Persistence and Adherence with Mirabegron versus Antimuscarinic Agents in Patients with Overactive Bladder: A Retrospective Observational Study in UK Clinical Practice

Update on the management of overactive bladder

Overactive bladder (OAB) syndrome is a common condition characterised by urinary urgency, with or without urgency incontinence, frequency and nocturia, in the absence of any other pathology. Clinical diagnosis is based upon patient self-reported symptomology. Currently there is a plethora of treatments available for the management of OAB. Clinical guidelines suggest treatment via a multidisciplinary pathway including behavioural therapy and pharmacotherapy, which can be commenced in primary care, with referral to specialist services in those patients refractory to these treatments. Intradetrusor botulinum A and sacral neuromodulation provide safe and efficacious management of refractory OAB. Percutaneous tibial nerve stimulation and augmentation cystoplasty remain available and efficacious in a select group of patients. Unfortunately, there remains a high rate of patient dissatisfaction and discontinuation in all treatments and thus there remains a need for emerging therapies in the management of OAB.

Mirabegron has longer treatment persistence than antimuscarinics: Real-world data from a Korean national cohort database

AIMS

To descriptively evaluate treatment persistence among adults who received mirabegron or antimuscarinics in South Korea.

METHODS

This study involved a retrospective analysis of the Health Insurance Review and Assessment (HIRA) database. Patients (≥18 years) who had a new prescription for an overactive bladder (OAB) target medication (mirabegron/antimuscarinic) within an 8-month index period (July 1, 2015-February 29, 2016) were included. The date when the target (index) medication was dispensed was the index date. The 6-month period before the index date was used to assess patient eligibility. A 12-month post-index period was used to assess medication persistence, which was defined as the time to discontinuation. Overall data were analyzed and the results were also stratified by age group (≤65, >65 years), sex, or prior OAB medication experience. Persistence rates were calculated after the 1st, 3rd, 6th, 9th, and 12th months.

RESULTS

A data set of 52 722 cases was obtained (mirabegron: 11 424, antimuscarinics: 41 298). The mean age was 60.9 ± 16.1 years and the majority of the patients were female (30 862 [58.5%] patients). Median persistence was longer with mirabegron (51 days) versus antimuscarinics (25 days). The persistence rate with mirabegron was higher throughout the study compared with all the antimuscarinics (12-month data: 13.5% and 4.9%, respectively). Longer treatment persistence was noted in older, male, and treatment-experienced patients.

CONCLUSION

The results from the HIRA database showed that persistence was longer with mirabegron than with antimuscarinics in South Korea. This finding may help inform clinical decision-making within the South Korean healthcare system.

The use of mono- and combination drug therapy in men and women with lower urinary tract symptoms (LUTS) in the UK: a retrospective observational study

BACKGROUND

Combination drug therapy for lower urinary tract symptoms (LUTS) is beneficial to selected patients and recommended by guidelines. Patterns of real-world LUTS drug use, especially combination drug therapy, have not been studied extensively. Moreover, further understanding of the recent landscape is required following the introduction of the beta-3-adrenoceptor agonist mirabegron in the UK in 2013 for overactive bladder (OAB). The objective was to describe mono- and combination drug therapy use for LUTS in patients in UK clinical practice.

METHODS

This was a retrospective, descriptive, observational database study using UK Clinical Practice Research Datalink GOLD and linked databases. Men and women ≥ 18 years with a first prescription for any LUTS drug from 2014 to 2016 with ≥ 12 months continuous enrollment pre- and post-index date were included. Primary endpoints were mono- or combination drug therapy use for LUTS in male and female cohorts. Secondary endpoints were description of treatment prescribed, treatment persistence and patient demographics. Data were analyzed descriptively. Sub-cohorts were defined by drugs prescribed at index date.

RESULTS

79,472 patients (61.3% male) were included, based on index treatments. Of all men, 82.5% received any benign prostatic obstruction (BPO) drug, 25.4% any OAB drug, and 7.9% any BPO drug plus any OAB drug. As either mono- or combination drug therapy, 77.1% received an alpha-blocker, 18.9% a 5-alpha reductase inhibitor, 23.9% an antimuscarinic agent, and 2.1% mirabegron. Of all women, 94.5% received any OAB drug, 6.0% duloxetine, and 0.5% any OAB drug plus duloxetine. As either mono- or combination drug therapy, 87.7% received an antimuscarinic, and 9.7% mirabegron. In men or women receiving OAB treatment, approximately 2.5% received combination drug therapy with an antimuscarinic agent and mirabegron. For OAB drug monotherapies, mirabegron had the highest persistence in both male and female cohorts.

CONCLUSIONS

This study provides a better understanding of the recent landscape of LUTS drug use in UK clinical practice. It highlights potential undertreatment of storage symptoms in men with LUTS and the low use of combination OAB treatments.

Comparison of antimuscarinic drugs to beta adrenergic agonists in overactive bladder: A literary review

BACKGROUND

The purpose of this study was to carry an extended literature review to compare antimuscarnics with beta adrenergic agonists (mirabegron) in treatment of overactive bladder.

MATERIALS AND METHODS

A literature review was carried out, using key words in different databases including MEDLINE, PUBMED, and EMBASE. All relevant published articles during last 5 years with full texts available were included in this review for critical analysis and evaluation. In total, there were 20 studies including 7 systemic reviews, 6 retrospective cohort, 3 prospective cohort, 2 randomized controlled trials, and 2 cross sectional studies.

RESULTS

After critical evaluation the results were considered under parameters of efficacy, adverse effects, adherence and persistence, tolerability, cost-effectiveness. In 9 studies efficacy was evaluated, 5 studies dealt with adverse effects, same number evaluated adherence and persistence. Cost effectiveness was compared in 3 and same number of studies also compared tolerability.

CONCLUSIONS

To conclude, we found mirabegron is as efficacious as any other antimuscarnics, has better tolerability (including elderly), has better adverse effect profile, is cost effective, has better persistence and adherence rates at 12 months.

The prostaglandin pathway is activated in patients who fail medical therapy for benign prostatic hyperplasia with lower urinary tract symptoms

BACKGROUND

Little is known about how benign prostatic hyperplasia (BPH) develops and why patients respond differently to medical therapy designed to reduce lower urinary tract symptoms (LUTS). The Medical Therapy of Prostatic Symptoms (MTOPS) trial randomized men with symptoms of BPH and followed response to medical therapy for up to 6 years. Treatment with a 5α-reductase inhibitor (5ARI) or an alpha-adrenergic receptor antagonist (α-blocker) reduced the risk of clinical progression, while men treated with combination therapy showed a 66% decrease in risk of progressive disease. However, medical therapies for BPH/LUTS are not effective in many patients. The reasons for nonresponse or loss of therapeutic response in the remaining patients over time are unknown. A better understanding of why patients fail to respond to medical therapy may have a major impact on developing new approaches for the medical treatment of BPH/LUTS. Prostaglandins (PG) act on G-protein-coupled receptors (GPCRs), where PGE₂ and PGF₂ elicit smooth muscle contraction. Therefore, we measured PG levels in the prostate tissue of BPH/LUTS patients to assess the possibility that this signaling pathway might explain the failure of medical therapy in BPH/LUTS patients.

METHOD

Surgical BPH (S-BPH) was defined as benign prostatic tissue collected from the transition zone (TZ) of patients who failed medical therapy and underwent surgical intervention to relieve LUTS. Control tissue was termed Incidental BPH (I-BPH). I-BPH was TZ obtained from men undergoing radical prostatectomy for low-volume, low-grade prostatic adenocarcinoma (PCa, Gleason score ≤ 7) confined to the peripheral zone. All TZ tissue was confirmed to be cancer-free. S-BPH patients divided into four subgroups: patients on α-blockers alone, 5ARI alone, combination therapy (α-blockers plus 5ARI), or no medical therapy (none) before surgical resection. I-BPH tissue was subgrouped by prior therapy (either on α-blockers or without prior medical therapy before prostatectomy). We measured prostatic tissue levels of prostaglandins (PGF_2α , PGI₂ , PGE₂ , PGD₂ , and TxA₂ ), quantitative polymerase chain reaction levels of mRNAs encoding enzymes within the PG synthesis pathway, cellular distribution of COX1 (PTGS1) and COX2 (PTGS2), and tested the ability of PGs to contract bladder smooth muscle in an in vitro assay.

