Ocular side-effects of tolterodine and oxybutynin, a single-blind prospective randomized trial

BCLA CLEAR Presbyopia: Epidemiology and impact

The global all-ages prevalence of epidemiologically-measured 'functional' presbyopia was estimated at 24.9% in 2015, affecting 1.8 billion people. This prevalence was projected to stabilise at 24.1% in 2030 due to increasing myopia, but to affect more people (2.1 billion) due to population dynamics. Factors affecting the prevalence of presbyopia include age, geographic location, urban versus rural location, sex, and, to a lesser extent, socioeconomic status, literacy and education, health literacy and inequality. Risk factors for early onset of presbyopia included environmental factors, nutrition, near demands, refractive error, accommodative dysfunction, medications, certain health conditions and sleep. Presbyopia was found to impact on quality-of-life, in particular quality of vision, labour force participation, work productivity and financial burden, mental health, social wellbeing and physical health. Current understanding makes it clear that presbyopia is a very common age-related condition that has significant impacts on both patient-reported outcome measures and economics. However, there are complexities in defining presbyopia for epidemiological and impact studies. Standardisation of definitions will assist future synthesis, pattern analysis and sense-making between studies.

Comparison of the effects of trospium and solifenacin on intraocular pressure and tear secretion in patients with overactive bladder

INTRODUCTION AND HYPOTHESIS

Comparison of the effects of trospium and solifenacin used for the treatment of overactive bladder (OAB) on intraocular pressure (IOP) and tear secretion.

METHODS

This study was planned as a prospective study and was conducted at a single center between October 2014 and April 2016. OAB patients were included in the study following an ophthalmic examination, IOP measurement with an applanation tonometer, and tear secretion measurement with the Schirmer I test in the ophthalmology outpatient department. The patients were started with trospium 30 mg oral bid or solifenacin 5 mg oral qd. They were then followed up at the 4th and 12th weeks.

RESULTS

A total of 225 OAB patients with a mean age of 47.80 (18-75) years were evaluated. The mean age was 47.41 ± 12.65 years in the trospium group (n = 104) and 48.14 ± 11.82 years in the solifenacin group (n = 121) with no statistically significant difference. When the two medications were compared, no statistically significant difference was observed at the 4th and 12th weeks in terms of IOP (p = 0.988, p = 0.822) and dry eye (p = 0.764, p = 0.581).

CONCLUSIONS

No statistically significant difference was observed between trospium and solifenacin in terms of their effects on IOP and tear secretion in OAB patients. We therefore concluded that the effects of trospium and solifenacin on IOP and tear secretion changes were similar in OAB patients without comorbidities.

Evaluation of pupil responses and anterior chamber parameters in overactive bladder syndrome before and after antimuscarinic treatment

PURPOSE

To evaluate the static and dynamic pupillometric responses and anterior chamber parameters in overactive bladder (OAB) patients before and after solifenacin succinate treatment and to compare these results with those of healthy control subjects.

MATERIALS AND METHODS

Forty OAB patients who were planned to be treated with solifenacin succinate and 40 control subjects without any systemic or ocular diseases were included in the study. Following detailed ophthalmological examination, Pentacam imaging in order to detect anterior chamber angle, depth and volume; and static and dynamic pupillometry measurement in order to detect high-photopic (100 cd/m²), low-photopic (10 cd/m²), mesopic (1 cd/m²) and scotopic (0.1 cd/m²) pupil diameters, amplitude of pupil contraction, latency of pupil contraction, duration of pupil contraction, velocity of pupil contraction, latency of pupil dilation, duration of pupil dilation and velocity of pupil dilation were performed at baseline and at the first month of treatment. Data from the right eyes of the participants were used for statistical analysis.

RESULTS

Baseline low- and high-photopic pupil diameters, duration of pupil contraction, latency of pupil dilatation and velocity of pupil dilatation values were significantly higher; and velocity of pupil contraction and duration of pupil dilation values were lower in the OAB group compared to the control group (P < 0.05 for all). One-month treatment with oral solifenacin succinate revealed higher scotopic and mesopic pupil diameters (P = 0.042, P = 0.031, respectively). Also, latency of pupil contraction was found to be increased and velocity of pupil dilatation was found to be decreased compared to pretreatment (P = 0.003, P < 0.001, respectively). We did not find any significant change in anterior chamber angle, depth and volume measured with Pentacam HR compared to pretreatment.

CONCLUSIONS

Patients with OAB also have pupil abnormalities which probably reflect an underlying autonomic disorder that affects the bladder and pupils. One-month treatment of solifenacin succinate may lead to enlargement of pupil diameters under low illumination conditions and may lead to changes in dynamic pupillometric responses compatible with antimuscarinic treatment. Systemic antimuscarinic therapy has no effect on anterior chamber depth and intraocular pressure.

