Pharmacological management of overactive bladder : a systematic and critical review of published economic evaluations

Urologic symptoms and functional neurologic disorders

The term functional urologic disorders covers a wide range of conditions related broadly to altered function rather than structure of the lower urinary tract, mainly of impaired urine voiding or storage. Confusingly, for a neurologic readership, these disorders of function may often be due to a urologic, gynecologic, or neurologic cause. However, there is a subset of functional urologic disorders where the cause remains uncertain and, in this chapter, we describe the clinical features of these disorders in turn: psychogenic urinary retention; Fowler's syndrome; paruresis (shy-bladder syndrome); dysfunctional voiding; idiopathic overactive bladder, and interstitial cystitis/bladder pain syndrome. Some of these overlap in terms of symptoms, but have become historically separated. Psychogenic urinary retention in particular has now largely been abandoned as a concept, in part because of the finding of specific urethral electromyogram findings in patients with this symptom now described as having Fowler's syndrome, and their successful treatment with sacral neurostimulation. In this chapter we review the poorly researched interface between these "idiopathic" functional urologic disorders and other functional disorders (e.g., irritable-bowel syndrome, fibromyalgia) as well as specifically functional neurologic disorders. We conclude that there may be a relationship and overlap between them and that this requires further research, especially in those idiopathic functional urologic disorders which involve disorders of the urethral sphincter (i.e., voluntary muscle).

Efficacy and safety of onabotulinumtoxinA in treating neurogenic detrusor overactivity: a systematic review and meta-analysis

Background:

OnabotulinumtoxinA is widely used in treating neurogenic detrusor overactivity (NDO). We carried out a systematic review and meta-analysis to assess the efficacy and safety of the drug for treating NDO.

Methods:

We searched the following databases: Medline, EMBASE, and the Cochrane Controlled Trials Register. All published randomized double-blind, placebo-controlled trials of onabotulinumtoxinA for the treatment of NDO were identified in the analysis. The reference lists of the retrieved studies were also investigated.

Results:

Four publications involving a total of 807 patients were identified in the analysis, which compared onabotulinumtoxinA with placebo. The changes of the mean number of urinary incontinence per week (the standardized mean difference [SMD] = −10.91, 95% confidence intervals [CIs] = −14.18–−7.63, P < 0.0001); maximum cystometric capacity (SMD = 146.09, 95% CI = 126.19–165.99, P < 0.0001) and maximum detrusor pressure (SMD = −32.65, 95% CI = −37.83–−27.48, P < 0.0001) indicated that onabotulinumtoxinA was more effective than the placebo, despite the doses of onabotulinumtoxinA. Safety assessments primarily localized to the urinary tract indicated onabotulinumtoxinA were often associated with more complications. Urinary tract infections (relative risk [RR] =1.48, 95% CI = 1.20–1.81, P = 0.0002); hematuria (RR = 1.81, 95% CI = 1.00–3.24, P = 0.05) and urinary retention (RR = 5.87, 95% CI = 3.61–9.56, P < 0.0001).

Conclusions:

This meta-analysis indicates that onabotulinumtoxinA to be an effective treatment for NDO with side effects primarily localized to urinary tract.

Efficacy and safety of imidafenacin for overactive bladder in adult: a systematic review and meta-analysis

PURPOSE

We carried out a systematic review and meta-analysis to assess the efficacy and safety of imidafenacin for treating overactive bladder in adult.

METHODS

A literature review was performed to identify all published randomized placebo-controlled trials of imidafenacin for the treatment of OAB. The search included the following databases: MEDLINE, EMBASE. The reference lists of retrieved studies were also investigated.

RESULTS

Five publications involving a total of 1,428 patients were used in the analysis, which compared imidafenacin with propiverine and solifenacin. We found that imidafenacin was effective in treating OAB in our meta-analysis, which was similar to propiverine in its efficacy. The mean number of UI per week (the standardized mean difference (SMD) = 1.23, 95% CI -0.19 to 2.65, p = 0.09), the mean number of urgency episodes per day (SMD = 0.26, 95% CI -0.11 to 0.63, p = 0.17), the mean number of micturitions per day (SMD = 0.01, 95% CI -0.30 to 0.31, p = 0.96), and the mean urine volume (ml) per micturition (SMD = -13.04, 95% CI -20.45 to -5.62, p = 0.0006) indicated that imidafenacin was similar to propiverine in its efficacy. Mean OABSS (SMD = 0.48, 95% CI -0.08 to 1.03, p = 0.09) indicated that imidafenacin was also similar to solifenacin in its efficacy. Besides, imidafenacin was better tolerated than propiverine in the safety, indicated by dry mouth (OR 0.73, 95% CI 0.54-0.98, p = 0.04) and any adverse events (OR 0.63, 95% CI 0.46-0.88, p = 0.006). Moreover, imidafenacin was also better tolerated than solifenacin in the safety, indicated by constipation (OR 0.21, 95% CI 0.08-0.53, p = 0.001) and any adverse events (OR 0.33, 95% CI 0.15-0.71, p = 0.004).