RESULTS

All PGs were significantly elevated in TZ tissues from S-BPH patients (n = 36) compared to I-BPH patients (n = 15), regardless of the treatment subgroups. In S-BPH versus I-BPH, mRNA for PG synthetic enzymes COX1 and COX2 were significantly elevated. In addition, mRNA for enzymes that convert the precursor PGH₂ to metabolite PGs were variable: PTGIS (which generates PGI₂ ) and PTGDS (PGD₂ ) were significantly elevated; nonsignificant increases were observed for PTGES (PGE₂ ), AKR1C3 (PGF_2α ), and TBxAS1 (TxA₂ ). Within the I-BPH group, men responding to α-blockers for symptoms of BPH but requiring prostatectomy for PCa did not show elevated levels of COX1, COX2, or PGs. By immunohistochemistry, COX1 was predominantly observed in the prostatic stroma while COX2 was present in scattered luminal cells of isolated prostatic glands in S-BPH. PGE₂ and PGF_2α induced contraction of bladder smooth muscle in an in vitro assay. Furthermore, using the smooth muscle assay, we demonstrated that α-blockers that inhibit alpha-adrenergic receptors do not appear to inhibit PG stimulation of GPCRs in bladder muscle. Only patients who required surgery to relieve BPH/LUTS symptoms showed significantly increased tissue levels of PGs and the PG synthetic enzymes.

CONCLUSIONS

Treatment of BPH/LUTS by inhibition of alpha-adrenergic receptors with pharmaceutical α-blockers or inhibiting androgenesis with 5ARI may fail because of elevated paracrine signaling by prostatic PGs that can cause smooth muscle contraction. In contrast to patients who fail medical therapy for BPH/LUTS, control I-BPH patients do not show the same evidence of elevated PG pathway signaling. Elevation of the PG pathway may explain, in part, why the risk of clinical progression in the MTOPS study was only reduced by 34% with α-blocker treatment.

Efficacy and safety of onabotulinumtoxin A injection in male patients with detrusor overactivity after stress urinary incontinence surgery

INTRODUCTION AND OBJECTIVE

The use of onabotulinumtoxin A (BoNT-A) injection in male patients with detrusor overactivity (DO) after stress urinary incontinence (SUI) surgery has been scarcely described. Our aim was to assess results of this treatment in this specific population.

MATERIALS AND METHODS

Retrospective analysis of men with previous SUI surgery who had been treated with a first injection of 100U BoNT-A because of DO since 2010 in our department. Treatment response was assessed with the Treatment Benefit Scale: 1) greatly improved; 2) improved; 3) not changed; 4) worsened after treatment (Treatment Benefit Scale 1 or 2: treatment response). Complications were classified according to the Clavien-Dindo classification. Treatment continuation was considered present if, at the last visit, patients had received a BoNT-A injection within the preceding 12 months. Pre- and post-treatment urodynamic variables were compared.

RESULTS

Eighteen patients were included, median age 71.1 (59.1-83.5) years. Twelve (66.7%) patients reported response to treatment. Two (11.1%) complications were detected: urinary retention requiring clean intermittent catheterization (Clavien-Dindo 2). No complications related to previous SUI surgery were detected. Fifteen (83.3%) patients had a follow-up>12 months (median follow-up 57 [15-89] months) and all of them had discontinued treatment at the end of follow-up. Urodynamic studies showed significant improvement in terms of DO and bladder compliance.

CONCLUSION

Although most men with DO after SUI surgery respond to intradetrusor BoNT-A injection, all of them discontinue treatment due to personal reasons. It is a safe procedure, with urinary retention requiring clean intermittent catheterization being the most frequent complication.

Rethinking Second-Line Therapy for Overactive Bladder to Improve Patient Access to Treatment Options

Idiopathic overactive bladder (OAB) is a chronic condition that negatively affects quality of life, and oral medications are an important component of the OAB treatment algorithm. Recent literature has shown that anticholinergics, the most commonly prescribed oral medication for the treatment of OAB, are associated with cognitive side effects including dementia. β3-adrenoceptor agonists, the only alternative oral treatment for OAB, are similar in efficacy to anticholinergics with a more favorable side effect profile without the same cognitive effects. However, there are marked cost variations and barriers to access for OAB medications, resulting in expensive copays and medication trial requirements that ultimately limit access to β3-adrenoceptor agonists and more advanced procedural therapies. This contributes to and perpetuates health care inequality by burdening the patients with the least resources with a greater risk of dementia. When prescribing these medications, health care professionals are caught in a delicate balancing act between cost and patient safety. Through multilevel collaboration, we can help disrupt health care inequalities and provide better care for patients with OAB.

Low Intensity Extracorporeal Shock Wave Therapy as a Potential Treatment for Overactive Bladder Syndrome

Simple Summary

Overactive bladder (OAB) is a common urologic condition with urinary frequency, urinary urgency, nocturia, and urgency incontinence, which can get in the way of a patient’s social life, exercise, work, and sleep. Exploring a promising option for OAB patients is very important, especially one with less side effects or invasive alternations. This study uses low intensity extracorporeal shock wave therapy (LiESWT) to investigate the therapeutic effect and duration on OAB symptoms.

Abstract

Background: The present study attempted to investigate the therapeutic effect and duration of low intensity extracorporeal shock wave therapy (LiESWT) on overactive bladder (OAB) symptoms, including social activity and the quality of life (QoL). Methods: In this prospective, randomized, single-blinded clinical trial, 65 participants with OAB symptom were randomly divided into receive LiESWT (0.25 mJ/mm², 3000 pulses, 3 pulses/second) once a week for 8 weeks, or an identical sham LiESWT treatment without the energy transmission. We analyzed the difference in overactive bladder symptom score (OABSS) and 3-day urinary diary as the primary end. The secondary endpoint consisted of the change in uroflowmetry, post-voided residual (PVR) urine, and validated standardized questionnaires at the baseline (W0), 4-week (W4) and 8-week (W8) of LiESWT, and 1-month (F1), 3-month (F3) and 6-month (F6) follow-up after LiESWT. Results: 8-week LiESWT could significantly decrease urinary frequency, nocturia, urgency, and PVR volume, but meaningfully increase functional bladder capacity, average voided volume and maximal flow rate (Qmax) as compared with the W0 in the LiESWT group. In addition, the scores calculated from questionnaires were meaningfully reduced at W4, W8, F1, F3, and F6 in the LiESWT group. Conclusions: Our results revealed that the therapeutic efficacy of LiESWT could improve voided volume and ameliorate OAB symptoms, such as urgency, frequency, nocturia, and urinary incontinence, and lasted up to 6 month of follow-up. Moreover, LiESWT treatment brought statistically significant and clinically meaningful improvements in social activity and QoL of patients. These findings suggested that LiESWT could serve as an alternative non-invasive therapy for OAB patients.

Neurogenic bladder - concepts and treatment recommendations

Introduction:

Bladder and urinary sphincter malfunctioning that results from some change in the central and/or peripheral nervous system is defined as neurogenic bladder. The urinary tract symptoms that can be related to its filling, emptying, or both have a significant impact on the quality of life of individuals. The present review was based on the document prepared for the public health system in Brazil as a treatment guidelines proposal.

Material and Methods:

Survey questions were structured as per PICO (Population, Intervention, Control, and Outcome). Search strategies were defined and performed in the MEDLINE/Pubmed, Embase, Epistemonikos and Google Scholar databases. The selection of articles followed the evidence hierarchy concept; evidence body was identified, and the quantitative study data were extracted. The quality of evidence and grade of recommendation were qualitatively assessed according to GRADE (Grading of Recommendations, Assessment, Development and Evaluations).

Results:

A total of 2.707 articles were identified, with 49 of them being selected to compose the basis for this review. Neurogenic bladder treatments were classified according to their focus on filling or emptying symptoms and sub- classified in pharmacological and surgical treatments.

Conclusion:

Treatment guidelines are important tools for the public health system to promote the best practice when treating neurogenic bladder patients.