Comparision effects of solifenacin, darifenacin, propiverine on ocular parameters in eyes: A prospective study

Objective

To evaluate the effects of solifenacin, darifenacin, and propiverine on nasal-, subfoveal-, temporal choroidal thicknesses (NCT, SFCT, TCT), intraocular pressure (IOP) and pupil diameter (PD).

Materials and Methods

Patients with overactive bladder (OAB) diagnosed according to The International Continence Society were administered with solifenacin, darifenacin or propiverine on a daily basis between November 2017 and May 2018. NCT, SFCT, TCT, IOP, and PD of these patients were measured and compared as initial, fourth and twelfth weeks.

Results

A total of 165 patients (330 eyes) with OAB were evaluated. Solifenacin (n=140) significantly reduced IOP from 17.30±2.72 mmHg to 16.67±2.56 mmHg (p=0.006) and 16.57±2.41 mmHg (p=0.002), at the fourth and twelfth weeks, respectively. Darifenacin (n=110) significantly reduced NCT from 258.70±23.96 μm to 257.51±22.66 μm (p=0.002) and 255.36±19.69 μm (p=0.038), at the fourth and twelfth weeks, respectively. Propiverine (n=80) significantly increased PD from 4.04±0.48 mm to 4.08±0.44 mm (p=0.009) and 4.09±0.45 mm (p=0.001), at the fourth and twelfth weeks, respectively.

Conclusion

These findings can help to decide appropriate anticholinergic drug choice in OAB patients. We finally suggest further well-designed randomized prospective studies with a larger population to evaluate the anticholinergic-related complications in eyes.

Drug-induced Acute Angle-closure Glaucoma: A Review

Aim

Our goal is to review current literature regarding drug-induced acute angle-closure glaucoma (AACG) and provide ophthalmologists and general practitioners with a thorough understanding of inciting medications and treatment pitfalls to be avoided.

Background

Drug-induced AACG is an ophthalmological emergency that ophthalmologists and general practitioners should be familiar with, given its potentially blinding consequences. Common anatomical risk factors for AACG include a shallow anterior chamber depth, short axial length, plateau iris configuration, thick lens, anteriorly positioned lens, and rarely, intraocular tumor. Demographic risk factors include female sex, Asian ethnicity, family history, and advanced age. In patients with predisposing factors, acute angle closure can be triggered by various classes of medications including adrenergic agonists, anticholinergics, cholinergics, sulfonamides, supplements, and serotonergic medications. Physicians prescribing such inciting medications should be aware of their potentially sight-threatening adverse effects and to inform patients of the warning symptoms. Patients typically present with elevated intraocular pressure (IOP), headache, nausea, blurry vision, and halos around lights.

Review results

There are two main mechanisms of drug-induced AACG, both with different treatment strategies. The first mechanism of drug-induced AACG is pupillary block and iridocorneal angle closure secondary to thickening of iris base with mydriasis. The second mechanism of drug-induced AACG is anterior displacement of the lens-iris diaphragm due to mass effect (e.g., blood, misdirected aqueous humor, and tumors), uveal effusion, or weakened zonules.

Conclusion

This paper reviews drug-induced AACG, high-risk anatomical features, underlying mechanisms, inciting medications, and options for treatment and prevention.

Clinical significance

With proper understanding of the underlying mechanism of drug-induced AACG, physicians can respond promptly to save their patients' vision by employing the correct treatment strategy.

How to cite this article

Yang MC, Lin KY. Drug-induced Acute Angle-closure Glaucoma: A Review. J Curr Glaucoma Pract 2019;13(3):104-109.

A Novel Association between Oxybutynin Use and Bilateral Acute Angle Closure Glaucoma: A Case Report and Literature Review

We are reporting a case of a 62-year-old male presenting with headache and blurry vision. His condition resolved with cessation of the presumed offending medication and urgent bilateral laser peripheral iridotomies since he failed medical therapy. This case presents a novel association between oxybutynin and bilateral acute angle-closure glaucoma (AACG).

How long do we have to treat overactive bladder syndrome (OAB)? A questionnaire survey of Canadian urologists and gynecologists

INTRODUCTION

Overactive bladder syndrome (OAB) is a highly prevalent and costly condition worldwide with negative impact on health-related quality of life. Although many guidelines exist and anticholinergics are considered to be the mainstay of pharmacological treatment, data are lacking regarding optimal treatment duration. Therefore, the aim of this study was to determine practice patterns of Canadian urologists and gynecologists regarding duration of OAB pharmacotherapy.