CONCLUSIONS

This meta-analysis indicates that imidafenacin was similar to propiverine or solifenacin in its efficacy for OAB and was better tolerated than propiverine or solifenacin in the safety for OAB. We conclude that imidafenacin is preferable to propiverine or solifenacin from a perspective of safety.

Patient preferences for different severities of and treatments for overactive bladder

OBJECTIVE

: Symptoms of overactive bladder (OAB) can have profound effects on women's quality of life. However, quantitative data on how women value these symptoms and their treatments are limited. We sought to assess women's preferences, which are referred to as utilities, for different severities of and treatment options for OAB.

METHODS

: Eighty women-40 with OAB symptoms and 40 without OAB-were recruited from urogynecology and urology practices at an academic institution from April to November 2009. A single, trained interviewer administered a computerized preference elicitation tool to measure preferences for 4 OAB severity levels (urgency/frequency and mild, moderate, and severe urge incontinence), as well as 3 OAB treatments with and without adverse effects or complications, which included (1) anticholinergic medications, (2) botulinum toxin injection, and (3) sacral neuromodulation. Preferences were assessed using the time trade-off (TTO) method.

RESULTS

: Median TTO scores for OAB decreased as severity increased (urgency/frequency, 0.88; mild, 0.92; moderate, 0.85; severe, 0.73). Median TTO scores assigned to anticholinergic medications were higher (0.93) than those for botulinum (0.88) and sacral neuromodulation (0.85), and adverse effects or complications lowered the utilities for each treatment (anticholinergics, 0.88; botulinum, 0.75; and sacral neuromodulation, 0.78).

CONCLUSIONS

: Women view symptoms of OAB, particularly moderate or severe symptoms, as being quite burdensome. The degree of invasiveness and the number of adverse effect/complications are important contributors to the utilities that women assign to the various treatment options.

Overactive Bladder Syndrome: The Social and Economic Perspective

Overactive bladder syndrome (OAB) is a highly prevalent condition associated with a significant impairment of patients’ Quality of Life (QoL) because of its adverse effects on social, sexual, interpersonal, and professional functions. Cost-of-illness analyses showed the huge economic burden related to OAB for patients, public healthcare systems, and society, secondary to both direct and indirect costs. These types of cost analyses, however, exclude intangible costs related to QoL impairment. Recently, many novel therapies have been introduced, arising the need to apply the modern methodology of Health Technology Assessment (HTA) to new therapies in order to evaluate objectively their value in terms of both improvement in length/Quality of Life and costs. By producing information on the clinical, economic, organizational, social and ethical impact of health technologies, HTA has been used worldwide to inform decision makers at different levels in health systems. The HTA approach demonstrated, worldwide, to be a useful approach to increase the level of appropriateness in the use of medical technology and, as a consequence of that, of resources. Health utilities are instruments that allow a measurement of QoL and its integration in the economic evaluation using the Quality-of-life-Adjusted-Life-Years (QALYs) model and cost-utility analysis. The development of suitable instruments for quantifying utility in the specific group of OAB patients is vitally important to extend the application of cost-utility analysis in OAB and to guide healthcare resources allocation for this disorder. Studies are required to define the cost-effectiveness of available pharmacological and non-pharmacological therapy options.

Social, economic, and health utility considerations in the treatment of overactive bladder

Overactive bladder (OAB) is a highly prevalent urinary syndrome with a profound impact on quality of life (QoL) of affected patients and their family because of its adverse effects on social, sexual, interpersonal, and professional function. Cost-of-illness analyses showed the huge economic burden related to OAB for patients, public healthcare systems, and society, secondary to both direct and indirect costs; however, intangible costs related to QoL impact are usually omitted from these analyses. Recently many novel treatment modalities have been introduced and the need to apply the modern methodology of health technology assessment to these treatment strategies was immediately clear in order to evaluate objectively their value in term of both improvement in length/quality of life and costs. Health utilities are instruments that allow a measurement of QoL and its integration in the economic evaluation using the quality-adjusted life-years model and cost-utility analysis. The development of suitable instruments for quantifying utility in the specific group of OAB patients is vitally important to extend the application of cost-utility analysis in OAB and to guide healthcare resources allocation for this disorder. Studies are required to define the cost-effectiveness of available pharmacological and nonpharmacological therapy options for this disorder.