Bladder Hyperactivity Induced by Oxidative Stress and Bladder Ischemia: A Review of Treatment Strategies with Antioxidants

Overactive bladder (OAB) syndrome, including frequency, urgency, nocturia and urgency incontinence, has a significantly negative impact on the quality-of-life scale (QoL) and can cause sufferer withdrawal from social activities. The occurrence of OAB can result from an imbalance between the production of pro-oxidants, such as free radicals and reactive species, and their elimination through protective mechanisms of antioxidant-induced oxidative stress. Several animal models, such as bladder ischemia/reperfusion (I/R), partial bladder outlet obstruction (PBOO) and ovarian hormone deficiency (OHD), have suggested that cyclic I/R during the micturition cycle induces oxidative stress, leading to bladder denervation, bladder afferent pathway sensitization and overexpression of bladder-damaging molecules, and finally resulting in bladder hyperactivity. Based on the results of previous animal experiments, the present review specifically focuses on four issues: (1) oxidative stress and antioxidant defense system; (2) oxidative stress in OAB and biomarkers of OAB; (3) OAB animal model; (4) potential nature/plant antioxidant treatment strategies for urinary dysfunction with OAB. Moreover, we organized the relationships between urinary dysfunction and oxidative stress biomarkers in urine, blood and bladder tissue. Reviewed information also revealed the summary of research findings for the effects of various antioxidants for treatment strategies for OAB.

What are the chances of improvement or cure from overactive bladder? A pooled responder analysis of efficacy and treatment emergent adverse events following treatment with fesoterodine

Aim

This study describes patients with different degrees and combinations of symptom resolution in response to fesoterodine exposure to aid physicians in counselling patients with overactive bladder (OAB) on the likelihood of treatment success.

Methods

Data came from 12‐week fixed‐dose studies of fesoterodine. The proportions of patients experiencing symptom resolution and change in patient‐reported outcome measures (PROM) at 4, 8, and 12 weeks were calculated. Treatment‐emergent adverse events (TEAE) were reported according to response in urinary urgency episodes (UUE). The relationship between PROM and response was examined.

Results

Out of 6689 patients, 81.6% female, urgency urinary incontinence (UUI) episodes/24 h were more responsive to fesoterodine than UUE; with roughly 50% of patients reporting a 50% reduction and fewer than 10% reporting absence of UUE at 12 weeks compared to approximately 40%–50% reporting absence of UUI. TEAE was numerically lower in patients with greater response. There was a statistically significant relationship between improvement in urinary urgency and associated change in OAB‐q symptom bother scores, r = 0.54, p < 0.001. At Week 4, 64.0%–76.7% of patients who had achieved a significant change in Patient Perception of Bladder Condition (PPBC) had a 50% reduction in UUI. At Week 12 this proportion was between 80% and 87.9%, with those being exposed to fesoterodine treatment reporting response in PPBC at numerically higher rates.

Conclusion

These data provide clinicians with information from which they may usefully communicate the likelihood of symptom resolution in response to pharmacotherapy for OAB and answer a key clinical question posed by many care providers. Roughly ⅓ of fesoterodine treated patients reported a 50% reduction urgency and ¾ reported 50% resolution of incontinence at 12 weeks. Total resolution of all symptoms was seldom achieved.

The 1-year continuation rate and discontinuation factors of vibegron and mirabegron: A retrospective comparative study in a rehabilitation hospital in Japan

OBJECTIVES

To compare the 1-year continuation rate and discontinuation factors between vibegron and mirabegron in patients with neurogenic and nonneurogenic overactive bladder.

METHODS

Continuation or discontinuation of the target drugs and reasons for discontinuation as well as patients' grounds and adverse effects were evaluated retrospectively from the medical records between September 2018 and December 2020. After selecting patients according to the inclusion and exclusion criteria, 180 cases taking mirabegron and 132 taking vibegron were adjusted for intergroup variability by propensity score matching. We performed Cox proportional hazards regression for the 1-year continuation rate and Fine-Gray proportional hazards regression for the 1-year cumulative incidence of discontinuation events. Subgroup analysis was also performed for the background factors related to the 1-year continuation rate.

RESULTS

The 1-year continuation rate was 83.8% for vibegron and 58.2% for mirabegron, and the hazard ratio was 0.32 (95% CI: 0.18-0.57, P < .001) as for an incidence of discontinuation events of vibegron against mirabegron. The incidence of discontinuation due to an inadequate efficacy was 8.7% for vibegron and 29.1% for mirabegron, and similarly the hazard ratio was 0.26 (95% CI: 0.12-0.55, P < .001). The subgroup analysis indicated a similar tendency in each subgroup except for that of catheterization, and there was no significant interaction between the groups.

CONCLUSIONS

It is suggested that vibegron is superior to mirabegron in the continuity of administration in neurogenic and nonneurogenic overactive bladder populations without catheterization with fewer discontinuations due to inadequate efficacy.

Persistence with mirabegron or antimuscarinic treatment for overactive bladder syndrome: Findings from the PERSPECTIVE registry study

Objectives

This analysis from the PERSPECTIVE (a Prospective, Non‐interventional Registry Study of Patients Initiating a Course of Drug Therapy for Overactive Bladder) study evaluated treatment persistence with mirabegron or antimuscarinics over a 12‐month period.

Methods

Participants were adults diagnosed with overactive bladder (OAB) by their health care provider (HCP), who were initiating mirabegron or antimuscarinic treatment. The HCP made all treatment decisions, and patients were followed for 12 months with no mandatory scheduled visits. Information requests were sent to patients at baseline and months 1, 3, 6, and 12. Patients were nonpersistent if they switched, discontinued, or added OAB medications/therapies to their initial treatment. Reasons for discontinuation and switching patterns were investigated.

Results

Overall, 1514 patients were included (613 mirabegron and 901 antimuscarinic initiators). Persistence rates decreased steadily over time in both groups. A low proportion of patients added or switched medication at each time point. Unadjusted Kaplan‐Meier analysis showed similar persistence rates for both groups. When the data were adjusted for patient characteristics (age, sex, and OAB treatment status), mirabegron initiators had higher persistence rates. No significant differences were noted in unadjusted median time to end of persistence. However, end of treatment persistence by any cause was longer with mirabegron (median: 9.5 vs 6.7 months for antimuscarinics). HCPs stated that the most common reasons for nonpersistence were no symptomatic improvement and side effect aversion.

Conclusions

Treatment persistence was longer for mirabegron compared with antimuscarinic initiators after controlling for patient characteristics. End of treatment persistence by any cause was also longer with mirabegron.

Drug Delivery Approaches for Managing Overactive Bladder (OAB): A Systematic Review

Overactive bladder syndrome (OAB) is characterised by urgency symptoms, with or without urgency incontinence, usually with frequency and nocturia and severely affects the quality of life. This systematic review evaluates the various drug delivery strategies used in practice to manage OAB. Advanced drug delivery strategies alongside traditional strategies were comprehensively analysed and comparatively evaluated. The present review was conducted according to the preferred reporting items for systematic reviews and meta-analyses guidelines. A total of 24 studies reporting the development of novel formulations for the treatment of OAB were considered eligible and were further categorised according to the route of drug administration. The review found that various drug delivery routes (transdermal, intravesicular, oral, vaginal and intramuscular) are used for the administration of drugs for managing OAB, however, the outcomes illustrated the marked potential of transdermal drug delivery route. The findings of the current review are expected to be helpful for pharmaceutical scientists to better comprehend the existing literature and challenges and is anticipated to provide a basis for designing and fabricating novel drug delivery systems to manage OAB.

Sacral neuromodulation in patients with refractory overactive bladder symptoms after failed Botulinum toxin therapy: Results in a large cohort of patients

Aims

Sacral neuromodulation (SNM) and Botulinum toxin A (BoNT‐A) injections are well‐known third‐line treatment options in patients with refractory overactive bladder (OAB). Our aim is to evaluate the success rate of SNM in patients who received prior therapy with BoNT‐A injections.

Methods

All patients with OAB symptoms referred for SNM between 2006 and 2019 were included. History taking and 3‐day voiding diaries assessed the complaints and suitability for SNM. The success rate of SNM in patients who received prior BoNT‐A was compared with BoNT‐A naive patients. Success was defined as an improvement of 50% or greater in voiding diary parameters. Satisfaction was registered at their most recent visit.

Results

A total of 263 patients underwent SNM test stimulation, of which 75 (16 male/57 female) received prior BoNT‐A and 188 (46 male/142 female) were BoNT‐A naive. Success rate for SNM in BoNT‐A naive patients was 72.9% and in BoNT‐A patients 66.7% (p = 0.316). Success rate after ≤2 BoNT‐A injections was 68.5%, compared to 61.1% after ≥3 injections (p >  0.05). Success rate in patients perceiving lack of efficacy of BoNT‐A was 67.4% (p > 0.05), subjected to temporary CISC was 73.7% (p > 0.05) and with temporary effect of BoNT‐A was 50% (p > 0.05). In 86% of BoNT‐A patients the system was still activated and used to their satisfaction at their last follow‐up visit (mean FU, 40.70 months).