METHODS

A 14-question survey was designed and survey links (English and French) were sent by email to all practicing urologists and gynecologists registered with the Canadian Urological Association and the Society of Obstetricians and Gynecologists of Canada via the associations' email lists. The SurveyMonkey website served as platform where responses were collected and stored.

RESULTS

A total of 301 physicians completed the questionnaire; 250 respondents (83%) prescribe anticholinergics or beta-3-adrenoceptor agonist (mirabegron) in their practice, and 202 (81%) start patient treatment with the lowest recommended medication dose. One hundred and twelve respondents (45% of those who prescribe OAB medications) classified OAB pharmacotherapy as a lifelong management strategy, whereas 130 (52% of those who prescribe OAB medications) think that OAB pharmacotherapy should be administered for a defined time period. Six-month and one-year time periods of drug treatments are the most commonly chosen answers given by physicians who treat their patients for a defined duration.

CONCLUSION

There is general agreement among Canadian urologists and gynecologists that OAB treatment should be started with the lowest recommended medication dose. A slim majority of respondents think that OAB pharmacotherapy should be administered for a defined duration.

TFOS DEWS II iatrogenic report

Dry eye can be caused by a variety of iatrogenic interventions. The increasing number of patients looking for eye care or cosmetic procedures involving the eyes, together with a better understanding of the pathophysiological mechanisms of dry eye disease (DED), have led to the need for a specific report about iatrogenic dry eye within the TFOS DEWS II. Topical medications can cause DED due to their allergic, toxic and immuno-inflammatory effects on the ocular surface. Preservatives, such as benzalkonium chloride, may further aggravate DED. A variety of systemic drugs can also induce DED secondary to multiple mechanisms. Moreover, the use of contact lens induces or is associated with DED. However, one of the most emblematic situations is DED caused by surgical procedures such as corneal refractive surgery as in laser-assisted in situ keratomileusis (LASIK) and keratoplasty due to mechanisms intrinsic to the procedure (i.e. corneal nerve cutting) or even by the use of postoperative topical drugs. Cataract surgery, lid surgeries, botulinum toxin application and cosmetic procedures are also considered risk factors to iatrogenic DED, which can cause patient dissatisfaction, visual disturbance and poor surgical outcomes. This report also presents future directions to address iatrogenic DED, including the need for more in-depth epidemiological studies about the risk factors, development of less toxic medications and preservatives, as well as new techniques for less invasive eye surgeries. Novel research into detection of early dry eye prior to surgeries, efforts to establish appropriate therapeutics and a greater attempt to regulate and oversee medications, preservatives and procedures should be considered.

The effects of tolterodine on anterior segment and choroidal thickness in patients with overactive bladder syndrome

BACKGROUND

To evaluate the effects of tolterodine on anterior segment and choroidal thickness by using the Pentacam system and optical coherence tomography (OCT) (Pentacam).

METHODS

A total of 122 eyes of 61 patients (34 female; 27 male) were included in the study. All patients underwent a regular ocular examination and intraocular pressure measurements before and after 3 months of antimuscarinic drug tolterodine treatment, in addition, pupil diameter, anterior chamber depth, anterior chamber volume, anterior chamber angle, and lens thickness were measured through Pentacam (Oculus Inc., Wetzlar, Germany) system. Measurements of choroidal thickness were performed by OCT (Spectralis^®, Heidelberg Engineering, Heidelberg, Germany).

RESULTS

The mean age was 58.4 ± 7.3 years and 56.5 ± 11.1 years for female and male patients. The mean intraocular pressure was 15.10 ± 2.75 mmHg before treatment and 15.18 ± 2.65 mmHg after treatment. Pupil diameters were 3.09 ± 0.48 mm before treatment and 3.12 ± 0.43 mm after treatment. Anterior chamber depth, before and after treatment were 2.68 ± 0.65 mm and 2.70 ± 0.61 mm. The mean value for subfoveal choroidal thickness was 267.92 ± 81.35 μm before the administration of tolterodine, whereas the mean choroidal thickness was 271.83 ± 75.42 μm after the administration of tolterodine. The alterations in the subfoveal choroidal thickness were not statistically significant (p = 0.862).

CONCLUSIONS

After 3 months of therapy with tolterodine, there were no significant changes in anterior segment parameters and choroidal thickness.

An overlooked effect of systemic anticholinergics: alteration on accommodation amplitude

AIM

To investigate the effect of oral solifenacin succinate, tolterodine-L-tartarate and oxybutinin hydrochloride (HCl) on accommodation amplitude.

METHODS

Female overactive bladder syndrome (OAB) patients who were planned to use oral anticholinergics, patients that uses solifenacin succinate 5 mg (Group I, n=25), tolterodine-L-tartarate 4 mg (Group II, n=25), and oxybutinin HCl 5 mg b.i.d (Group III, n=25) and age matched healthy female subjects (Group IV, n=25) were recruited and complete ophthalmological examination and accommodation amplitude assessment were done at baseline and 4wk after initiation of treatment.

