A calcium blocking and anticholinergic agent (terodiline) in the treatment of detrusor hyperreflexia: a placebo-controlled, cross-over trial

Effects of terodiline on urinary incontinence among older non-institutionalized women. Terodiline in the Elderly American Multicenter Study Group

OBJECTIVE

To determine the effectiveness of terodiline, a drug with calcium antagonist and anticholinergic properties, on the frequency of incontinence in older non-institutionalized women.

DESIGN

Randomized, placebo-controlled, parallel-group, double-blind trial.

SETTING

Twelve outpatient clinics across the United States affiliated with programs in either geriatrics, gynecology, or urology.

PARTICIPANTS

Ninety-eight women, age 60 or older, with symptoms of urge incontinence and self-reported frequency of incontinence four or more times per week and involuntary bladder contractions on dual-channel water cystometry.

MAIN OUTCOME MEASURES

Self-reported urinary frequency, urgency, number of incontinence episodes, and number of heavily soaked pads.

RESULTS

Eighty-one women, average age 71, completed the trial, 40 in the active drug group, 41 in the placebo group. Incontinence frequency and the number of heavily soaked pads were reduced in the active drug group by 64% and 55%, respectively, and by 21% (P = 0.002) and 9% (P = 0.04) in the placebo group. No patients dropped out due to adverse effects. An intention-to-treat analysis of all 98 patients yielded the same conclusion.

CONCLUSION

Terodiline is highly effective in reducing incontinence in older, noninstitutionalized women with urge incontinence. Because of its potential association with polymorphic ventricular tachycardia (torsades de pointes), terodiline must undergo further testing to define its safety before it can be recommended for clinical use in the incontinent geriatric population.

Terodiline causes polymorphic ventricular tachycardia due to reduced heart rate and prolongation of QT interval

Recent reports have suggested an association between terodiline hydrochloride and cardiac arrhythmias. We report 4 patients presenting over a six month period who developed polymorphic ventricular tachycardia (polymorphic VT) while receiving treatment with this agent. In each case there was prolongation of QT interval on electrocardiogram (ECG). Two patients had hypokalaemia associated with diuretic therapy. In the 3 cases in which follow-up ECG was available, QT interval returned to normal after discontinuation of terodiline. In order to define the effects of terodiline on corrected QT interval (QTc) and heart rate in the elderly, a prospective study was performed in 8 elderly in-patients treated with terodiline for urinary incontinence. After 7 days treatment with terodiline 12.5 mg twice daily, there was a significant increase in QT by a mean of 29 ms, QTc by 15 ms and a decrease in resting heart rate by a mean of 6.7 beats.min-1. Terodiline increases QTc and reduces resting heart rate in elderly patients. Both these effects may be associated with polymorphic VT, a potentially life threatening arrhythmia. This drug should be avoided in patients with other known risk factors for polymorphic VT, particularly hypokalaemia and cardiac disease.

Terodiline. A review of its pharmacological properties, and therapeutic use in the treatment of urinary incontinence

Terodiline has both anticholinergic and calcium antagonist properties and, as a result, effectively reduces abnormal bladder contractions caused by detrusor instability. When administered to adult patients with urge incontinence (generally as a 25mg twice-daily dose) terodiline reduces diurnal and nocturnal micturition frequency and incontinence episodes. In studies also assessing cystometric parameters, bladder volume at first urge and bladder capacity are increased. Children with diurnal enuresis respond similarly to a daily 25mg dose. Several studies have shown that terodiline 50 mg/day is preferred by patients when compared with emepronium 600 mg/day or flavoxate 600 mg/day, and tends to reduce voluntary micturition frequency and episodes of incontinence more effectively than these drugs. Terodiline is well tolerated in short and long term (up to 3.5 years) studies. Anticholinergic effects are most commonly reported; other adverse effects occur equally during terodiline and placebo treatment. Thus, terodiline is effective and well tolerated in patients with urge incontinence or neurogenic bladder dysfunction, and will claim an important place in the treatment of such patients in light of the limitations of alternative therapies.

Tolerability and steady-state pharmacokinetics of terodiline and its main metabolites in elderly patients with urinary incontinence

The elderly form an important target group for the treatment of urinary urge incontinence with drugs such as terodiline (Mictrol, Terolin). In order to evaluate its steady-state pharmacokinetics and tolerability in geriatric patients terodiline 12.5 mg b.d. was given to 28 hospitalized patients with urinary incontinence (mean age 85 years) for six weeks. The patients were monitored during the study and for 6 weeks afterwards, blood samples being taken at regular intervals. In addition to these multi-diseased and polymedicated patients, a small, homogenous group of healthy volunteers (mean age 40 years) was studied as a reference group, being given terodiline 12.5 mg b.d. for 2 weeks. Terodiline was generally well tolerated by the patients and no significant change in blood pressure or heart rate were found. One patient was withdrawn due to adverse effects. The mean terminal half-life of terodiline was 131 h and the clearance after oral administration (clearance/systemic availability) was 39 ml.min-1. The corresponding figures for the healthy volunteers were 57 h and 75 ml.min-1. The average steady-state serum concentration was 518 micrograms.l-1 in the geriatric patients and 238 micrograms.l-1 in the healthy volunteers. Steady-state was reached within 3 weeks in 20 of the 28 patients and within 5 weeks in 7 patients. In the geriatric patients the steady-state serum concentration of the main metabolite p-hydroxyterodiline, during the last three weeks on terodiline was 45 micrograms.l-1, 57 micrograms.l-1, and 45 micrograms.l-1, respectively, and a similar value was found in the healthy volunteers, 47 micrograms.l-1.(ABSTRACT TRUNCATED AT 250 WORDS)

Prazosin treatment of neurological patients with detrusor hyperreflexia and bladder emptying disability

In a placebo-controlled clinical trial with cross-over design the effect of alpha-adrenoceptor blockade with prazosin was studied in 18 neurological patients with detrusor hyperreflexia and bladder emptying disability. During active treatment both the distance to maximal urethral closure pressure (MUCP) and MUCP were significantly reduced. In addition, the volume at first bladder contraction was increased. The urodynamic parameters measured during voiding were unaffected. We conclude that prazosin decreases detrusor hyperreflexia but only in rare cases may benefit bladder emptying in these patients.