Conclusion

SNM in patients with refractory OAB who failed prior BoNT‐A is an excellent approach. The number of injections nor reason of BoNT‐A discontinuation have predictive value for success with SNM.

Long-term effectiveness of an intervention to enhance mirabegron use revision and its deprescribing: 36-month follow-up of a quasi-experimental trial in primary care

OBJECTIVE

This is a follow-up study from a multicenter, prospective, before-and-after quasi-experimental, controlled trial to assess effectiveness at 36 months of an intervention designed to promote the revision and deprescribing of mirabegron in primary care in patients with overactive bladder.

METHODS

Intervention included patients who attended in 17 PHCs located in North Barcelona; control included patients who attended in the other 34 PHCs located in South, East and West Barcelona. The primary endpoint was mirabegron review and deprescribing when GPs considered appropriate, which was measured by the percentage of change of the number of patients with treatment at 36 months compared to the baseline. The intervention consisted of meetings with all the directors of the PHCs; distribution of the infographic to the GPs; providing information regarding the intervention for urologist and gynaecologist; and review of the treatments by the GPs. A monthly follow-up was done during the first year, and every three months thereafter until month 36.

RESULTS

Overall, 1932 patients were included, mean age 71.6 years (female 53.8%). A total of 540 patients included in the intervention discontinued mirabegron at some point during the 36 months follow-up (540/762, 70.8%) compared to 759 patients in the control (759/1170, 64.9%), (p < 0.001). A total of 324/433 patients (74.8%) who discontinued mirabegron use at 12 months remained without pharmacological treatment at 36 months. With respect to the baseline cohort, there was a lower introduction of new patients with mirabegron in the intervention (546/762, 71.6%) compared to the control (1246/1170, 106.5%), (p < .001). Regarding the treated patients, there was an increase of 41.6% in the control and a slight increase of 0.8% in the intervention at 36 months, (p < .001).

CONCLUSION

Our data indicate that an intervention can enhance the review use of mirabegron in the primary care setting, and promote their deprescribing.

Clustering of patients with overactive bladder syndrome

BACKGROUND

Overactive bladder is a heterogenous condition with poorly characterized clinical phenotypes. To discover potential patient subtypes in patients with overactive bladder (OAB), we used consensus clustering of their urinary symptoms and other non-urologic factors.

METHODS

Clinical variables included in the k-means consensus clustering included OAB symptoms, urinary incontinence, anxiety, depression, psychological stress, somatic symptom burden, reported childhood traumatic exposure, and bladder pain.

RESULTS

48 OAB patients seeking care of their symptoms were included. k-means consensus clustering identified two clusters of OAB patients: a urinary cluster and a systemic cluster. The systemic cluster, which consisted of about half of the cohort (48%), was characterized by significantly higher psychosocial burden of anxiety (HADS-A, 9.5 vs. 3.7, p < 0.001), depression (HADS-D, 6.9 vs. 3.6, p < 0.001), psychological stress (PSS, 21.4 vs. 12.9, p < 0.001), somatic symptom burden (PSPS-Q, 28.0 vs. 7.5, p < 0.001), and reported exposure to traumatic stress as a child (CTES, 17.0 vs. 5.4, p < 0.001), compared to the urinary cluster. The systemic cluster also reported more intense bladder pain (3.3 vs. 0.8, p = 0.002), more widespread distribution of pain (34.8% vs. 4.0%, p = 0.009). The systemic cluster had worse urinary incontinence (ICIQ-UI, 14.0 vs. 10.7, p = 0.028) and quality of life (SF-36, 43.7 vs. 74.6, p < 0.001). The two clusters were indistinguishable by their urgency symptoms (ICIQ-OAB, OAB-q, IUSS, 0-10 ratings). The two OAB clusters were different from patients with IC/BPS (worse urgency incontinence and less pain).

CONCLUSIONS

The OAB population is heterogeneous and symptom-based clustering has identified two clusters of OAB patients (a systemic cluster vs. a bladder cluster). Understanding the pathophysiology of OAB subtypes may facilitate treatments.

Percutaneous tibial nerve stimulation for idiopathic and neurogenic overactive bladder dysfunction: a four-year follow-up single-centre experience

OBJECTIVE

Overactive bladder (OAB) affects hundreds of millions of people worldwide and has significant detrimental effects on quality-of-life. Percutaneous tibial nerve stimulation (PTNS) is endorsed in the European guidelines of Urology as second-line therapy - on par with pharmacological treatment for women with OAB.

METHODS

This prospective cohort study describes our clinical experience with PTNS in a daily outpatient clinic, on a consecutive cohort. The cohort of 116 patients was mixed; including both men and women with idiopathic (iOAB) and neurogenic (nOAB) overactive bladder. Patients were treated with a 12-week course of PTNS followed by monthly maintenance treatment. Data were collected during 4 years.

RESULTS

The most common indication for PTNS was OAB with urge incontinence (53%) followed by OAB-dry and nocturia (both 16%). One hundred and ten (95%) patients completed follow-up and 68 patients (62%) continued to maintenance treatment. A total of 68 patients reported an effect on PROM, BD and ICIQ-OAB, which is the same 62% that continue in maintenance PTNS. A significant decline was seen in overall ICIQ-OAB score, with a median drop from 87 to 54, a significant decline in overall frequency and nocturia on bladder diary and a shift in pad test group in 19% of the incontinence patients.

CONCLUSION

PTNS shows an equally significant effect on men as well as women both in the iOAB and nOAB subgroups in a daily outpatient clinic. In our opinion, PTNS should be a standard treatment option available at urological departments, where both men and women in both sub-groups could benefit from treatment. Further randomized studies focusing on men with iOAB are needed.

Diagnosis and management of overactive bladder: A review

AIM

Overactive bladder (OAB) is a common and troublesome condition that can significantly impair quality of life. This review aims to educate providers of obstetrics and gynecology services about available therapies for OAB and what to expect following treatment.

METHODS

Here, we review published data from studies that have evaluated available treatments for OAB. Relevant articles published over the past 2 decades, including large multicenter trials, were identified through a literature search using PubMed.gov, and the references in those articles were also manually searched to find additional articles. Treatment guidelines and product labels were also reviewed.

RESULTS

Behavioral therapy is recommended as a first choice for OAB management; pharmacologic treatment (anticholinergics, β₃ -adrenoceptor agonists) as second-line treatment; and onabotulinumtoxinA, peripheral tibial nerve stimulation, and sacral nerve stimulation as third-line therapy for patients refractory or intolerant to first- and second-line treatments. A stepwise approach to treatment through first-, second-, and third-line therapies is recommended, recognizing this may not be appropriate for all patients.

CONCLUSIONS

To optimize symptom control and set realistic expectations, patients should be carefully monitored and counseled appropriately on available treatment options.

National Patterns of Filled Prescriptions and Third-Line Treatment Utilization for Privately Insured Women With Overactive Bladder

OBJECTIVE

The aim of this study was to evaluate national patterns of care for women with overactive bladder (OAB) in an administrative data set and identify potential areas for improvement.

METHODS

We performed an analysis using the OptumLabs Data Warehouse, which contains deidentified administrative claims data from a large national US health insurance plan. The study included women, older than 18 years, with a new OAB diagnosis from January 1, 2007, to June 30, 2017. We excluded those with an underlying neurologic etiology, with interstitial cystitis/painful bladder syndrome, were pregnant, or did not have continuous enrollment for 12 months before and after OAB diagnosis. Trends in management were assessed via the Cochran-Armitage test. Time to discontinuation among medications was compared using t test.

RESULTS

Of 1.4 million women in the database during the study time frame, 60,246 (4%) were included in the study. Median age was 61 years [interquartile range (IQR), 50-73], and median follow-up was 2.6 years (IQR, 1.6-4.2). Overall, 37% were treated with anticholinergics, 5% with beta-3 agonists, 7% with topical estrogen, and 2% with pelvic floor physical therapy; 26% saw a specialist; and 2% underwent third-line therapy. Median time to cessation of prescription filling was longer for beta-3 agonists versus anticholinergics [median, 4.1 months (IQR, 1-15) vs 3.6 months (IQR, 1-10); P < 0.0001]. Use of third-line therapies significantly increased over the study time frame, from 1.1% to 2.2% (P < 0.0001).