RESULTS

The mean age of 100 consecutive female subjects was 51.6±5.7 (40-60)y and there were no statistically significant difference with regard to the mean age (P=0.107) and baseline accommodation amplitude (P=0.148) between study groups. All treatment groups showed a significant decrease in accommodation amplitude following a 4-week course of anticholinergic treatment (P=0.008 in Group I, P=0.002 in Group II, P=0.001 in Group III), but there was no statistically significant difference in Group IV (P=0.065).

CONCLUSION

A 4-week course of oral anticholinergic treatment have statistically significant effect on accommodation amplitude. Clinicians should avoid both overestimating this result, as this would unnecessarily restrict therapeutic possibilities, and also underestimating it which may lead to drug intolerance.

Duration of Antimuscarinic Administration for Treatment of Overactive Bladder Before Which One Can Assess Efficacy: An Analysis of Predictive Factors

Purpose:

To determine the duration of antimuscarinic therapy for overactive bladder syndrome (OAB) appropriate for assessment of the efficacy of treatment, and to evaluate the possible predictive factors for response to therapy.

Methods:

All OAB patients who visited a urology outpatient clinic of a tertiary referral center and who were prescribed 5 mg of solifenacin or 4 mg of tolterodine extended release capsules daily were enrolled in the study. Patients were asked to continue therapy for 6 months. All enrolled patients completed the patient perception of bladder condition, overactive bladder symptom score (OABSS), and the modified Indevus Urgency Severity Scale questionnaires. All patients underwent uroflowmetry.

Results:

A total of 164 patients were enrolled and 125 patients (76%) had at least one follow-up visit. The mean follow-up interval was 1 month (range, 0.5–6 months). Sixty-two patients (49.6%; 95% confidence interval [CI], 40.7–58.5) responded to antimuscarinic treatment. The median time for the onset of response was 3 months (95% CI, 1–6). Multivariate Cox proportional-hazards model revealed that elevated baseline OABSS was an independent predictor of responsiveness to therapy. Receiver operating characteristic (ROC) curve analysis revealed an optimal OABSS cutoff value of ≥7, with an area under the ROC curve of 0.79 (95% CI, 0.70–0.88; sensitivity, 91.9%; specificity, 60.7%).

Conclusions:

The median time for a therapeutic response was 3 months, and OABSS was the only predictor for responsiveness. These findings may serve as a guideline when prescribing antimuscarinic treatment for OAB patients.

The short-term and long-term adverse ocular effects of fesoterodine fumarate

AIM

To evaluate the short-term and long-term effects of fesoterodine fumarate treatment which is used for overactive bladder (OAB) on pupil diameter (PD), intraocular pressure (IOP) and accommodation amplitude (AA).

METHOD

Ophthalmic examination was performed before and after receiving medication (on the 30th and 90th day) on 120 eyes of 120 women whom were planned to begin anticholinergic treatment (fesoterodine fumarate, 4 mg/day, peroral) for OAB, prospectively. The changes in PD, IOP and AA were analyzed statistically.

RESULTS

The mean age of 120 women was 52.06 ± 9.39 years (30-70 years). The mean PD, IOP and AA values were 4.12 ± 0.61 mm (3.00-5.70 mm), 15.58 ± 1.74 mmHg (11-20 mmHg) 2.28 ± 1.26 Diopter (D) (0.50-5.50 D) at baseline; 4.68 ± 0.65 mm (3.20-5.80 mm), 16.11 ± 1.72 mmHg (11-20 mmHg), 1.68 ± 1.04 D (0.25-4.50 D) at 30th day; and 4.28 ± 0.58 mm (3.10-5.70 mm), 16.09 ± 1.96 mmHg (11-19 mmHg), 2.18 ± 1.19 D (0.50-5.00 D) at 90th day, respectively. Although increases in PD values and decreases in AA values were statistically significant (p < 0.001 for each), the changes in IOP values were not as such (p = 0.642). Visual complaint was not observed in any patient.

DISCUSSION

The newest anticholinergic medication in women with OAB increased the PD and decreased the AA statistically significantly. Clinically, it seems to be well-tolerated by the patient.

The effect of oral solifenacin succinate treatment on intraocular pressure: glaucoma paradox during overactive bladder treatment

INTRODUCTION AND HYPOTHESIS

Anticholinergic medication is the mainstay of pharmacotherapy for overactive bladder (OAB). The aim of the study is to investigate the effect of oral solifenacin succinate on intraocular pressure (IOP) in female OAB patients and to discuss the ocular drawbacks during treatment.

