and frequency of bladder-related autonomic dysreflexia events and improving quality of life. Twelve men and five women with chronic, traumatic spinal cord injuries at or above the sixth thoracic level, and concomitant autonomic dysreflexia and neurogenic detrusor overactivity, underwent blood pressure monitoring during urodynamics and over a 24 h period using ambulatory blood pressure monitoring pre- and 1 month post-treatment. Post-onabotulinumtoxinA, autonomic dysreflexia severity was reduced during urodynamics (systolic blood pressure increase: 42 ± 23 mm Hg vs. 20 ± 10 mm Hg, p < 0.001) and during bladder-related events across the 24 h period (systolic blood pressure increase: 49 ± 2 mm Hg vs. 26 ± 22 mm Hg, p = 0.004). Frequency of 24 h bladder-related autonomic dysreflexia events was also decreased post-onabotulinumtoxinA (4 ± 2 events vs. 1 ± 1 events, p < 0.001). Autonomic dysreflexia and incontinence quality of life indices were also improved post-onabotulinumtoxinA (p < 0.05). Intradetrusor injections of onabotulinumtoxinA for the management of neurogenic detrusor overactivity in individuals with high level spinal cord injuries decreased the severity and frequency of bladder-related episodes of autonomic dysreflexia, and improved bladder function and quality of life.

Prediction of autonomic dysreflexia during urodynamics: a prospective cohort study

“…Given the potential of NDO to elicit AD, successful treatment of NDO could also have a positive effect on AD incidence and extent of related cardiovascular changes. In line with this hypothesis, Fougere et al [ 42 ] provided evidence of effectively reducing the frequency and severity of AD after intradetrusor onabotulinumtoxinA injections in patients with SCI. By improving LUT function and concurrently reducing cardiovascular responses to LUT stimuli, treatment of NDO appears to have the capacity to lower the risk for AD-related long-term complications.…”

Ancillary benefits of bladder chemodenervation for SCI neurogenic bladder

“…Fougere et al performed a study demonstrating the attenuation or elimination of hypertension due to AD in 17 persons with SCI during urodynamics before and after bladder chemodenervation [18]. That study also showed a similar result with ambulatory blood pressure monitoring outside of the urodynamics suite.…”

Effects of liposome-based local suppression of nerve growth factor in the bladder on autonomic dysreflexia during urinary bladder distention in rats with spinal cord injury

“…Intravesical instillation with capsaicin, but not vehicle instillation, acutely worsened AD induced by bladder distention, but, one month later, it reduced bladder-related AD and urinary incontinence, suggesting that capsaicin-sensitive bladder afferents are involved in bladder-related AD (Igawa et al, 2003). A recent open-label clinical trial revealed that intradetrusor injections of onabotulinumtoxin-A decreased the severity and frequency of AD during urodynamics and during bladder-related events, and improved quality of life in patients with SCI (Fougere et al, 2016). In SCI rats, onabotulinumtoxin-A is also shown to reduce bladder-related AD in association with a decrease in bladder NGF expression (Elkelini et al, 2012).…”