CONCLUSIONS

Most of the patients do not continue filling prescriptions for OAB medications, and a minority of patients were referred for specialty evaluation. Although third-line therapy use is increasing, it is used in a small proportion of women with OAB. Given these patterns, there may be underutilization of specialist referral and other OAB therapies.

Efficacy and Safety of Mirabegron in Men with Overactive Bladder Symptoms and Benign Prostatic Hyperplasia

PURPOSE OF REVIEW

To review the efficacy and safety of mirabegron in men with overactive bladder (OAB) and benign prostatic hyperplasia (BPH).

RECENT FINDINGS

Numerous studies have shown mirabegron to be efficacious and safe in treating symptoms of OAB. More recent studies evaluating the use of mirabegron in men with OAB and BPH have also shown the medication to be effective with few adverse side effects when used as monotherapy or in combination therapy. Mirabegron is an effective and safe treatment for men with OAB and BPH.

Treatment of neurogenic lower urinary tract symptoms: main contributions from 2018 and 2019

PURPOSE OF REVIEW

This review aims to update the studies involving the treatment of lower urinary tract symptoms (LUTS) in neurogenic patients, published in the last two years.

RECENT FINDINGS

Treatment of neurogenic LUTS (NLUTS) patients with β3 adrenoreceptor agonists was investigated in real-life conditions. A randomized controlled trial compared the efficacy of antimuscarinics versus onabotulinum toxin A in neurogenic patients. The use of desmopressin to treat nocturia in multiple sclerosis patients is also reported. The long-term treatment with BontA efficacy, its discontinuation, and possible strategies to maintain patients on treatment were also evaluated. Sacral neuromodulation and tibial nerve stimulation are continuously being evaluated in neurogenic patients, especially in the last years.

SUMMARY

The management of urinary tract infections and vesical lithiasis, two common complications in NLUTS patients, and the management of both these patients was assessed in clinical trials.A trial evaluating the use of the anti-Nogo-A antibody after a spinal cord injury to facilitate neuronal rewiring and prevent or improve NLUTS was reported for the first time.

Overactive bladder medication: Persistence, drug switching, and reinitiation

AIM

To assess real-world treatment profiles, including the time to and reasons for discontinuation or drug switching, treatment reinitiation, and postdiscontinuation follow-up in patients receiving antimuscarinics or ß3-agonists for overactive bladder (OAB) through a retrospective chart review.

METHODS

We retrospectively reviewed medical charts of 777 patients, aged ≥18 years, who underwent antimuscarinic or ß3-agonist therapy at our hospital. Data on patient's age, sex, chief complaint, and OAB symptom score at therapy initiation were collected. Treatment persistence was assessed with respect to the median time to discontinuation and the persistence rate at 12 months.

RESULTS

Older patients, male patients, and those with more severe urgency symptoms were more likely to show treatment persistence with OAB medications. Treatment persistence with mirabegron was significantly longer than that with antimuscarinics when administered as either the first- or second-line medication. Multivariate analyses showed that urgency severity and use of mirabegron were independently associated with better persistence (p = .026 and p = .018, respectively). Out of 583 patients who discontinued medication, 344 continued with the visit schedule, and the reinitiation rate of the OAB medication was 19% at a median follow-up of 24 months.

CONCLUSION

Although the persistence rates for OAB medications improved with the introduction of mirabegron, most patients still discontinued the medication therapy within 1 year. The treatment strategies for patients with mild symptoms and those who are resistant to medication can still be improved. Tailored individualized treatments that avoid excessive reliance on pharmacotherapy would be key to further improve treatment outcomes in OAB patients.

Treatment patterns and costs among patients with OAB treated with combination oral therapy, sacral nerve stimulation, percutaneous tibial nerve stimulation, or onabotulinumtoxinA in the United States

Introduction

Treatment patterns and costs were characterized among patients with overactive bladder (OAB) receiving later‐line target therapies (combination mirabegron/antimuscarinic, sacral nerve stimulation [SNS], percutaneous tibial nerve stimulation [PTNS], or onabotulinumtoxinA).

Methods

In a retrospective cohort study using 2013 to 2017 MarketScan databases, two partially overlapping cohorts of adults with OAB (“IPT cohort”: patients with incident OAB pharmacotherapy use; “ITT cohort,” incident target therapy) with continuous enrollment were identified; first use was index. Demographic characteristics, treatment patterns and costs over the 24‐month follow‐up period were summarized. Crude mean (standard deviation [SD]) OAB‐specific (assessed by OAB diagnostic code or pharmaceutical dispensation record) costs were estimated according to target therapy.

Results

The IPT cohort comprised 54 066 individuals (mean [SD] age 58.5 [15.0] years; 76% female), the ITT cohort, 1662 individuals (mean [SD] age 62.8 [14.9] years; 83% female). Seventeen percent of the IPT cohort were treated with subsequent line(s) of therapy after index therapy; among those, 73% received antimuscarinics, 23% mirabegron, and 1.4% a target therapy. For the ITT cohort, 32% were initially treated with SNS, 27% with onabotulinumtoxinA, 26% with combination mirabegron/antimuscarinic, and 15% with PTNS. Subsequently, one‐third of this cohort received additional therapies. Mean (SD) costs were lowest among patients receiving index therapy PTNS ($6959 [$7533]) and highest for SNS ($29 702 [$26 802]).

Conclusions

Costs for SNS over 24 months are substantially higher than other treatments. A treatment patterns analysis indicates that oral therapies predominate; first‐line combination therapy is common in the ITT cohort and uptake of oral therapy after procedural options is substantial.

Antimuscarinic Discontinuation in Patients with Overactive Bladder in Nursing Homes: A Retrospective Study of Medicare Beneficiaries

Introduction

Although antimuscarinics form the first-line therapy in overactive bladder (OAB), little is known regarding antimuscarinic discontinuation among OAB patients in nursing homes. This study examined treatment patterns and predictors of antimuscarinic discontinuation among long-term nursing home (LTNH) residents with OAB.

Methods

The study cohort included LTNH residents (defined as residents staying ≥ 101 consecutive days) from the Minimum Data Set linked 2013–2015 Medicare claims data. Patients with OAB were defined by OAB-related claims and medication codes. Treatment patterns and discontinuation (medication gap ≥ 30 days) were characterized by examining OAB-specific antimuscarinics prescribed during LTNH stays. The Andersen Behavioral Model was used to identify predisposing, enabling and need factors that predict discontinuation. Kaplan-Meier curves and multivariable Cox proportional hazards regression model were used to assess the unadjusted and adjusted times to discontinuation, respectively, among different antimuscarinics.

Results

The mean age of the study cohort (n = 11,012) was 81.6 years (± 8.5), 74.6% were female, and 89.8% were non-Hispanic White. The mean duration of nursing home stay was 530.1 (± 268.4) days. The most commonly prescribed OAB-specific antimuscarinic was oxybutynin (69.8%). Overall, 66.5% of the study cohort discontinued the index antimuscarinic. Multivariable Cox PH regression analysis revealed that compared to LTNH residents who initiated treatment with oxybutynin, treatment discontinuation was lower with solifenacin or fesoterodin and discontinuation was more frequent when treatment was initiated with tolterodine, darifenacin or trospium compared with oxybutynin. In addition, several need factors (comorbidities, medication use and anticholinergic burden, etc.) were associated with antimuscarinic discontinuation.

Conclusion

About  two-thirds of LTNH residents with OAB discontinued their index antimuscarinic during their nursing home stay. There was significant variation in discontinuation based on the index antimuscarinic agent with lowest risk of discontiuation with solifenacin and fesoterodin. Concerted efforts to optimize antimuscarinic use are needed to improve the management of OAB in nursing homes.

Electronic Supplementary Material

The online version of this article (10.1007/s12325-020-01412-z) contains supplementary material, which is available to authorized users.

Efficacy of adding mirabegron to alpha-adrenoreceptor blocker in patients with benign prostatic hyperplasia with persistent overactive bladder symptoms: A prospective study

Purpose

To compare the efficacies of mirabegron 50 mg addition after alpha-adrenoreceptor blocker in terms of reducing storage symptoms in patients with BPH.

Materials and Methods

Fifty-eight patients that had been taking alpha-adrenoreceptor blocker for more than 8 weeks, but had an OABSS of greater than 3 points, were initially enrolled. One group added any alpha-adrenoreceptor blocker with mirabegron 50 mg (n=39; the mirabegron group) and the other group received alpha-adrenoreceptor blocker only (n=19; the control group) for 8 weeks.

