1
|
Fisher SR, Villasante-Tezanos A, Allen LM, Pappadis MR, Kilic G. Comparative effectiveness of pelvic floor muscle training, mirabegron, and trospium among older women with urgency urinary incontinence and high fall risk: a feasibility randomized clinical study. Pilot Feasibility Stud 2024; 10:1. [PMID: 38178267 PMCID: PMC10765875 DOI: 10.1186/s40814-023-01440-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 12/21/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Untreated, urgency urinary incontinence (UUI) and overactive bladder (OAB) can precipitate a vicious cycle of decreasing physical activity, social isolation, fear of falling, and falls. Structured behavioral interventions and medications are common initial treatment options, but they elicit their effects through very different mechanisms of action that may influence fall-related outcomes differently. This study will determine the feasibility of conducting a comparative effectiveness, three-arm, mixed methods, randomized clinical trial of a behaviorally based pelvic floor muscle training (PFMT) intervention versus two recent drug options in older women with UUI or OAB who are also at increased risk of falling. METHODS Forty-eight women 60 years and older with UUI or OAB who screen positive for increased fall risk will be recruited through the urogynacology and pelvic health clinics of our university health system. Participants will be randomly assigned to one of three 12-week treatment arms: (1) a course of behavioral and pelvic floor muscle training (PFMT) provided by physical therapists; (2) the beta-3 agonist, mirabegron; and (3) the antimuscarinic, trospium chloride. Study feasibility will be established through objective metrics of evaluability, adherence to the interventions, and attrition. We will also assess relevant measures of OAB symptom severity, quality of life, physical activity, incident falls, and concern about falling. DISCUSSION The proposed research seeks to ultimately determine if linkages between reduction in UI symptoms through treatment also reduce the risk of falling in this patient population. TRIAL REGISTRATION NCT05880862. Registered on 30 May 2023.
Collapse
Affiliation(s)
- Steve R Fisher
- Department of Physical Therapy, University of Texas Medical Branch at Galveston, Galveston, USA.
| | | | - Lindsay M Allen
- Department of Physical Therapy, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Monique R Pappadis
- Department of Population Health and Health Disparities, University of Texas Medical Branch at Galveston, Galveston, USA
| | - Gokhan Kilic
- Department of Obstetrics and Gynecology, University of Texas Medical Branch at Galveston, Galveston, USA
| |
Collapse
|
2
|
Stoniute A, Madhuvrata P, Still M, Barron-Millar E, Nabi G, Omar MI. Oral anticholinergic drugs versus placebo or no treatment for managing overactive bladder syndrome in adults. Cochrane Database Syst Rev 2023; 5:CD003781. [PMID: 37160401 PMCID: PMC10167789 DOI: 10.1002/14651858.cd003781.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
BACKGROUND Around 16% of adults have symptoms of overactive bladder (OAB; urgency with frequency and/or urge incontinence), with prevalence increasing with age. Anticholinergic drugs are commonly used to treat this condition. This is an update of a Cochrane Review first published in 2002 and last updated in 2006. OBJECTIVES To assess the effects of anticholinergic drugs compared with placebo or no treatment for treating overactive bladder syndrome in adults. SEARCH METHODS We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 14 January 2020), and the reference lists of relevant articles. We updated this search on 3 May 2022, but these results have not yet been fully incorporated. SELECTION CRITERIA We included randomised or quasi-randomised trials in adults with overactive bladder syndrome that compared an anticholinergic drug alone with placebo treatment. DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligibility and extracted data from the included studies, including an assessment of the risk of bias. We assessed the certainty of the body of evidence using the GRADE approach. We processed data as described in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS We included 104 studies, 71 of which were new or updated for this version of the review. Although 12 studies did not report the number of participants, there were 47,106 people in the remainder of the included studies. The majority of the studies had insufficient information to allow judgement of risk of bias and we judged them to be unclear for all domains. Nine anticholinergic drugs were included in these studies: darifenacin; fesoterodine; imidafenacin; oxybutynin; propantheline; propiverine; solifenacin; tolterodine and trospium. No studies were found that compared anticholinergic drugs to no treatment. At the end of the treatment period, anticholinergics may slightly increase condition-specific quality of life (mean difference (MD) 4.41 lower, 95% confidence interval (CI) 5.28 lower to 3.54 lower (scale range -100 to 0); 12 studies, 6804 participants; low-certainty evidence). Anticholinergics are probably better than placebo in terms of patient perception of cure or improvement (risk ratio (RR) 1.38, 95% CI 1.15 to 1.66; 9 studies, 8457 participants; moderate-certainty evidence), and the mean number of urgency episodes per 24-hour period (MD 0.85 lower, 95% CI 1.03 lower to 0.67 lower; 23 studies, 16,875 participants; moderate-certainty evidence). Compared to placebo, anticholinergics may result in an increase in dry mouth adverse events (RR 3.50, 95% CI 3.26 to 3.75; 66 studies, 38,368 participants; low-certainty evidence), and may result in an increased risk of urinary retention (RR 3.52, 95% CI 2.04 to 6.08; 17 studies, 7862 participants; low-certainty evidence). Taking anticholinergics may be more likely to lead to participants withdrawing from the studies due to adverse events (RR 1.37, 95% CI 1.21 to 1.56; 61 studies, 36,943 participants; low-certainty evidence). However, taking anticholinergics probably reduces the mean number of micturitions per 24-hour period compared to placebo (MD 0.85 lower, 95% CI 0.98 lower to 0.73 lower; 30 studies, 19,395 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS The use of anticholinergic drugs by people with overactive bladder syndrome results in important but modest improvements in symptoms compared with placebo treatment. In addition, recent studies suggest that this is generally associated with only modest improvement in quality of life. Adverse effects were higher with all anticholinergics compared with placebo. Withdrawals due to adverse effects were also higher for all anticholinergics except tolterodine. It is not known whether any benefits of anticholinergics are sustained during long-term treatment or after treatment stops.
