We all know bladder medications have long-been the go-to option in the treatment of Overactive Bladder (OAB) after behavioral changes fail to achieve satisfactory results. Sure there are known issues with compliance and side-effects but those are reasonable risks to providing the best OAB care, right? Given the position of some expert groups, the answer might be, “Maybe not.”
Recently the American Urogynecologic Society (AUGS) added their collective voice to those calling for more careful prescribing of anticholinergic (antimuscarinic) medications stating that, “Given the available evidence, which has shown significant associations between anticholinergic medication use and increased risk of cognitive impairment and dementia, providers should counsel on the associated risks, prescribe the lowest effective dose, and consider alternative medications in patients at risk.”
This statement is part of AUGS Guidance Committee brief statement entitled “AUGS Consensus Statement: Association of Anticholinergic Medication Use and Cognition in Women With Overactive Bladder” published in the May/June issue of Female Pelvic Medicine & Reconstructive Surgery.
But AUGS is not the first group to warn against drugs in older patients. In the 2012 AGS Beers Criteria List for Potentially Inappropriate Medication Use in Older Adults, the American Geriatric Society recommends avoiding or using caution before prescribing anticholinergics to elderly patients citing the risk of confusion among other side-effects as potential problems as patients advance in age.
Are Bladder Medications Overprescribed in the Elderly?
In March, a presentation at the European Association of Urology Annual Meeting in London, raised questions about the number of patients prescribed antimuscarinics in the U.S. While the data is only considered preliminary, of the 12.7 million new antimuscarinic prescriptions between 2006 and 2012, an overwhelming percentage were prescribed to patients who were elderly (55.2%), female (61.7%), white (61.7%), and Medicare insured (84.1%).
Of particular concern to the researchers was the antimuscarinic drug oxybutynin, which was prescribed or continued 27% of the time with patients 65 and over. The article quotes study lead author Dr. Daniel Purcheril who said, "It's a great and effective drug for younger patients, but is a risky drug for older patient. It boosts dementia risk even when not taken indefinitely.”
The FDA recommends monitoring patients taking the drug for signs of central nervous system (CNS) problems, but the study found only 9% of those who took the drug underwent a neurological exam, though it is unclear whether patients were monitored for neurologic problems in other ways.
Are Newer Drugs Better?
While some have argued that newer antimuscarinics are safer, in this article, urologist Dr. David Staskin mentioned only trospium has been shown not to penetrate very far into the central nervous system. When speaking about the safety of other antimuscarinics he is quoted as saying, “no one has ever shown that tolterodine, darifenacin, or solifenacin is safer… The problem here is whether it would eliminate the risk to switch everyone to another antimuscarinic.”
Even as new advances in drug therapy, such as the β3-agonist, show superior 12-month adherence rates over antimuscarinics, 70% of patients still dropped the drug before one year, leaving a significant number of patients searching for other treatment options.
3rd Line Therapies Succeed When Medication Fails
Recently, a poster presented at the 2017 American Urological Association Annual Meeting by Dena Moskowitz from the Virginia Mason Center highlighted the power of specialty and subspecialty groups to expand penetration of 3rd-line therapy beyond the 5% that’s typically reported.
The AUA currently recognizes three 3rd line therapies for OAB patients who fail drug therapy. OnabotulinumtoxinA and sacral nerve stimulation both have the potential for severe risks and side-effects, whereas PTNS (percutaneous tibial nerve stimulation) has no severe side-effects.
PTNS therapy performed with Urgent PC Neuromodulation system has been proven to be effective in over 50 publications with up to 80% of patients responding to treatment. In comparison to extended-release tolterodine, 79.5% of Urgent PC patients reported cure or improvement in their symptoms, but only 54.8% of tolterodine patients reported the same. In objective improvements, Urgent PC was as effective as tolterodine for reductions in urinary frequency, urge incontinence, urge severity and nighttime voids.
Urgent PC is indicated for the treatment of Overactive Bladder and associated symptoms of urinary urgency, urinary frequency and urge incontinence. Treatment with Urgent PC is contraindicated for patients with pacemakers or implantable defibrillators, patients prone to excessive bleeding, patients with nerve damage that could impact either percutaneous tibial nerve or pelvic floor function or patients who are pregnant or planning to become pregnant during the duration of the treatment. Most patients don't experience side-effects. If side-effects occur, they are typically temporary and include mild pain and skin inflammation at or near the stimulation site. Caution: Federal law (USA) restricts this device to sale by or on the order of a physician. For complete instructions for use, storage, warnings, indications, contraindications, precautions, adverse reactions and disclaimer of warranties, please refer to the insert accompanying each product or online at www.cogentixmedical.com. Models are for illustrative purpose only. Urgent is a registered trademark of Cogentix Medical. © 2017 Cogentix Medical. All rights reserved.