Part 4 in the series,OAB Treatment Plans: What Works?When a patient presents with symptoms of Overactive Bladder, there are a lot of things that come to mind. It is not always as easy as following the AUA/SUFU Guideline for OAB. These guidelines are a great template for finding the right path to take your patients through. However, keep in mind all the little differences patients present with as this may determine successful outcomes. Based on my experience, I have developed a series of blog posts that discuss individualizing treatment plans for the OAB patient.
Balancing Efficacy and Side Effects
There are many medications on the market for OAB. They all have efficacy to some extent. Some have more side effects than others and some are dosed differently. The route of administration runs the gamut of pill, capsule, patch or gel. Most of them have issues especially their use in the elderly. Some cause very high percentages of constipation and dry mouth and yet others carry a blurred vision and CNS side effect that can be devastating for these same elderly, resulting in catastrophic co-morbidities. Are we making sure we know the make-up of all these drugs and which patients would benefit most by each one?
In my practice I have given and ordered every OAB drug on the market. I have published and spoken about their uses and efficacies. As newer drugs came on the market, there were different applications in different types of patients. Trying medications prior to moving to 3rd line therapy in OAB is important as the AUA Guideline points out. At this writing, there are two classes of medications for OAB, the anti-cholinergic (anti-muscarinics) and the beta-3 agonist. Both classes need to be considered.
When 3rd Line Therapy May Supersede Use of Medications in OAB
Obviously, allergy is the first and foremost consideration for the prescription of any medication. An allergy to these medications is good reason to forego them. Keep in mind that allergies, adverse reactions and/or sensitivities should all be documented as such. Patients will often make the determination for you whether they will try a drug or not.
Anti-cholinergic agents can have varying degrees of influence on the gut. Therefore, if there are problems involving slow gastric emptying, these drugs avoided. This is especially true for chronic idiopathic constipation with or without a history of bowel obstruction.
The drying effect resulting from the metabolism of anti-cholinergics in multiple receptor sites throughout the body can have devastating effects in certain patients. People who have difficulty talking, sleeping and are prone to tooth decay due to the effects of dry mouth should not be taking these drugs. If oral moisturizers help and the patient is willing, it is an option. Patients with Sjogrens Syndrome should also not be prescribed anti-cholingerics
Narrow angled glaucoma is also a contraindication. It is much less often diagnosed than wide angled glaucoma. Contact your patient’s ophthalmologist for accurate diagnosis and blessings for the prescription.
Also be careful and monitor patients with elevated post void residuals as anti-cholinergics can also cause a weakening of bladder contractions and exacerbate increased amounts of post void residuals where dangerously high levels can lead to worse problems.
Central nervous system effects (CNS) can also have devastating results in the elderly. Be careful to understand any co-morbidities that might be exacerbated by these side effects.
Beta 3 agonist (Myrbetriq) can be a very effective medication. Its action is different as it helps more with storage of urine versus decreasing urgency and unwanted bladder contractions. It carries with it few side effects. Caution should be taken in patients on multiple blood pressure medications whose pressures are not easily controlled. Myrbetriq has been found to cause a slight increase in blood pressure according to their clinical trials.
Points to Remember When it Comes to Overactive Bladder Medications
- Medications can be a powerful treatment with terrific efficacy if given to the right patient in the right dosage.
- Trying at least two different anti-cholinergics can be helpful in finding the one that eases symptoms of urgency, frequency and urge incontinence. However, the literature tells us that trying all of them may not have any change in efficacy if the first two do not help.
- Note allergies
- Know that each medication has its place and has documented efficacy
- Identify the differences between generic and branded drugs
- Have a keen awareness of all side effects
- Monitor your patients’ progress with bladder records
- Document medications used, patient responses and/or reasons why you are not prescribing medications when you move to 3rd line therapy for OAB
When medications do not help your patient reach their goals for treatment, it is time to consider 3rd line therapy as an adjunct to current treatments or a stand-alone therapy. The next question is: Which patients are right for which 3rd line therapies, a topic that will be covered next in the series.
Next in the series
Part 5: Choosing a 3rd Line Therapy in Overactive Bladder Treatment
Watch for it next week or subscribe to the blog to ensure you don’t miss any posts in this 7-part series.
This blog post reflects the opinions and experience of Leslie Wooldridge, a long-standing user of the Urgent PC Neuromodulation System, and was produced under a paid consulting agreement with Cogentix Medical.
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 purposes only. Urgent is a registered trademark of Cogentix Medical © 2016 Cogentix Medical. All rights reserved.