Collapse
Affiliation(s)
- Akvile Stoniute
- Evidence Synthesis Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Priya Madhuvrata
- Obstetrics & Gynaecology, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
| | - Madeleine Still
- Evidence Synthesis Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Evelyn Barron-Millar
- Evidence Synthesis Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ghulam Nabi
- Section of Academic Urology, Division of Cancer Research, University of Dundee, Dundee, UK
| | - Muhammad Imran Omar
- Guidelines Office, European Association of Urology, Arnhem, Netherlands
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| |
Collapse
|
3
|
Gibson W, Johnson T, Kirschner-Hermanns R, Kuchel G, Markland A, Orme S, Ostaszkiewicz J, Szonyi G, Wyman J, Wagg A. Incontinence in frail elderly persons: Report of the 6th International Consultation on Incontinence. Neurourol Urodyn 2020; 40:38-54. [PMID: 33085806 DOI: 10.1002/nau.24549] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/08/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Evidence-based guidelines for the management of frail older persons with urinary incontinence are rare. Those produced by the International Consultation on Incontinence represent an authoritative set of recommendations spanning all aspects of management. AIMS To summarize the available evidence relating to the management of urinary incontinence in frail older people published since the 5th International Consultation on Incontinence. MATERIALS AND METHODS A series of systematic reviews and evidence updates were performed by members of the working group to update the 2012 recommendations. RESULTS Along with the revision of the treatment algorithm and accompanying text, there have been significant advances in several areas of the management of lower urinary tract symptoms in frail older people. DISCUSSION The committee continues to note the relative paucity of data concerning frail older persons and draw attention to knowledge gaps and research opportunities. Clinicians treating older people with lower urinary tract symptoms should use the available evidence from studies of older people combined with careful extrapolation of those data from younger subjects. Due consideration to an individual's frailty and wishes is crucial.
Collapse
Affiliation(s)
- William Gibson
- Division of Geriatric Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Theodore Johnson
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - George Kuchel
- UConn Center on Aging, University of Connecticut, Farmington, Connecticut, USA
| | - Alayne Markland
- Division of Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Susie Orme
- Care of the Elderly Department, Barnsley Hospital NHS Foundation Trust, Barnsley, UK
| | - Joan Ostaszkiewicz
- Director of Aged Care, National Ageing Research Institute, Melbourne, Victoria, Australia
| | - George Szonyi
- Department of Geriatric Medicine, Balmain Hospital, Sydney, New South Wales, Australia
| | - Jean Wyman
- School of Nursing, University of Minnesota, Minneapolis, Minnesota, USA
| | - Adrian Wagg
- Division of Geriatric Medicine, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
4
|
Lozano-Ortega G, Walker DR, Johnston K, Mickle A, Harrigan S, Rogula B, Kristy RM, Hairston JC, Schermer CR. Comparative Safety and Efficacy of Treatments for Overactive Bladder Among Older Adults: A Network Meta-analysis. Drugs Aging 2020; 37:801-816. [PMID: 32960422 PMCID: PMC7595992 DOI: 10.1007/s40266-020-00792-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cumulative exposure to one or more anticholinergic medications ("anticholinergic burden") is associated with an increased risk of adverse outcomes, particularly among older individuals. Mirabegron, an oral selective β3-adrenergic receptor agonist, has demonstrated efficacy in managing the symptoms of overactive bladder without contributing to anticholinergic burden. However, it is not known whether the favorable safety profile of mirabegron relative to antimuscarinics varies with increasing age among a patient population who may have a high anticholinergic burden. OBJECTIVE The primary objective of this study was to indirectly compare the safety and efficacy profile of mirabegron relative to antimuscarinics in older adults with overactive bladder. METHODS A systematic literature review was conducted to identify randomized controlled trials that reported safety and efficacy endpoints among patients aged ≥ 65 years. Identified randomized controlled trials were subsequently synthesized via a network meta-analysis. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines in designing, performing, and reporting the literature review were followed. In line with current best practices, the network meta-analysis was conducted using a Bayesian approach and according to the overall general guidance for evidence synthesis developed by the National Institute for Health and Care Excellence decision support unit. Estimates of relative safety were assessed via the odds ratio and estimates of relative efficacy were assessed via means and credible intervals. RESULTS A total of 3078 abstracts, 300 of which underwent full-text screening, were identified using the search criteria. Twenty articles reporting on 21 randomized controlled trials were eligible for data extraction and synthesis. Following review, five safety and five efficacy endpoints were considered for inclusion in the network meta-analysis. Regarding findings typical of anticholinergic exposure in older adults, mirabegron was not associated with an increased odds of dry mouth (odds ratio 95% credible interval 0.76 [0.26-2.37]) or constipation (1.08 [0.39-3.02]) relative to placebo, whereas antimuscarinics were strongly associated with these events (odds ratio range 3.78-7.85 and 2.12-4.66, respectively). In this older population, mirabegron was associated with a similar odds of experiencing adverse event-related treatment discontinuations relative to placebo (0.99 [0.57-1.70]), while the odds of experiencing an adverse event-related treatment discontinuation for antimuscarinics had a range of 1.14-3.03 (in most cases, the association was mild). No increased odds of experiencing overall treatment-emergent adverse events was observed for mirabegron or antimuscarinics (odds ratio range 1.25-1.55), apart from fesoterodine (2.23 [1.37-3.37]). Finally, a similar treatment effect was observed across all efficacy endpoints between mirabegron and antimuscarinics in this older population. CONCLUSIONS This study indicates that the safety and efficacy profile of mirabegron remains favorable compared with antimuscarinics among older adults. This includes safety outcomes typically associated with anticholinergic burden, which were less frequently observed in patients treated with mirabegron.