Social, economic, and health utility considerations in the treatment of overactive bladder

Overactive bladder (OAB) is a highly prevalent urinary syndrome with a profound impact on quality of life (QoL) of affected patients and their family because of its adverse effects on social, sexual, interpersonal, and professional function. Cost-of-illness analyses showed the huge economic burden related to OAB for patients, public healthcare systems, and society, secondary to both direct and indirect costs; however, intangible costs related to QoL impact are usually omitted from these analyses. Recently many novel treatment modalities have been introduced and the need to apply the modern methodology of health technology assessment to these treatment strategies was immediately clear in order to evaluate objectively their value in term of both improvement in length/quality of life and costs. Health utilities are instruments that allow a measurement of QoL and its integration in the economic evaluation using the quality-adjusted life-years model and cost-utility analysis. The development of suitable instruments for quantifying utility in the specific group of OAB patients is vitally important to extend the application of cost-utility analysis in OAB and to guide healthcare resources allocation for this disorder. Studies are required to define the cost-effectiveness of available pharmacological and nonpharmacological therapy options for this disorder.

Survey assessment of continuation of and satisfaction with pharmacological treatment for urinary incontinence

PURPOSE

To evaluate treatment satisfaction and compliance with pharmacologic therapy in urinary incontinence patients.

MATERIALS AND METHODS

An online survey was returned by 1447 individuals from a nationwide panel of adults who had previously reported treatment for incontinence symptoms and agreed to participate in survey research. Data on demographics, incontinence severity, treatment compliance, and satisfaction were obtained. Logistic regression was used to estimate crude and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for characteristics associated with pharmacologic treatment dissatisfaction and discontinuation.

RESULTS

The sample was predominantly female (87%) and white (93%) with a mean age of 56 years. On average, patients urinated 10 times/day and experienced 16 wetting accidents in the week preceding survey. Overall, 25% reported being somewhat or very dissatisfied with treatment. Those who reported a severe effect of incontinence on their lives were most likely to be dissatisfied (OR = 2.82, 95% CI = 1.89-4.23). Discontinuation of drug treatment was reported by 45% of study subjects, with major reasons being poor efficacy (in 41.3% of discontinuations), side effects (22.4%), and cost (18.7%). Predictors for discontinuation included young age (OR = 1.8, 95% CI = 1.2-2.8), experiencing symptoms for 10 or more years (OR = 1.5, 95% CI = 1.1-2.0), and experiencing more than 16 wetting accidents in the last week (OR = 1.6, 95% CI = 1.3-2.1).

CONCLUSIONS

This online survey of self-selected incontinence patients indicated that almost half of those who have received drug treatment for incontinence had discontinued primarily because of lack of efficacy, side effects, and cost concerns. Our findings suggest a substantial degree of unmet need from current therapy among those with incontinence.

New transdermal bioadhesive film containing oxybutynin: In vitro permeation across rabbit ear skin

Oxybutynin is used extensively in the treatment of patients with overactive bladder. The aim of this work was to realize and test in vitro a new transdermal bioadhesive film containing oxybutynin. Transdermal films were prepared by dissolving in water an adhesive (Plastoid), a film-forming polymer (polyvinyl alcohol), a plasticizer (sorbitol) and the drug. The mixture was then spread on siliconized paper and oven-dried. Permeation experiments were conducted in Franz-type diffusion cells using rabbit ear skin as barrier. The donor compartment contained a water solution, the prepared film (with or without backing) or the commercial patch (Oxytrol). The experiments were performed for 24h. Oxybutynin showed good permeation characteristics across the skin. When the film was applied in occlusive conditions the release profiles were much higher than in non-occlusive conditions, reaching 50% of drug permeated after 24h. Compared to the commercial patch Oxytrol, the film was more efficient suggesting that a smaller area or a lower drug loading could be employed. The results obtained show that the bioadhesive film can be a promising and innovative therapeutic system for the transdermal administration of oxybutynin.

The Current and Future Burden and Cost of Overactive Bladder in Five European Countries

OBJECTIVE

To estimate and compare the current and future direct cost of overactive bladder (OAB) to the health care systems of five European countries.

METHOD

A health economic model was created to estimate the number of people currently affected by OAB symptoms, the expected number to be affected in the future, and the resultant economic burden on health care systems in Germany, Italy, Spain, Sweden, and the United Kingdom.

RESULTS

The model estimated that in 2000, 20.2 million people over age 40 in the five countries experienced the symptoms of OAB; 7 million of these had urgency with urge incontinence. This figure is expected to rise to 25.5 million by 2020, including 9 million who will have urgency with urge incontinence. Average annual direct costs of OAB management ranged from euro269 to euro706 per patient per year. The largest cost was the use of incontinence pads, accounting for an average of 63% of the annual per patient cost of OAB management. Total cost to health care systems across all five countries was estimated at euro4.2 billion in 2000, and by 2020, the expected total cost was estimated to be euro5.2 billion, an increase of euro1 billion (26%).

CONCLUSION

OAB is prevalent, with a substantial direct cost that is anticipated to increase in the future in line with aging populations. The overall burden, including indirect costs, may be considerably larger, and will fall predominantly on the elderly OAB population with urge incontinence. Recommended medical treatments could help manage those costs and should be evaluated.