Results

In the control group, mean total IPSS decreased from 15.7 to 13.1 (p=0.298) and in mirabegron group, mean total IPSS decreased from 19.4 to 16.5 (p=0.024). Mean storage symptom scores reduced in the control and mirabegron groups from 8.5 to 7.9 (p=0.584) and from 9.1 to 7.6 (p=0.015), respectively, and mean QoL scores from 3.7 to 3.1 (p=0.052) and 3.6 to 3.2 (p=0.027), respectively. Mean overall OABSS in the control and mirabegron groups reduced from 8.4 to 7.2 (p=0.173) and from 8.8 to 7.3, respectively (p=0.005); mean OABSS Q3 from 3.6 to 2.9 (p=0.073) and from 3.5 to 2.7 (p=0.002), respectively; and mean OABSS Q4 from 2.4 to 2.0 (p=0.306) and from 2.7 to 2.0 (p=0.016), respectively. The change of mean Qmax and PVR was insignificant in 2 groups.

Conclusions

IPSS total scores, storage symptom scores, QoL, overall OABSS, OABSS Q3 and Q4 were more improved significantly by alpha-adrenoreceptor blocker with mirabegron 50 mg in BPH patients with persistent overactive symptoms. Mirabegron 50 mg addition is considered to patients with persistent storage symptoms after alpha-adrenoreceptor blocker.

Effectiveness of antimuscarinics and a beta-3 adrenoceptor agonist in patients with overactive bladder in a real-world setting

Both antimuscarinics and beta-3 adrenoceptor agonists are generally used as first-line pharmacotherapy for overactive bladder (OAB). This study aimed to investigate the differences in clinical characteristics and manifestations between different medication groups using real-world data. In this retrospective study, we recruited all patients aged > 18 years diagnosed with OAB at our institute from March 2010 to December 2017. They were allocated into three groups, the antimuscarinics (group A), beta-3 adrenoceptor agonist (group B), and discontinued (group C) treatment groups, and they completed OAB symptom score and quality of life questionnaires before and after treatment. In addition, the Clinical Global Impression was recorded for treatment outcomes. A premedication urodynamic study was also applied. A total of 215 patients were analyzed (group A: 43, B: 35, C: 137). Group B was significantly older (mean age 77.4 years) than group A (69.2 years, p = 0.012) and group C (68.6 years, p = 0.001). However, there were no significant differences in sex or underlying diseases among the groups. Before treatment, there were no significant differences in the questionnaire results among all groups. The cystometric capacity of group A (mean ± SD, 257.3 ± 135.1 cm³) was significantly larger than that of group B (125.8 ± 46.0 cm³, p = 0.002) and group C (170.5 ± 99.2 cm³, p = 0.001). After treatment, there were no significant differences between group A and group B in any of the questionnaire scores; however, their scores were better than those of group C. The OAB patients who adhered to antimuscarinics tended to be younger and have larger cystometric bladder capacity in the urodynamic study. However, there were no significant differences in effectiveness between the patients who took antimuscarinics and those who took a beta-3 adrenoceptor agonist.

Management of urinary incontinence

Urinary incontinence is a common problem affecting 25-45% women. Effective management can have a huge impact on a patient's quality of life and many treatments are available. Management should be dictated by the degree of bother the symptoms are having, and vary depending on the type on incontinence. Conservative measures should always be initiated, including optimisation of body mass index and smoking cessation. Overactive bladder and urge urinary incontinence can be improved with bladder retraining and avoidance of bladder stimulants. Medical treatment then includes anticholinergic medications or Mirabegron. More invasive options include Botulinum Toxin A (Botox®) injections, sacral nerve stimulation or urological surgery. Stress urinary incontinence should be managed initially with pelvic floor exercises, and input from a specialist nurse or physiotherapist is beneficial. The surgical options for managing stress incontinence have changed considerably over the years, but include bladder neck injections, mid-urethral slings, colposuspension or autologous fascial slings. Mixed urinary incontinence is more challenging to manage, but all conservative measures should be started. Further treatment is directed towards the predominant symptom, but overactivity should be controlled before surgical measures for stress urinary incontinence are performed.

Optimizing Nonsurgical Treatments of Overactive Bladder in the United States

Overactive bladder syndrome is a prevalent condition impacting quality of life, activities of daily living, work productivity, physical and psychological health, sleep, and sexuality. Published guideline recommendations and effective behavioral, pharmacologic, and neuromodulatory therapies exist; however, adherence can be poor. Clinicians have important roles educating patients, setting treatment expectations, and providing follow-up. Determining patient goals, routinely assessing and adjusting therapy, and combining treatment strategies may improve outcomes. We review the benefits and challenges of overactive bladder treatments and propose approaches to improve patient management, with the goals of initiating therapy earlier and achieving better patient satisfaction, functioning, and quality of life.

Effect of amniotic fluid stem cell transplantation on the recovery of bladder dysfunction in spinal cord-injured rats

The effects of human amniotic fluid stem cell (hAFSC) transplantation on bladder function and molecular changes in spinal cord-injured (SCI) rats were investigated. Four groups were studied: sham and SCI plus phosphate-buffered saline (SCI + PBS), human embryonic kidney 293 (HEK293) cells, and hAFSCs transplantation. In SCI + PBS rat bladders, cystometry showed increased peak voiding pressure, voiding volume, bladder capacity, residual volume, and number of non-voiding contractions, and the total elastin/collagen amount was increased but collagen concentration was decreased at days 7 and 28. Immunoreactivity and mRNA levels of IGF-1, TGF-β1, and β3-adrenoceptor were increased at days 7 and/or 28. M2 immunoreactivity and M3 mRNA levels of muscarinic receptor were increased at day 7. M2 immunoreactivity was increased, but M2/M3 mRNA and M3 immunoreactivity levels were decreased at day 28. Brain derived-neurotrophic factor mRNA was increased, but immunoreactivity was decreased at day 7. HEK293 cell transplantation caused no difference compared to SCI + PBS group. hAFSCs co-localized with neural cell markers and expressed BDNF, TGF-β1, GFAP, and IL-6. The present results showed that SCI bladders released IGF-1 and TGF-β1 to stimulate elastin and collagen for bladder wall remodelling, and hAFSC transplantation improved these changes, which involved the mechanisms of BDNF, muscarinic receptors, and β3-adrenoceptor expression.

Is imidafenacin an alternative to current antimuscarinic drugs for patients with overactive bladder syndrome?

PURPOSE

Previous studies have included a limited number of randomized controlled trials (RCTs) and compared limited parameters after treatment with imidafenacin and other anticholinergic drugs (ADs) for overactive bladder syndrome (OAB), and controversy about the superiority of these ADs still remains. We aim to update the evidence and provide better clinical guidance.

METHODS

A systematic search of PubMed, Embase, ClinicalTrial.gov and Cochrane Library Central Register of Controlled Trials was conducted from January 2007 to April 2019. Meta-analysis of all published RCTs comparing imidafenacin with other ADs in patients with OAB was performed. The primary outcomes were the changes in OAB symptoms and OAB symptom score (OABSS). Secondary outcomes included adverse events (AEs) and the dropout rate related to AEs.

RESULTS

A total of 6 studies including 7 RCTs involving 1430 patients with mean follow-up of 23.43 weeks were included. All ADs improved OAB symptoms. Regarding efficacy, these drugs had similar efficacy in voids, urgency episodes, urgency incontinence episodes, incontinence episodes and OABSS. However, imidafenacin performed better in the reduction of nocturia episodes (MD = -0.24, 95% CI -0.44 to -0.04, P = 0.02). Moreover, imidafenacin was associated with a statistically lower dry mouth rate (RR = 0.87, 95% CI 0.75-1.00, P = 0.04), lower constipation rate (RR = 0.68, 95% CI 0.50-0.93, P = 0.01) and lower AE-related withdrawal rate (RR = 0.51, 95% CI 0.29-0.89, P = 0.02). There was no significant difference in terms of other complications.

CONCLUSIONS

In conclusion, imidafenacin was comparable to other ADs in the treatment of OAB. Moreover, imidafenacin presented a lower dry mouth rate, lower constipation rate and higher adherence and persistence.