Collapse
Affiliation(s)
| | - David R. Walker
- Astellas Pharma Global Development, Inc., Northbrook, IL USA
| | - Karissa Johnston
- Broadstreet Health Economics and Outcomes Research, Vancouver, BC Canada
| | - Alexis Mickle
- Broadstreet Health Economics and Outcomes Research, Vancouver, BC Canada
| | - Sean Harrigan
- Broadstreet Health Economics and Outcomes Research, Vancouver, BC Canada
| | - Basia Rogula
- Broadstreet Health Economics and Outcomes Research, Vancouver, BC Canada
| | - Rita M. Kristy
- Astellas Pharma Global Development, Inc., Northbrook, IL USA
| | | | | |
Collapse
|
5
|
Effets cardio-vasculaires des traitements anticholinergiques à visée vésicale chez la personne âgée : une revue. Prog Urol 2018; 28:361-369. [DOI: 10.1016/j.purol.2018.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 02/19/2018] [Accepted: 03/06/2018] [Indexed: 11/30/2022]
|
6
|
Kistler KD, Xu Y, Zou KH, Ntanios F, Chapman DS, Luo X. Systematic literature review of clinical trials evaluating pharmacotherapy for overactive bladder in elderly patients: An assessment of trial quality. Neurourol Urodyn 2017; 37:54-66. [PMID: 28763112 DOI: 10.1002/nau.23309] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 04/16/2017] [Indexed: 01/10/2023]
Abstract
AIMS Overactive bladder (OAB) disproportionately affects older-aged adults, yet most randomized controlled trials (RCTs) underrepresent patients ≥65. This systematic literature review (SLR) identified RCTs evaluating β-3 adrenergic agonists or muscarinic antagonists in elderly patients with OAB, and compared study quality across trials. METHODS MEDLINE® , Embase® , and Cochrane Collaboration Central Register of Clinical Trials databases were searched from inception through April 28, 2015 to identify published, peer-reviewed RCT reports evaluating β-3 adrenergic agonists or muscarinic antagonists in elderly OAB patients (either ≥65 years or study-described as "elderly"). To assess study quality of RCT reports, we focused on internal/external validity, assessed via two scales: the validated Effective Public Health Practice Project [EPHPP]): Quality Assessment Tool for Quantitative Studies, and a tool commissioned by the Agency for Healthcare Research and Quality (AHRQ). RESULTS Database searches yielded 1380 records that were then screened according to predefined inclusion/exclusion criteria. We included eight papers meeting study criteria. Despite scientific community efforts to improve RCT reporting standards, published reports still include incomplete and inconsistent reporting-of subject attrition, baseline patient characteristics, inclusion/exclusion criteria, and other important details. Only three of the eight OAB RCTs in this review received quality ratings of Strong (EPHPP) or Fair (AHRQ) and were multicenter with large samples. CONCLUSIONS Despite the prevalence of OAB among older age individuals, relatively few RCTs evaluate OAB treatments explicitly among elderly subjects. The findings from this quality assessment suggest some areas for improvement in both conduct and reporting of future RCTs assessing OAB treatment in elderly.
Collapse
|
7
|
Tan J, Markland AD. Nonsurgical Management of Urinary Incontinence in Older Women. CURRENT GERIATRICS REPORTS 2017. [DOI: 10.1007/s13670-017-0200-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
8
|
Adverse events and treatment discontinuations of antimuscarinics for the treatment of overactive bladder in older adults: A systematic review and meta-analysis. Arch Gerontol Geriatr 2016; 69:77-96. [PMID: 27889591 DOI: 10.1016/j.archger.2016.11.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 11/10/2016] [Accepted: 11/10/2016] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Antimuscarinics should be used with caution in older adults with overactive bladder (OAB) due to anticholinergic adverse events (AEs). Systematic reviews and meta-analyses (SRMAs) have analyzed safety-related outcomes but have not specified risk in the elderly, the population at highest risk for AEs. The aim of this review is to explore and evaluate AEs and treatment discontinuations in adults 65 or older taking antimuscarinics for OAB. METHODS Keywords were searched in MEDLINE, EMBASE, SCOPUS, and Cochrane Central Register for Controlled Trials. Randomized controlled trials (RCTs) along with sub-analyses and pooled analyses that compared antimuscarinics to placebo or another antimuscarinic were performed in February 2015. Studies assessing AEs or treatment discontinuations in a population of adults 65 or older were included. The Jadad Criteria and McHarm Tool were used to assess the quality of the trials. RESULTS A total of 16 studies met the inclusion criteria. Eighty AEs and 27 reasons for treatment discontinuation were described in the included studies and further explored. Anticholinergic AEs were more common in antimuscarinics compared to placebo. Incidence of dizziness, dyspepsia, and urinary retention with fesoterodine, headache with darifenacin, and urinary tract infections with solifenacin were significantly higher compared to placebo. Treatment discontinuation due to AEs and dry mouth were higher in the antimuscarinics when compared to placebo in older adults. CONCLUSIONS Treatment for overactive bladder using antimuscarinics in adults aged 65 or older resulted in significant increases in risk for several AEs compared to placebo including anticholinergic and non-anticholinergic AEs.