METHODS

The female patients with a clinical diagnosis of OAB in whom use of oral solifenacin succinate 5 mg/day (group I) and age-matched healthy female subjects (group II) underwent complete ophthalmological examination, including IOP measurement at the beginning of the oral treatment and after 4 weeks. The patients with a history of previous ocular surgery and those with ocular diseases besides refraction disorders and presbyopia were excluded.

RESULTS

The data from the right eyes of 60 consecutive patients in group I and 30 consecutive patients in group II were used for analysis. No statistically significant change was detected in the IOP (from 16.05 ± 2.30 mmHg to 16.30 ± 2.25 mmHg at the 4th week in group I, p = 0.160; from 15.60 ± 2.14 mmHg to 15.60 ± 2.09 mmHg at the 4th week in group II, p = 0.864) of the eyes in both groups.

CONCLUSIONS

Since the power of the study is not enough to draw a clear conclusion, a 4-week course of solifenacin succinate treatment in women with OAB seemed to have no clinically significant effect on IOP values. Further larger studies are needed to determine the effect of anticholinergics on anterior chamber parameters and to evaluate their safety in glaucoma patients.

Urologic medications and ophthalmologic side effects: a review

Commonly prescribed urologic medications can have significant ophthalmologic side effects. The existing information can be conflicting. We looked at alpha-blockers and intraoperative floppy iris syndrome (IFIS), phosphodiesterase type 5 (PDE5) inhibitors and non-arteritic ischemic optic neuropathy (NAION) and lastly anticholinergic medications and glaucoma. There is no conclusive scientific data on what to do if the risk of urinary retention is low to moderate, however, we recommend that patients having cataract surgery should stop alpha-blocker medications preoperatively. If there is a high risk of urinary retention, the alpha-blocker should not be withheld, with the active involvement of the ophthalmologist. The role of using 5 alpha-reductase inhibitors (5ARIs) can be considered. There is no convincing evidence that PDE5 inhibitors cause non-arteritic anterior ischemic optic neuropathy (NAION), but patients should be advised of the possible risk of visual loss, especially in patients with risk factors of ischemic heart disease. Acute angle closure glaucoma (AACG or closed angle glaucoma) is very rarely caused by anticholinergic medications in patients with narrow angle anterior eye chambers. However, these medications are safe in patients with open angle glaucoma or treated closed angle glaucoma. Urologists should inquire about the patient's glaucoma history from his/her ophthalmologist before starting an anticholinergic medication.

Efficacy and adverse events of antimuscarinics for treating overactive bladder: network meta-analyses

CONTEXT

Millions of people worldwide experience overactive bladder (OAB), and antimuscarinics are the pharmacologic treatment of choice. Several conventional meta-analyses have been published, but they fail to quantify efficacy and adverse events across drugs, dosages, formulations, and pharmaceutical forms.

OBJECTIVE

To perform two network meta-analyses summarizing the efficacy and adverse events of antimuscarinics in the treatment of OAB.

EVIDENCE ACQUISITION

Medline and Scopus searches, previous systematic reviews, conference abstracts, book chapters, and the reference lists of relevant articles were searched. Trialists were contacted. Eligible studies were randomized trials that compared at least one antimuscarinic for treating OAB with placebo or with another antimuscarinic, and that reported efficacy and/or adverse event outcomes. Efficacy was assessed for six outcomes (perception of cure or improvement, urgency episodes per 24h, leakage episodes per 24h, urgency incontinence episodes per 24h, micturitions per 24h, and nocturia episodes per 24h). Adverse events were assessed in seven categories according to the Common Terminology Criteria for Adverse Events. Across all outcomes, a summary efficacy and an adverse event score were computed. Two authors independently extracted data.

EVIDENCE SYNTHESIS

For the comparison of the efficacy, 76 trials enrolling 38 662 patients were included; for adverse events, 90 trials enrolling 39 919 patients were included. In the subset of studies reporting on treatments and dosages as used in clinical practice, 40 mg/d trospium chloride, 100mg/g per day oxybutynin topical gel, and 4 mg/d fesoterodine had the best efficacy, while higher dosages of orally administered oxybutynin and propiverine had the least favorable relationship of efficacy and adverse events.

CONCLUSIONS

This is the first study allowing trade-offs between efficacy and adverse events of various drugs and dosages in the treatment of patients with OAB. Differences among the various antimuscarinics call for careful, patient-centered management in which regimen changes should be considered.

An overview on mixed action drugs for the treatment of overactive bladder and detrusor overactivity

OBJECTIVES

To provide an overview on the efficacy, tolerability, safety and health-related quality of life (HRQoL) of drugs with a mixed action used in the treatment of overactive bladder (OAB).

