How to Approach Antimuscarinic Medications During PTNS Treatment
There are a couple of scenarios that resonate with patients who are refractory to conventional treatments for OAB.
There is that patient for whom you have done absolutely everything. They are compliant with behavioral interventions and have tried a multitude of antimuscarinic medications. Somehow they are just not where they want to be. PTNS would be the next obvious option.
My first strategy is to keep them on the last antimuscarinic being used until the 5th treatment. Then I wean them off their medication. My strategy is to achieve that of a placebo effect. We are weaning them off daily doses while they think they are getting adequate doses. When they are completely off the drugs and they are still doing great, they are happy. In my experience, I have found that the effect of just stopping animuscarinics too often presents with a show of panic for the patient. We always want to invest confidence in our patients that we will not let them fall backwards.
That brings me to my next scenario. So you have weaned your patient off his/her anitmuscarinic medication. Most of the time they will continue to improve, get even better and be very happy patients. Then, there are those who will fall back into where they were when they started PTNS. Better, but not great.
Restart their medication. Keep in mind there are 20% of our patients who are refractory to any and all treatments. There isn’t data on outcomes of combining these treatments in the published literature. However, in our clinic, we do it when we need to and have positive results. It works. Insurance pays. Unfortunately there are those patients who need more than one approach to reach their goals. We have the tools. Let's use them!
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