Collapse
|
9
|
Chu CM, Harvie HS, Smith AL, Arya LA, Andy UU. The Impact of Treatment of Overactive Bladder on Physical Activity Limitations. J Womens Health (Larchmt) 2016; 25:801-5. [PMID: 27135856 DOI: 10.1089/jwh.2015.5643] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To determine if treatment of overactive bladder (OAB) can improve self-reported limitations in physical activity in women. MATERIALS AND METHODS This is a prospective study of women with OAB treated with flexible-dose fesoterodine therapy and standardized behavioral counseling. Subjects were evaluated at baseline and 8 weeks post-treatment. Physical activity scores were assigned using two questions of the Short Form 12 (SF-12) and categorized into three levels of physical activity (no limitations, moderate limitations, severe limitations). Response of urinary symptoms to treatment at 8 weeks was measured using the Patient Global Impression of Improvement. Physical activity limitations at baseline and 8 weeks were compared. RESULTS We recruited 137 women. At baseline, 71 (52%) women had no limitations, 34 (25%) had moderate, and 32 (23%) had severe physical limitations. Eight weeks after treatment, the proportion of women reporting severe limitations in physical activity was significantly lower with 71 (52%) women reporting no limitations, 50 (36%) reporting moderate, and 16 (12%) reporting severe limitations in physical activity (p = 0.001). At 8 weeks, the proportion of women with no limitations in physical activity was higher in responders than nonresponders (52% vs. 33%), and the proportion of women with severe restriction was lower in responders (13% vs. 17%), although there was no significant difference between the groups (p = 0.24), which both showed overall improvement in physical activity limitations. CONCLUSION Treatment of OAB is associated with a decrease in perceived physical activity limitations; however, this is not directly associated with improvement in urinary symptoms.
Collapse
Affiliation(s)
- Christine M Chu
- 1 Division of Urogynecology, Department of Obstetrics & Gynecology, Hospital of the University of Pennsylvania , Philadelphia, Pennsylvania
| | - Heidi S Harvie
- 1 Division of Urogynecology, Department of Obstetrics & Gynecology, Hospital of the University of Pennsylvania , Philadelphia, Pennsylvania
| | - Ariana L Smith
- 2 Department of Urology, Hospital of the University of Pennsylvania , Philadelphia, Pennsylvania
| | - Lily A Arya
- 1 Division of Urogynecology, Department of Obstetrics & Gynecology, Hospital of the University of Pennsylvania , Philadelphia, Pennsylvania
| | - Uduak U Andy
- 1 Division of Urogynecology, Department of Obstetrics & Gynecology, Hospital of the University of Pennsylvania , Philadelphia, Pennsylvania
| |
Collapse
|
10
|
Wagg A, Nitti VW, Kelleher C, Castro-Diaz D, Siddiqui E, Berner T. Oral pharmacotherapy for overactive bladder in older patients: mirabegron as a potential alternative to antimuscarinics. Curr Med Res Opin 2016; 32:621-38. [PMID: 26828974 DOI: 10.1185/03007995.2016.1149806] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Overactive bladder (OAB) is a particular challenge to treat in older adults with co-morbid conditions taking multiple medications. Antimuscarinics (e.g., solifenacin, fesoterodine) and β3-adrenergic receptor agonists (mirabegron) are similarly efficacious; however, antimuscarinics may be associated with side effects that result in poor persistence and contribute to anticholinergic burden, particularly in those taking other medications with anticholinergic properties. With a mechanism of action distinct from antimuscarinics, mirabegron has a different tolerability profile and does not contribute to anticholinergic burden. The objective of this review was to compare and contrast the tolerability profiles of antimuscarinics and mirabegron in older patients to inform practice. METHODS Prospective trials or retrospective subgroup analyses of antimuscarinics for the treatment of OAB in older patients were identified through a search of PubMed. Tolerability data and results of subgroup analyses of mirabegron in patients aged ≥65 and ≥75 years from a pooled analysis of three trials each of 12 weeks and a 1 year trial are described. RESULTS Anticholinergic adverse events (AEs) including dry mouth and constipation were more frequent with antimuscarinics versus mirabegron. In patients aged ≥65 years, dry mouth occurred with a six-fold higher incidence with tolterodine extended-release (ER) 4 mg than with mirabegron 25 mg or 50 mg over 12 weeks, and a three-fold higher incidence with tolterodine ER than mirabegron 50 mg over 1 year. Mirabegron had a low incidence of central nervous system effects. A systematic review of the cardiovascular safety profile of mirabegron has not identified any clinically significant effects on blood pressure or pulse rate at therapeutic doses amongst patients aged ≥65 years. CONCLUSIONS Mirabegron has a more favorable tolerability profile than antimuscarinics amongst older patients and may provide an improved benefit-to-risk ratio and therefore be considered as an alternative to antimuscarinics for older patients.