Pharmacology of the lower urinary tract: update on LUTS treatment

The number of compounds used in the pharmacological treatment of lower urinary tract symptoms (LUTS) of patients who do not respond to conservative measures has been relatively stable during the last decade, with the exception of the introduction of the new class of β3 adrenoceptor agonists. However, different combinations have been investigated, and the long-term use of these compounds has raised new concerns about adherence and safety. This review summarizes the current state of pharmacology for LUTS, and presents a thorough discussion of the possible challenges concerning their future use. In this narrative review, we analyze the most recent articles related to LUTS pharmacotherapy, after an initial review of mechanisms of bladder function relevant in present clinical practice. The main problems with pharmacotherapy in LUTS are associated with its moderate efficacy, low persistence on treatment, and the incidence of short- and long-term adverse events (AE) associated with some compounds. The long-term AE, such as cognitive impairment in the elderly vulnerable patients associated with antimuscarinic drugs or persistent erectile dysfunction in sexually active men after treatment with 5-α-reductase inhibitors (5-ARI), are some of the problems addressed in this review. Combination therapy taking advantage of the synergistic mechanisms of action between some classes of compounds may overcome AE associated with dose escalation. LUTS pharmacotherapy offers moderate results to most patients but not a full cure. The use of combination drugs to achieve better clinical results, reduce AE and improve both efficacy and adherence, will be used more frequently in the future. The recently raised concern on potential long-term irreversible AE associated with some of these drugs, like antimuscarinics and 5-ARI, are critically important and require further investigation.

Efficacy and Side Effects of Drugs Commonly Used for the Treatment of Lower Urinary Tract Symptoms Associated With Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) is the most common benign disease of the prostate gland and is caused by benign hyperplasia of the smooth muscle cells and stromal cells in this important gland. BPH is also the most common disease underlying lower urinary tract symptoms (LUTS). The incidence of BPH increases with age and affects more than half of all men 50 years or older. BPH mainly exerts effects on urinary function and can seriously reduce a patient's quality of life. At present, treatment for BPH aims primarily to improve the quality of life and reduce the risk of BPH-related complications. Pharmacological therapy is recommended for moderate-to-severe cases of LUTS that are suggestive of BPH. A range of drugs is currently available to treat this condition, including α1-adrenoceptor antagonists, 5α-reductase inhibitors (5-ARIs), phosphodiesterase type 5 inhibitors (PDE5Is), muscarinic receptor antagonists (MRAs), β3-adrenoceptor agonists, and plant extracts. Of these, the most commonly used drugs in the clinic are α1-adrenoceptor antagonists, 5-ARIs, and combination therapy. However, these drugs exert their effects via various mechanisms and are associated with adverse reactions. The purpose of this review is to provide current comprehensive perspectives on the mechanisms of action, efficacy, and adverse reactions associated with the drugs most commonly used for the treatment of BPH.

Quality of life and treatment persistence evaluation in Spanish patients treated with mirabegron. Results of the BELIEVE study

INTRODUCTION AND OBJECTIVE

The BELIEVE study is a European, non-interventional study which includes patients with overactive bladder who were prescribed mirabegron as part of routine clinical practice. Data from the Spanish subpopulation has been obtained for the present study, aiming to analyze health-related quality-of-life (HRQoL) and treatment persistence of these patients.

MATERIALS AND METHODS

Data from 11 Spanish hospitals of the BELIEVE study were analyzed. The primary endpoint was to evaluate change of HRQoL from baseline with overactive bladder questionnaire (OAB-q). Secondary endpoints included treatment persistence, HRQoL based on the EQ-5D-5L questionnaire and adverse events. Study follow-up was 12 months, with two visit windows at 2-4 months and 10-12 months.

RESULTS

153 Spanish patients were enrolled in the study. In the Full Analysis Set (FAS), 63.1% were women, and the mean age was 66 years. Symptom bother and HRQoL improved from baseline to 2-4 months and 10-12 months. EQ-5D-5L questionnaire also showed an improved patients' HRQoL. Treatment persistence was high, as 49% of patients remained with mirabegron at 10-12 months. Adverse events were consistent with previous safety profile results of mirabegron, and no unexpected safety issues were observed.

CONCLUSIONS

Spanish patients treated with mirabegron in real clinical practice reported improvements in HRQoL, with a good tolerability and persistence to treatment.

Italian real-life clinical setting: the persistence and adherence with mirabegron in women with overactive bladder

INTRODUCTION AND HYPOTHESIS

The aims of this study were to evaluate the persistence, the adherence on treatment with mirabegron, the reasons for the interruption in patients with overactive bladder syndrome (OAB) and their satisfaction.

METHODS

This was an Italian multicentre prospective study. Four tertiary urological centers were involved. We included women with no neurogenic OAB symptoms already in therapy with once-daily mirabegron 50 mg for 1 month. They were followed up at 1, 3 and 6 months post-treatment with uroflowmetry with voiding diary for 3 days and post-void residual measurement. They completed self-administered Overactive Bladder questionnaire short form (OABq), Morisky Medication Adherence Scale-4 short form (MMAS), Patient Global Impression-Improvement questionnaire. Patients were divided in OAB wet and OAB dry groups, and in treatment-naive and treatment-experienced groups.

RESULTS

Between January 2018 and July 2018, 80 patients with OAB were included. Fifteen (18.7%) patients continued the treatment for 6 months; 17.5% interrupted the therapy before 1 month: 30% within the third month, while, 33.7% after 1 month. The median time to discontinuation with mirabegron was 62.5 days. The mean adherence was 0.42 ± 0.33, median MMAS was 2 (0-4). The adherence was significantly greater in treatment-naïve (22.4%) than treatment-experienced (6.5%) patients, without statistically significant differences in the different OAB form. The cost is the main cause of interruption of therapy (50% of cases).There was an improvement of OABqSF score and PGI-I score.

CONCLUSION

In Italy, the cost compromises adherence and persistence of therapy with mirabegron despite the good functional outcomes.

Hypnotherapy or medications: a randomized noninferiority trial in urgency urinary incontinent women

BACKGROUND

Urgency urinary incontinence afflicts many adults, and most commonly affects women. Medications, a standard treatment, may be poorly tolerated, with poor adherence. This warrants investigation of alternative interventions. Mind-body therapies such as hypnotherapy may offer additional treatment options for individuals with urgency urinary incontinence.

OBJECTIVE

To evaluate hypnotherapy's efficacy compared to medications in treating women with urgency urinary incontinence.

MATERIALS AND METHODS

This investigator-masked, noninferiority trial compared hypnotherapy to medications at an academic center in the southwestern United States, and randomized women with non-neurogenic urgency urinary incontinence to weekly hypnotherapy sessions for 2 months (and continued self-hypnosis thereafter) or to medication and weekly counseling for 2 months (and medication alone thereafter). The primary outcome was the between-group comparison of percent change in urgency incontinence on a 3-day bladder diary at 2 months. Important secondary outcomes were between-group comparisons of percent change in urgency incontinence at 6 and 12 months. Outcomes were analyzed based on noninferiority margins of 5% for between group differences (P < 0.025) (that is, for between group difference in percentage change in urgency incontinence, if the lower bound of the 95% confidence interval was greater than -5%, noninferiority would be proved).

RESULTS

A total of 152 women were randomized to treatment between April 2013 and October 2016. Of these women, 142 (70 hypnotherapy, 72 medications) had 3-day diary information at 2 months and were included in the primary outcome analysis. Secondary outcomes were analyzed for women with diary data at the 6-month and then 12-month time points (138 women [67 hypnotherapy, 71 medications] at 6 months, 140 women [69 hypnotherapy, 71 medications] at 12 months. There were no differences between groups' urgency incontinence episodes at baseline: median (quartile 1, quartile 3) for hypnotherapy was 8 (4, 14) and medication was 7 (4, 11) (P = .165). For the primary outcome, although both interventions showed improvement, hypnotherapy did not prove noninferior to medication at 2 months. Hypnotherapy's median percent improvement was 73.0% (95% confidence interval, 60.0-88˖9%), whereas medication's improvement was 88.6% (95% confidence interval, 78.6-100.0%). The median difference in percent change between groups was 0% (95% confidence interval, -16.7% to 0.0%); because the lower margin of the confidence interval did not meet the predetermined noninferiority margin of greater than -5%, hypnotherapy did not prove noninferior to medication. In contrast, hypnotherapy was noninferior to medication for the secondary outcomes at 6 months (hypnotherapy, 85.7% improvement, 95% confidence interval, 75.0-100%; medications, 83.3% improvement, 95% confidence interval, 64.7-100%; median difference in percent change between groups of 0%, 95% confidence interval, 0.0-6.7%) and 12 months (hypnotherapy, 85.7% improvement, 95% confidence interval, 66.7-94.4%; medications, 80% improvement, 95% confidence interval, 54.5-100%; median difference in percent change between groups of 0%, 95% confidence interval, -4.2% to -9.5%).