EVIDENCE ACQUISITION

MEDLINE database and abstract books of the major conferences were searched for relevant publications from 1966 to 2011 and using the key words 'overactive bladder', 'detrusor overactivity', 'oxybutynin', 'propiverine', and 'flavoxate'. Two independent reviewers considered publications for inclusion and extracted relevant data, without performing a meta-analysis.

EVIDENCE SYNTHESIS

Old and conflicting data do not support the use of flavoxate, while both propiverine and oxybutynin were found to be more effective than placebo in the treatment of OAB. Propiverine was at least as effective as oxybutynin but with a better tolerability profile even in the pediatric setting. Overall, no serious adverse event for any product was statistically significant compared to placebo. Improvements were seen in HRQoL with treatment by the oxybutynin transdermal delivery system and propiverine extended release.

CONCLUSIONS

While there is no evidence to suggest the use of flavoxate in the treatment of OAB, both oxybutynin and propiverine appear efficacious and safe. Propiverine shows a better tolerability profile than oxybutynin. Both drugs improve HRQoL of patients affected by OAB. Profiles of each drug and dosage differ and should be considered in making treatment choices.

Which anticholinergic drug for overactive bladder symptoms in adults

BACKGROUND

Around 16% to 45% of adults have overactive bladder symptoms (urgency with frequency and/or urge incontinence - 'overactive bladder syndrome'). Anticholinergic drugs are common treatments.

OBJECTIVES

To compare the effects of different anticholinergic drugs for overactive bladder symptoms.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 8 March 2011) and reference lists of relevant articles.

SELECTION CRITERIA

Randomised trials in adults with overactive bladder symptoms or detrusor overactivity that compared one anticholinergic drug with another, or two doses of the same drug.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed eligibility, trial quality and extracted data. Data were processed as described in the Cochrane Reviewers' Handbook.

MAIN RESULTS

Eighty six trials, 70 parallel and 16 cross-over designs were included (31,249 adults). Most trials were described as double-blind, but were variable in other aspects of quality. Crossover studies did not present data in a way that could be included in the meta-analyses. Twenty nine collected quality of life data (the primary outcome measure) using validated measures, but only fifteen reported useable data.Tolterodine versus oxybutynin: There were no statistically significant differences for quality of life, patient reported cure or improvement, leakage episodes or voids in 24 hours, but fewer withdrawals due to adverse events with tolterodine (Risk Ratio (RR) 0.52, 95% confidence interval (CI) 0.40 to 0.66, data from eight trials), and less risk of dry mouth (RR 0.65, 95% CI 0.60 to 0.71, data from ten trials).Solifenacin versus tolterodine: There were statistically significant differences for quality of life (standardised mean difference (SMD) -0.12, 95% CI -0.23 to -0.01, data from three trials), patient reported cure/improvement (RR 1.25, 95% CI 1.13 to 1.39, data from two trials), leakage episodes in 24 hours (weighted mean difference (WMD) -0.30, 95% CI -0.53 to -0.08, data from four studies) and urgency episodes in 24 hours (WMD -0.43, 95% CI -0.74 to -0.13, data from four trials), all favouring solifenacin. There was no difference in withdrawals due to adverse events and dry mouth, but after sensitivity analysis the dry mouth (RR 0.69, 95% CI 0.51 to 0.94) was statistically significantly lower with solifenacin when compared to Immediate Release (IR) tolterodine.Fesoterodine versus extended release tolterodine: Three trials contributed to the meta analyses. There were statistically significant differences for quality of life (SMD -0.20, 95% CI -0.27 to -0.14), patient reported cure/improvement (RR 1.11, 95% CI 1.06 to 1.16), leakage episodes (WMD -0.19, 95% CI -0.30 to -0.09), frequency (WMD -0.27, 95% CI -0.47 to -0.06) and urgency episodes (WMD -0.44, 95% CI -0.72 to -0.16) in 24 hours, all favouring fesoterodine, but those taking fesoterodine had higher risk of withdrawal due to adverse events (RR 1.45, 95% CI 1.07 to 1.98) and higher risk of dry mouth (RR 1.80, 95% CI 1.58 to 2.05) at 12 weeks.Different doses of tolterodine: The standard recommended starting dose (2 mg twice daily) was compared with two lower (0.5 mg and 1 mg twice daily), and one higher dose (4 mg twice daily). The effects of 1 mg, 2 mg and 4 mg doses were similar for leakage episodes and micturitions in 24 hours, with greater risk of dry mouth with 2 and 4 mg doses at two to 12 weeks.Different doses of solifenacin: The standard recommended starting dose of 5 mg once daily was compared to 10 mg: while frequency and urgency were less (better) with 10 mg compared to 5 mg, there was a higher risk of dry mouth with 10 mg solifenacin at four to 12 weeks.Different doses of fesoterodine:The recommended starting dose of 4mg once daily was compared to 8 and 12 mg. The clinical efficacy (patient reported cure, leakage episodes, micturition per 24 hours) of 8 mg was better than 4 mg fesoterodine but with a higher risk of dry mouth with 8 mg.There was no statistically significant difference between 4 and 12 mg in the efficacy but the dry mouth was significantly higher with 12 mg at eight to 12 weeks.Extended versus immediate release preparations of oxybutynin and/or tolterodine: There were no statistically significant differences for cure/improvement, leakage episodes or micturitions in 24 hours, or withdrawals due to adverse events, but there were few data. Overall, extended release preparations had less risk of dry mouth at two to 12 weeks.One extended release preparation versus another: There was less risk of dry mouth with oral extended release tolterodine than oxybutynin (RR 0.75, 95% CI 0.59 to 0.95), but no difference between transdermal oxybutynin and oral extended release tolterodine although some people withdrew due to skin reaction at the transdermal patch site at 12 weeks.