Collapse
Affiliation(s)
| | | | - Con Kelleher
- c Guy's and St Thomas' NHS Foundation Trust , UK
| | | | - Emad Siddiqui
- e Astellas Pharma Europe Ltd , Chertsey , Surrey , UK
| | - Todd Berner
- f Formerly of Astellas Scientific and Medical Affairs , Northbrook , IL , USA
| |
Collapse
|
11
|
Treatment of Overactive Bladder in the Elderly Female: The Case for Trospium, Oxybutynin, Fesoterodine and Darifenacin. Drugs Aging 2015; 32:809-19. [PMID: 26391900 DOI: 10.1007/s40266-015-0301-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Overactive bladder (OAB) is a common constellation of lower urinary tract storage symptoms that causes a significant impact on a person's quality of life. The elderly may be disproportionally impacted by these symptoms due to concomitant poor mobility, comorbid conditions such as diabetes and heart failure, and polypharmacy. While behavioral modification and pelvic floor muscle training should be considered first-line treatment options, pharmacotherapy remains the backbone of the therapeutic regimen. Trospium, oxybutynin, fesoterodine, and darifenacin all have unique properties that may confer certain advantages in the elderly population. The hydrophilicity and quaternary amine structure of trospium may limit its ability to cross the blood-brain barrier and thus minimize impact on cognition in the elderly. In its oral form, oxybutynin may have the most significant effect on cognition; however, the transdermal preparations may be favorable in the elderly population due to the ability to avoid first-pass metabolism and its limited antimuscarinic adverse effects. Fesoterodine may be the most extensively studied OAB medication in the elderly population. Darifenacin has a strong affinity for the M3 receptor in the bladder, while having a weak affinity for the M1 receptor commonly found in the brain. It must be noted that all muscarinic receptor antagonists are associated with common adverse effects to some degree, and frequent re-evaluation of the elderly patient is necessary to confirm the proper benefit-to-risk profile.
Collapse
|
12
|
Lee YS, Lee HN, Cho WJ, Lee HS, Lee KS. Detrusor Overactivity with Impaired Contractility (DOIC) in the Elderly: Challenges in Management. CURRENT BLADDER DYSFUNCTION REPORTS 2015. [DOI: 10.1007/s11884-015-0313-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
13
|
Challenges in the Treatment of Overactive Bladder in the Octogenarian Female. CURRENT BLADDER DYSFUNCTION REPORTS 2015. [DOI: 10.1007/s11884-014-0281-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
14
|
Samuelsson E, Odeberg J, Stenzelius K, Molander U, Hammarström M, Franzen K, Andersson G, Midlöv P. Effect of pharmacological treatment for urinary incontinence in the elderly and frail elderly: A systematic review. Geriatr Gerontol Int 2015; 15:521-34. [DOI: 10.1111/ggi.12451] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2014] [Indexed: 12/17/2022]
Affiliation(s)
- Eva Samuelsson
- Department of Public Health and Clinical Medicine; Umeå University; Umeå Sweden
| | - Jenny Odeberg
- Swedish Council on Health Technology Assessment (SBU); Stockholm Sweden
| | | | - Ulla Molander
- Institute of Medicine; The Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - Margareta Hammarström
- Department of Clinical Science and Education; Karolinska Institutet; Stockholm Sweden
| | - Karin Franzen
- School of health and Medical Sciences; Örebro University; Örebro Sweden
| | - Gunnel Andersson
- School of health and Medical Sciences; Örebro University; Örebro Sweden
| | - Patrik Midlöv
- Center for Primary Health Care Research; Lund University; Malmö Sweden
| |
Collapse
|
15
|
Traitement anticholinergique de l’hyperactivité vésicale de la personne âgée et ses impacts sur la cognition. Revue de la littérature. Prog Urol 2014; 24:672-81. [DOI: 10.1016/j.purol.2014.06.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Revised: 06/02/2014] [Accepted: 06/03/2014] [Indexed: 12/20/2022]
|
16
|
Management of Lower Urinary Tract Dysfunction in Parkinson’s Disease: a Review of Recent Treatment Options. CURRENT BLADDER DYSFUNCTION REPORTS 2014. [DOI: 10.1007/s11884-014-0243-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
17
|
Abstract
The International Continence Society (ICS) defines overactive bladder (OAB) as an association of symptoms including "urgency, with or without urge incontinence, usually with increased frequency and nocturia". This conditon has been associated with a decrease in quality of life and a higher related risk of overall health condition decrease, and is rising since its prevalence increases with age and the forecast for the world population estimates an increase of those over 65 years old. Aging alone can be considered a major risk factor for developing OAB symptoms that are considered multifactorial and due to body tissue and anatomic changes, lifestyle-associated factors, comorbidities and personal characteristics. The high prevalence of this condition and multiple etiology factors makes of its treatment a challenge-especially in the older population. A major concern over OAB treatment of elderly patients is the risk of cognitive side effects due to the pharmacologic treatment with anticholinergic drugs. First-line treatment for OAB symptoms are the use of pharmacologic therapy with antimuscarinic drugs, which has been proved to be effective in controlling urgency, urge incontinence episodes, incontinence episodes, and nocturia. The impact caused by this condition is significant regarding the economic and human costs associated bringing into attention the need of studying and reviewing this specific population. Conservative Management and Lifestyle Modifications: Behavioral therapy's aims are to reduce urinary frequency and urgency to an accepted level and to increase bladder outlet volume. It consists of actions to teach patients to improve and learn bladder control. Lifestyle modifications are a conjunct of daily activities that can be managed to have the lowest interference on the functioning of the urinary tract. Pharmacologic Therapy: There are various medications with antimuscarinic properties available for the treatment of OAB symptoms. The most commonly used are oxybutinin, tolterodine, solifenacin, darifenacin, fesosterodine and trospium. Second-line Therapy: OAB treatment accounts for some refractory to conventional treatment patients who will require alternative therapies to achieve improvement of symptoms as the use of intradetrusor injection of botulinum A toxin by binding to receptors on the membrane of cholinergic nerves causing temporary chemodenervation and consequent muscle relaxation. Neuromodulation is also an effective therapy that aims to achieve inhibition of detrusor activity by continuous neural stimulation through peripheral nerves as the use of the tibial nerve or central as it is performed by direct spine stimulation on sacral roots through the implantation of an automated generator. In conclusion, evidence from the literature has shown that antimuscarinic treatment of OAB in the elderly population is safe and effective in improving symptoms and patient's quality of life. Managing OAB symptoms in this population is a great challenge. An optimal therapeutic approach to treat should involve medical treatment with drug and behavioral therapy in addition to lifestyle advice.