CONCLUSION

Both hypnotherapy and medications were associated with substantially improved urgency urinary incontinence at all follow-up. The study did not prove the noninferiority of hypnotherapy compared to medications at 2 months, the study's primary outcome. Hypnotherapy proved noninferior to medications at longer-term follow-up of 6 and 12 months. Hypnotherapy is a promising, alternative treatment for women with UUI.

Gender specific pharmacokinetic and pharmacodynamic considerations for antimuscarinic drugs for overactive bladder treatment

Introduction: Overactive bladder (OAB) has a heterogeneous presentation that varies between individuals and by gender. Treatment with antimuscarinic medications is standard first line pharmacotherapy for most patients with OAB. However, gender specific differences in the pharmacokinetics and pharmacodynamics of antimuscarinic therapy are often overlooked and not discussed.Areas covered: This review will explore differences by gender between the presentation and treatment of OAB. We will discuss the differences between sexes in terms of lower urinary tract anatomy, muscarinic receptors, and hormone variation. The effect of antimuscarinics on males and females as well as adherence and persistence patterns will be reviewed in order to fully review all available literature on the gender specific pharmacokinetic and pharmacodynamic considerations for antimuscarinic use in the treatment of OAB.Expert opinion: Despite extensive research into various antimuscarinic formulations and therapeutic regimens for the treatment of OAB, identification of gender specific pharmacokinetic and pharmacodynamics considerations remains scant. As our knowledge and understanding of OAB, muscarinic receptors, and antimuscarinic medications evolve, we will hopefully be better able to understand and implement gender-specific and genomic-sprecific treatment regimens and considerations for improved clinical outcomes.

Update on non-invasive treatment for female overactive bladder

Overactive bladder syndrome (OAB) is common chronic medical condition which has a major impact on health and quality of life. This condition affects daily activities, performance and social function and servers as a real challenge for care giver in attempt to treat patients' symptoms. Given the fact that therapy rarely results in cure and the high rate of discontinuation, treatment should primarily aim to reduce social and psychological disability. The purpose of our update is to give an overview of recent data regarding OAB, and to provide practical clinical tools for evaluation and management of OAB syndrome according to current literature evidence.

Qualitative Analysis of Factors Influencing Patient Persistence and Adherence to Prescribed Overactive Bladder Medication in UK Primary Care

Introduction

Pharmacotherapy for overactive bladder (OAB) is generally associated with low rates of persistence and adherence. This study was conducted to explore the patient journey in a UK primary care setting (experiences, perceptions, attitudes, and levels of engagement and expectations) and identify self-reported reasons for patient non-adherence and/or non-persistence to medications for OAB.

Methods

This was a qualitative, non-interventional study involving one-to-one semi-structured, face-to-face or phone interviews with individuals aged 40–80 years, diagnosed with OAB, and currently taking, or having taken, either antimuscarinic or β₃-adrenoceptor agonist medications within the last 12 months. Thematic analyses of interview transcripts identified themes surrounding the participants’ experiences with OAB.

Results

A total of 20 interviews were conducted (face-to-face, n = 13; telephone, n = 7). Interviews from five men and 13 women (mean age 70 years) were included in the final analysis. The most common OAB symptoms reported included urgency, frequency, incontinence and nocturia. Several key themes of factors influencing persistence and/or adherence to prescribed OAB medication were identified: patients’ attitude and condition adaptation behaviour; support with treatment; unmet efficacy/tolerability expectations; drug/condition hierarchy. Non-adherence and/or non-persistence to OAB medication was largely intentional, with patients balancing side effects against perceived clinical benefits. Perceived lack of efficacy was the primary reason for discontinuing treatment. Other factors cited included side effects of medication (either experienced or a fear of future effects), a general aversion to long-term medication taking, drug/condition hierarchy relative to other comorbidities, and limited healthcare professional (HCP) support/engagement. Patients expressed condition adaptation behaviours to help self-manage their condition.

Conclusion

Persistence and adherence to OAB medication may be suboptimal. HCPs might be able to improve persistence and adherence by fostering realistic treatment expectations and scheduling regular medication reviews. These measures may help optimise patient care and support more adherent behaviours, thus minimising the impact of undertreated OAB on patient quality of life.

Funding

Innovate UK and Astellas Pharma Europe Ltd (APEL).

Electronic Supplementary Material

The online version of this article (10.1007/s12325-019-01098-y) contains supplementary material, which is available to authorized users.

Physicochemical properties and drug-release mechanisms of dual-release bilayer tablet containing mirabegron and fesoterodine fumarate

Introduction: In this study, a dual release bi-layer tablet containing Fesoterodine fumarate (Fst) 5 mg and Mirabegron (Mrb) 50 mg was prepared to investigate the different release behavior of each drug in bilayer tablet. The bilayer tablet was prepared based on monolayer-tablet formulation of each drug.

Methods: The optimized bi-layer tablet showed an in vitro dissolution profile similar to commercial reference tablets Toviaz and Betmiga, based on a satisfactory similarity factor. Drug-release kinetics of each drug in the bilayer tablet were evaluated based on dissolution profiles. Drug-release behavior was evaluated by observing the surface of each layer by scanning electron microscopy and measuring the changes in weight and volume of the tablet during dissolution. Drug transfer between each layer was also investigated by Fourier -transform infrared spectroscopic imaging by observing the cross-section of the bilayer tablet cut vertically during dissolution.

Results: The release of Fst was well suited for the Higuchi model, and the release of Mrb was well suited for the Hixson-crowell model. Compared with dissolution rate of each monolayer tablet, that of Fst in the bilayer tablet was slightly reduced (5%), but the dissolution rate of Mrb in bilayer tablet was dramatically decreased (20%). Also, a drug-release study confirmed that polymer swelling was dominant in Fst layer compared with polymer erosion, and degradation was dominant in MRB layer. Fourier-transform infrared imaging and 3-D image reconstruction showed that drug transfer in the bilayer tablet correlates with the results of drug-release behavior.

Conclusion: These findings are expected to provide scientific insights in the development of a dual-release bilayer drug-delivery system for Fst and Mrb.

A Nordic registry-based study of drug treatment patterns in overactive bladder patients

Aim: To describe treatment patterns in Denmark, Norway and Sweden for patients receiving overactive bladder (OAB) pharmacotherapy.Methods: This was a prospective, multinational, registry-based study involving three nationwide prescribed drug registries (sample size 6000 patients per country), performed between 1 January and 30 June 2014. Patients were followed prospectively for 12 months after first pick-up of index medication. The primary objective was to evaluate the proportion of patients picking up first refill of index medication. Secondary objectives included evaluation of the average number of pick-ups collected during 1 year and time to discontinuation of index medication.Results: A high proportion of patients in the three Nordic countries picked up a first refill of OAB medication: 64-75% for mirabegron and 84-95% for individual antimuscarinics. Amongst treatment-naïve patients, the proportion picking up their first mirabegron refill was 60-64%; for individual antimuscarinics it was 30-63%. Mean number of pick-ups during 1 year ranged from 3.5-5.0 for mirabegron across the countries and for individual antimuscarinics from 3.8-12.3. Median time to discontinuation for mirabegron ranged from 140 (Denmark) to 207 days (Norway) and, for individual antimuscarinics (solifenacin), from 182 (Denmark) to 355 days (Sweden). At 12 months, the proportion of patients still on treatment with mirabegron and antimuscarinics was 21% and 38%, respectively.Conclusions: Treatment patterns in patients with OAB picking up a mirabegron or antimuscarinic prescription in Denmark, Norway and Sweden indicate that persistence remains a challenge.

Combination Pharmacotherapy for Treatment of Overactive Bladder (OAB)

Overactive bladder syndrome (OAB) negatively affects the quality of life of patients and their interactions with society. Treatment of OAB starts with behavioral modification and then pharmacotherapy using monotherapy with either antimuscarinics or β3 agonists. The third-line more invasive approaches are the next treatment option currently recommended. Both antimuscarinic agents and β3 agonists work through a different molecular pathway. This brings up the potential of having an additive effect when using a combination treatment for patients with OAB. Currently, the potential for using combination therapy to treat OAB in patients who had no improvement with a monotherapy approach before we attempt a more invasive approach is being explored. Several studies have shown the benefits of combination therapy which will be an additional option to the tools to treat OAB.