AUTHORS' CONCLUSIONS

Where the prescribing choice is between oral immediate release oxybutynin or tolterodine, tolterodine might be preferred for reduced risk of dry mouth. With tolterodine, 2 mg twice daily is the usual starting dose, but a 1 mg twice daily dose might be equally effective, with less risk of dry mouth. If extended release preparations of oxybutynin or tolterodine are available, these might be preferred to immediate release preparations because there is less risk of dry mouth.Between solifenacin and immediate release tolterodine, solifenacin might be preferred for better efficacy and less risk of dry mouth. Solifenacin 5 mg once daily is the usual starting dose, this could be increased to 10 mg once daily for better efficacy but with increased risk of dry mouth.Between fesoterodine and extended release tolterodine, fesoterodine might be preferred for superior efficacy but has higher risk of withdrawal due to adverse events and higher risk of dry mouth.There is little or no evidence available about quality of life, costs, or long-term outcome in these studies. There were insufficient data from trials of other anticholinergic drugs to draw any conclusions.

Adverse event assessment of antimuscarinics for treating overactive bladder: a network meta-analytic approach

Background

Overactive bladder (OAB) affects the lives of millions of people worldwide and antimuscarinics are the pharmacological treatment of choice. Meta-analyses of all currently used antimuscarinics for treating OAB found similar efficacy, making the choice dependent on their adverse event profiles. However, conventional meta-analyses often fail to quantify and compare adverse events across different drugs, dosages, formulations, and routes of administration. In addition, the assessment of the broad variety of adverse events is dissatisfying. Our aim was to compare adverse events of antimuscarinics using a network meta-analytic approach that overcomes shortcomings of conventional analyses.

Methods

Cochrane Incontinence Group Specialized Trials Register, previous systematic reviews, conference abstracts, book chapters, and reference lists of relevant articles were searched. Eligible studies included randomized controlled trials comparing at least one antimuscarinic for treating OAB with placebo or with another antimuscarinic, and adverse events as outcome measures. Two authors independently extracted data. A network meta-analytic approach was applied allowing for joint assessment of all adverse events of all currently used antimuscarinics while fully maintaining randomization.

Results

69 trials enrolling 26′229 patients were included. Similar overall adverse event profiles were found for darifenacin, fesoterodine, transdermal oxybutynin, propiverine, solifenacin, tolterodine, and trospium chloride but not for oxybutynin orally administered when currently used starting dosages were compared.

Conclusions

The proposed generally applicable transparent network meta-analytic approach summarizes adverse events in an easy to grasp way allowing straightforward benchmarking of antimuscarinics for treating OAB in clinical practice. Most currently used antimuscarinics seem to be equivalent first choice drugs to start the treatment of OAB except for oral oxybutynin dosages of ≥10 mg/d which may have more unfavorable adverse event profiles.

Evaluation of the effect of tolterodine on pupil diameter and anterior chamber parameters with the Pentacam

BACKGROUND

To evaluate the effect of tolterodine on pupil diameter and anterior chamber parameters, including volume, depth, and angle, with the Pentacam.

METHODS

The 56 eyes of 28 patients who were diagnosed as having overactive bladder and planned to be treated with tolterodine were followed up prospectively in the study. All the patients underwent full ophthalmic examination and scanning with the Pentacam (Oculus, Inc., Wetzlar, Germany) before and 4 weeks after the start date of tolterodine therapy. In addition, the 30 eyes of 15 healthy volunteers were analyzed twice as a control group for repeatability of the measurements.