Collapse
Affiliation(s)
- Ricardo Natalin
- Department of Geriatric Urology, Federal University of Sao Paulo, Rua Napoleão de Barros, 715, 2 andar, São Paulo, Brazil
| | | | | |
Collapse
|
18
|
[Guidelines concerning urinary incontinence in elderly: construction and validation of GRAPPPA algorithm]. Prog Urol 2014; 24:215-21. [PMID: 24560289 DOI: 10.1016/j.purol.2013.11.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Revised: 11/18/2013] [Accepted: 11/28/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Provide guidelines presented as an algorithm for practical evaluation and first line therapy of urinary incontinence in elderly. PATIENTS AND METHODS Guidelines using formalized consensus guidelines method. These guidelines have been validated by a group of 40 experts quoting proposals, subsequently reviewed by an independent group of multidisciplinary experts (urologist, general practitioner, neurologist, gynecologist, geriatrist, specialist in physical medicine and rehabilitation). RESULTS By means of 3 rounds of interrogation of the expert panel, GRAPPPA algorithm was constructed. This algorithm take in account both evaluation and first line therapeutic options in the different type of incontinences observed in this population (urge, stress and mixed incontinence). Initial evaluation consists to track down urinary retention (and subsequently fecal stool impaction, use of anticholinergic or morphinic drugs), urinary tract infection and cognitive impairment. Haematuria, bladder-pelvic pain, history of radiotherapy or recent pelvic surgery, lead to refer the patient to a specialized unit. First line therapy is in all the cases pelvic floor training, use of local oestrogenotherapy and dietetic measures. In urge incontinence, anticholinergic drugs may be used. CONCLUSIONS Implementation of this algorithm may promote best practice in management of urinary incontinence in elderly.
Collapse
|
19
|
Nassau. DE, Gerber JA, Weiss JP. The Prevalence and Treatment of Voiding Dysfunction in the Elderly. CURRENT GERIATRICS REPORTS 2014. [DOI: 10.1007/s13670-013-0075-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
|
20
|
Cetinel B, Onal B. Rationale for the use of anticholinergic agents in overactive bladder with regard to central nervous system and cardiovascular system side effects. Korean J Urol 2013; 54:806-15. [PMID: 24363860 PMCID: PMC3866282 DOI: 10.4111/kju.2013.54.12.806] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 09/23/2013] [Indexed: 02/01/2023] Open
Abstract
PURPOSE Central nervous system (CNS) and cardiovascular system (CVS) side effects of anticholinergic agents used to treat overactive bladder (OAB) are underreported. Hence, this review aimed to focus on the mechanisms of CNS and CVS side effects of anticholinergic drugs used in OAB treatment, which may help urologists in planning the rationale for OAB treatment. MATERIALS AND METHODS PubMed/MEDLINE was searched for the key words "OAB," "anticholinergics," "muscarinic receptor selectivity," "blood-brain barrier," "CNS," and "CVS side effects." Additional relevant literature was determined by examining the reference lists of articles identified through the search. RESULTS CNS and CVS side effects, pharmacodynamic and pharmacokinetic properties, the metabolism of these drugs, and the clinical implications for their use in OAB are presented and discussed in this review. CONCLUSIONS Trospium, 5-hydroxymethyl tolterodine, darifenacin, and solifenacin seem to have favorable pharmacodynamic and pharmacokinetic properties with regard to CNS side effects, whereas the pharmacodynamic features of darifenacin, solifenacin, and oxybutynin appear to have an advantage over the other anticholinergic agents (tolterodine, fesoterodine, propiverine, and trospium) with regard to CVS side effects. To determine the real-life situation, head-to-head studies focusing especially on CNS and CVS side effects of OAB anticholinergic agents are urgently needed.
Collapse
Affiliation(s)
- Bülent Cetinel
- Department of Urology, Cerrahpasa School of Medicine Faculty, Istanbul University, Istanbul, Turkey
| | - Bulent Onal
- Department of Urology, Cerrahpasa School of Medicine Faculty, Istanbul University, Istanbul, Turkey
| |
Collapse
|
21
|
Anticholinergic medication use for female overactive bladder in the ambulatory setting in the United States. Int Urogynecol J 2013; 25:479-84. [PMID: 24158462 DOI: 10.1007/s00192-013-2246-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 09/30/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Our objective was to estimate the prevalence and sociodemographic factors associated with anticholinergic medication use by adult women for overactive bladder (OAB) in the United States. METHODS We conducted a cross-sectional study using the 2009 National Ambulatory Medical Care Survey database (NAMCS). We included women aged 18 years and older and identified visits for which anticholinergic medications for OAB were in active use. We evaluated the prevalence of medications used and estimated the use of short-acting versus long-acting drugs. We also assessed variables associated with anticholinergic use, (age, race/ethnicity, insurance, geographic location) using survey weights in the analysis to estimate national data. RESULTS In 2009, adult women made 516.8 million outpatient office visits. Of these, 8.1 million (1.6 %) were associated with an OAB anticholinergic medication (annual rate 68 per 1,000 women). Women who used anticholinergics were predominantly insured by Medicare (61.0 %) and were older than those not using anticholinergic medications (70.0 ± 1.1 vs. 53.0 ± 0.5, p < 0.001). No racial or ethnic differences were evident between the two groups. Tolterodine (33.8 %) and oxybutynin (33.1 %) were the most commonly reported medications, followed by solifenacin (19.5 %), darifenacin (9.3 %), and trospium (4.4 %). Long-acting anticholinergics were used more often than short-acting medications (53.8 % vs. 46.3 %, respectively, p < 0.001). CONCLUSIONS Annually, more than 8 million outpatient visits occur in which adult women in the United States are using an OAB anticholinergic medication. Despite the abundance of newer-generation medications, tolterodine and oxybutynin remain the most commonly prescribed anticholinergic drugs for OAB. Solifenacin is the most popular newer-generation anticholinergic drug.
Collapse
|
22
|
Dubeau CE, Kraus SR, Griebling TL, Newman DK, Wyman JF, Johnson TM, Ouslander JG, Sun F, Gong J, Bavendam T. Effect of fesoterodine in vulnerable elderly subjects with urgency incontinence: a double-blind, placebo controlled trial. J Urol 2013; 191:395-404. [PMID: 23973522 DOI: 10.1016/j.juro.2013.08.027] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2013] [Indexed: 11/18/2022]
Abstract
PURPOSE We evaluated the efficacy and safety of flexible dose fesoterodine in medically complex vulnerable elderly subjects with urgency urinary incontinence. MATERIALS AND METHODS In this 12-week, randomized, double-blind, flexible dose, placebo controlled trial, subjects were community dwelling men and women 65 years old or older. Subjects had scores of 3 or more on the VES-13 (Vulnerable Elders Survey) and 20 or more on the MMSE (Mini-Mental State Examination), and 2 to 15 urgency urinary incontinence episodes and 8 or more micturitions per 24 hours on 3-day baseline diaries. Subjects randomized to fesoterodine received 4 mg once daily for 4 weeks and could then increase to 8 mg based on discussion with the investigator. Subjects receiving 8 mg could decrease the dose to 4 mg at any time (sham escalation and de-escalation for placebo). The primary outcome measure was change in daily urgency urinary incontinence episodes. Secondary outcomes included changes in other diary variables and patient reported quality of life measures. Safety evaluations included self-reported symptoms and post-void residual volume. RESULTS A total of 562 patients were randomized (mean age 75 years, 50.4% age 75 years or greater). Subjects had high rates of comorbidities, polypharmacy and functional impairment. At week 12 the fesoterodine group had significantly greater improvements in urgency urinary incontinence episodes per 24 hours (-2.84 vs -2.20, p = 0.002) and most other diary variables and quality of life, as well as a higher diary dry rate (50.8% vs 36.0%, p = 0.002). Adverse effects were generally similar to those of younger populations including risk of urinary retention. CONCLUSIONS To our knowledge this is the first antimuscarinic study in a community based, significantly older, medically complex elderly population with urgency urinary incontinence. Flexible dose fesoterodine significantly improved urgency urinary incontinence episodes and other outcomes vs placebo, and was generally well tolerated.
Collapse
Affiliation(s)
- Catherine E Dubeau
- University of Massachusetts Medical School and UMass Memorial Medical Center, Worcester, Massachusetts.
| | - Stephen R Kraus
- University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | | | | | | | | | | | | | | |
Collapse
|
23
|
|
24
|
Notz HJ, Hautumm B, Werdier D, Groves R, Odenthal KP. [Trospium chloride once daily for overactive bladder syndrome: results of a multicenter observational study]. Urologe A 2012; 52:65-70. [PMID: 23052979 DOI: 10.1007/s00120-012-2989-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND An extended release form of trospium chloride (Urivesc 60 mg® slow release capsules) was recently approved for the treatment of overactive bladder syndrome (OAB). A multicentric, prospective observational study was conducted under routine private practice conditions to assess the safety and efficacy of this treatment in this indication, as well as the effect on quality of life parameters. PATIENTS AND METHODS A total of 305 patients with OAB syndrome (mean age 60 years, 79% females) were evaluated in this prospective, non-interventional observation study. All patients received trospium chloride once daily (Urivesc® 60 mg extended release capsules) in accordance with the approved prescribing instructions. At the start of therapy and after a treatment period of 4 and 13 weeks (median) the patient urological endpoints and quality of life parameters were assessed. Safety and tolerability were evaluated from the documentation of all adverse events occurring during the entire observation period. RESULTS Mean daily frequency of micturition decreased over the treatment period with once daily trospium chloride from 11.7 ± 4.3 to 7.7 ± 2.9 per 24 h (p<0.0001). In parallel the mean individual urine volume voided increased from 169.3 ± 79.8 ml to 238.4 ± 122.0 ml (p<0.0001). The proportion of patients with incontinence fell from 36.7% at the initiation of therapy to 20.3% at the end of therapy. Furthermore, the mean number of incontinence pads used declined from 3 per day to 1 per day. More than one third of initially incontinent patients (39.3%) needed no incontinence pads at the end of the treatment period. Quality of life parameters improved significantly in all five subsections recorded (i.e. daily life, family life, sleep quality, self esteem and ability to travel). The safety and tolerability of Urivesc 60 mg extended release was good, with a particularly low incidence of mouth dryness (1% of patients) reported. No central nervous system (CNS) associated adverse events and no serious adverse events occurred. CONCLUSION As a once daily formulation prescribed under normal private practice conditions, the new trospium chloride extended-release formulation consistently demonstrated efficacy and tolerability for treatment of OBS. Treatment with once daily trospium chloride 60 mg extended release capsules significantly improved the frequency of micturition and nocturia, as well as incontinence episodes and use of absorptive pads in this patient population, accompanied by an improvement in quality of life. The reason for the good tolerability, in particular the relatively low incidence of mouth dryness, is probably due to the lower peak plasma concentration of trospium (cmax) enabled by the modified-release galenical form employed by the 60 mg extended release formulation. Once daily administration enabled enhanced compliance for the modified release formulation and associated improved tolerability. The limited access of trospium to the CNS afforded by the intact blood-brain barrier and absence of metabolic interaction potential via cytochrome P450 are established characteristics of trospium chloride. This infers a lower potential to impair cognitive function and a lower potential for metabolic interactions with concomitant medications. In the context of elderly patients and multimorbid and polypharmacy scenarios, the sum of these characteristics may afford distinct advantages in treating OAB patients.