RESULTS

The quantitative descriptors of the anterior chamber before and after the treatment, respectively, were as follows: pupil diameter, 3.02 ± 0.56 mm and 3.01 ± 0.55 mm; anterior chamber depth, 2.74 ± 0.35 mm and 2.75 ± 0.34 mm; anterior chamber volume, 150.23 ± 33.95 mm(3) and 150.27 ± 34.48 mm(3); and anterior chamber angle, 34.56° ± 5.68° and 35.03° ± 5.99°. For all the measurements, the differences did not reach statistical significance (p > .05). Also, the comparison of the same parameters obtained from the first and second measurements of healthy volunteers was not statistically significant (p > .05).

CONCLUSION

Our study demonstrates that tolterodine does not affect pupil diameter and anterior chamber parameters, including angle, volume, and depth. Most likely, it is an organ-selective agent, inhibiting muscarinic receptors in the bladder rather than in the anterior segment of the eye.

A systematic review and meta-analysis of randomized controlled trials with antimuscarinic drugs for overactive bladder

CONTEXT

Anticholinergic drugs are commonly used in patients with overactive bladder (OAB) who do not achieve symptom relief and quality of life improvement with conservative management. Several drugs, with different doses, formulations, and routes of administration are currently available, making the choice quite difficult.

OBJECTIVE

To evaluate efficacy and safety of different doses, formulations, and route of administration of the available anticholinergic drugs.

EVIDENCE ACQUISITION

A systematic review of the literature was performed in August 2007 using Medline, Embase, and Web of Science. Efficacy (micturitions per 24h, volume voided per micturition, urgency urinary incontinence episodes per 24h, incontinence episodes per 24h) and safety (mainly, adverse events and withdrawal rates) end points were evaluated in the randomized control trials (RCTs) assessing the role of anticholinergic drugs in non-neurogenic OAB. Meta-analysis of RCTs was conducted using the Review Manager software 4.2 (Cochrane Collaboration).

EVIDENCE SYNTHESIS

Our systematic search identified 50 RCTs and three pooled analyses. Tolterodine immediate release (IR) had a more favorable profile of adverse events than oxybutynin IR. Regarding different dosages of IR formulations, dose escalation might yield some limited improvements in the efficacy but at the cost of significant increase in the rate of adverse events. In the comparisons between IR and extended-release (ER) formulations, the latter showed some advantages, both in terms of efficacy and safety. With regard to the route of administration, use if a transdermal route of administration does not provide significant advantage over an oral one.

CONCLUSION

Many of the available RCTs have good methodological quality. ER formulations should be preferred to the IR ones. With regard to IR formulations, dose escalation might yield some improvements in the efficacy with significant increase in the AE. More clinical studies are needed to indicate which of the drugs should be used as first-, second-, or third-line treatment.

Oxybutynin-associated esotropia

A 5-year-old girl with previously unrecognized hyperopia of approximately +3.00 D developed esotropia while being treated with oxybutynin for enuresis. The esotropia disappeared with cessation of oxybutynin and correction of her hyperopia. When the hyperopic correction was removed, she had a small esophoria. The esotropia was presumably triggered by the anticholinergic effect of oxybutynin, which reduced the ability to accommodate. The increased accommodative effort for vision generated an esotropia as a result of the accommodative convergence/accommodation ratio.

New Options and Strategies for the Treatment of Urinary Incontinence

Urinary incontinence is a prevalent, although often unreported, disease within the elderly population, with consequences spanning many aspects of the patient's life. Treatments differ for each subtype of urinary incontinence: urge incontinence, stress incontinence, and incontinence associated with bladder outlet obstruction and lower urinary tract symptoms in men. Limitations in current therapies have negatively affected care for each of these subtypes, particularly in the vulnerable elderly population. An emergence of new treatment options and strategies has created opportunities to optimize care for the general population. These include the use of trospium, darifenacin, solifenacin, and duloxetine as well as the strategic use of antimuscarinic agents in conjunction with alpha adrenergic blockade in men with bladder outlet obstruction. Yet, the literature regarding use of these agents and strategies in the elderly should be carefully evaluated to determine the benefits and the unique risks posed by their use in this vulnerable population.

Oxybutynin: an overview of the available formulations

Overactive bladder (OAB) is a common problem presented to by physicians. Standard treatment with antimuscarinic medication is directed at suppressing involuntary detrusor contractions by blocking the binding of acetylcholine to muscarinic receptors in the bladder. Oxybutynin chloride is the first of several antimuscarinic medications to be marketed for OAB. Although efficacious for treating OAB symptoms, the side effects and suboptimal dosing regimen decrease its utility. To improve patient compliance and tolerability, alternative delivery systems for oxybutynin have subsequently been developed and include a once-daily formulation and a transdermal system. The currently available formulations of oxybutynin are the subject of this review.