Collapse
Affiliation(s)
- H-J Notz
- Praxis Urologie am Malkasten, Düsseldorf.
| | | | | | | | | |
Collapse
|
25
|
Summary of Anticholinergic Pharmacotherapy Available for Overactive Bladder. CURRENT BLADDER DYSFUNCTION REPORTS 2012. [DOI: 10.1007/s11884-011-0118-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
|
26
|
Pagoria D, O'Connor RC, Guralnick ML. Antimuscarinic drugs: review of the cognitive impact when used to treat overactive bladder in elderly patients. Curr Urol Rep 2012; 12:351-7. [PMID: 21607875 DOI: 10.1007/s11934-011-0198-9] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The blockade of muscarinic receptors in the management of overactive bladder (OAB) symptoms provides beneficial as well as adverse effects. The cognitive changes observed are caused by the drugs' ability to cross the blood-brain barrier and bind to muscarinic receptors within the central nervous system (CNS). To date, while not specifically testing for CNS side effects, most of the controlled efficacy trials of multiple OAB medications have not shown significant adverse effects on cognitive function. However, elderly individuals, in whom OAB is more prevalent, often are excluded from these studies. The few trials that have performed cognitive testing in healthy elderly people taking antimuscarinics have clearly shown that oxybutynin can adversely affect cognition. Darifenacin, trospium, solifenacin, and tolterodine appear to have little to no risk of causing CNS side effects in this population. However, caution needs to be used in elderly patients with preexisting dementia.
Collapse
Affiliation(s)
- Dustin Pagoria
- Department of Urology, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
| | | | | |
Collapse
|
27
|
Oefelein MG. Safety and Tolerability Profiles of Anticholinergic Agents Used for the Treatment of Overactive Bladder. Drug Saf 2011; 34:733-54. [DOI: 10.2165/11592790-000000000-00000] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
|
28
|
Paquette A, Gou P, Tannenbaum C. Systematic Review and Meta-Analysis: Do Clinical Trials Testing Antimuscarinic Agents for Overactive Bladder Adequately Measure Central Nervous System Adverse Events? J Am Geriatr Soc 2011; 59:1332-9. [DOI: 10.1111/j.1532-5415.2011.03473.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
29
|
Chancellor M, Boone T. Anticholinergics for overactive bladder therapy: central nervous system effects. CNS Neurosci Ther 2011; 18:167-74. [PMID: 22070184 DOI: 10.1111/j.1755-5949.2011.00248.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The mainstay of pharmacological treatment of overactive bladder (OAB) is anticholinergic therapy using muscarinic receptor antagonists (tertiary or quaternary amines). Muscarinic receptors in the brain play an important role in cognitive function, and there is growing awareness that antimuscarinic OAB drugs may have adverse central nervous system (CNS) effects, ranging from headache to cognitive impairment and episodes of psychosis. This review discusses the physicochemical and pharmacokinetic properties of OAB antimuscarinics that affect their propensity to cause adverse CNS effects, as observed in phase III clinical trials and in specific investigations on cognitive function and sleep architecture. PubMed/MEDLINE was searched for "OAB" plus "muscarinic antagonists" or "anticholinergic drug." Additional relevant literature was identified by examining the reference lists of papers identified through the search. Preclinical and clinical trials in adults were assessed, focusing on the OAB antimuscarinics approved in the United States. The blood-brain barrier (BBB) plays a key role in protecting the CNS, but it is penetrable. The lipophilic tertiary amines, particularly oxybutynin, are more likely to cross the BBB than the hydrophilic quaternary amine trospium chloride, for which there are very few reports of adverse CNS effects. In fact, in 2008 the US product labels for oral oxybutynin were modified to include the potential for anticholinergic CNS events and a warning to monitor patients for adverse CNS effects. Even modest cognitive impairment in the elderly may negatively affect independence; therefore, selection of an antimuscarinic OAB drug with reduced potential for CNS effects is advisable.
Collapse
Affiliation(s)
- Michael Chancellor
- Oakland University William Beaumont School of Medicine, Department of Urology, William Beaumont Hospital, Royal Oak, MI 48073, USA.
| | | |
Collapse
|
30
|
Griebling TL. TROSPIUM CHLORIDE ONCE-DAILY EXTENDED RELEASE IS EFFICACIOUS AND TOLERATED IN ELDERLY SUBJECTS (AGED ≥75 YEARS) WITH OVERACTIVE BLADDER SYNDROME. BJU Int 2011. [DOI: 10.1111/j.1464-410x.2011.10394.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|