1
|
Sartori AM, Kessler TM, Castro-Díaz DM, de Keijzer P, Del Popolo G, Ecclestone H, Frings D, Groen J, Hamid R, Karsenty G, Musco S, Padilla-Fernández B, Pannek J, Schouten N, van der Vorm A, Blok BFM. Summary of the 2024 Update of the European Association of Urology Guidelines on Neurourology. Eur Urol 2024; 85:543-555. [PMID: 38594103 DOI: 10.1016/j.eururo.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 03/14/2024] [Accepted: 03/25/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND AND OBJECTIVE Most patients with neurourological disorders require lifelong medical care. The European Association of Urology (EAU) regularly updates guidelines for diagnosis and treatment of these patients. The objective of this review is to provide a summary of the 2024 updated EAU guidelines on neurourology. METHODS A structured literature review covering the timeframe 2021-2023 was conducted for the guideline update. A level of evidence and a strength rating were assigned for each recommendation on the basis of the literature data. KEY FINDINGS AND LIMITATIONS Neurological conditions significantly affect urinary, sexual, and bowel function, and lifelong management is required for neurourological patients to maintain their quality of life and prevent urinary tract deterioration. Early diagnosis and effective treatment are key, and comprehensive clinical assessments, including urodynamics, are crucial. Management should be customised to individual needs and should involve a multidisciplinary approach and address sexuality and fertility. Lifelong monitoring and follow-up highlight the importance of continuous care for neurourological patients. CONCLUSIONS AND CLINICAL IMPLICATIONS The 2024 EAU guidelines on neurourology provide an up-to-date overview of available evidence on diagnosis, treatment, and follow-up for neurourological patients. PATIENT SUMMARY Neurological disorders very frequently affect the lower urinary tract and sexual and bowel function and patients need lifelong management. We summarise the updated European Association of Urology guidelines on neurourology to provide patients and caregivers with the latest insights for optimal health care support.
Collapse
Affiliation(s)
- Andrea M Sartori
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland; Harvard Medical School, Boston, MA, USA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - David M Castro-Díaz
- Department of Urology, Complejo Hospitalario Universitario de Canarias, Universidad de La Laguna, Tenerife, Spain
| | - Peter de Keijzer
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Giulio Del Popolo
- Department of Neuro-urology, Careggi University Hospital, Florence, Italy
| | | | - Dennis Frings
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jan Groen
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Rizwan Hamid
- Department of Neuro-Urology, London Spinal Injuries Centre, Stanmore, UK
| | - Gilles Karsenty
- Department of Urology, Aix Marseille University, Marseille, France
| | - Stefania Musco
- Department of Neuro-urology, Careggi University Hospital, Florence, Italy
| | - Bárbara Padilla-Fernández
- Department of Urology, Complejo Hospitalario Universitario de Canarias, Universidad de La Laguna, Tenerife, Spain
| | - Jürgen Pannek
- Neuro-Urology Department, Swiss Paraplegic Center, Nottwil, Switzerland; Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Natasha Schouten
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | | | - Bertil F M Blok
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
2
|
Vargas Maldonado D, Schulte PJ, Latuche LR, Vassilaki M, Petersen RC, Occhino JA, Linder BJ. Assessing the Impact of Overactive Bladder Medications on Cognition. UROGYNECOLOGY (PHILADELPHIA, PA.) 2024:02273501-990000000-00223. [PMID: 38710025 DOI: 10.1097/spv.0000000000001522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
IMPORTANCE Emerging literature has associated the use of anticholinergic medications to cognitive decline. OBJECTIVE The aim of this study was to evaluate the association of overactive bladder medications on cognitive function with prospective longitudinal cognitive assessments. STUDY DESIGN A population-based cohort of individuals 50 years and older who had serial validated cognitive assessment, in accordance with the Mayo Clinic Study of Aging, was evaluated from October 2004 through December 2021. Anticholinergic overactive bladder medications were grouped by traditional anticholinergic medications and central nervous system (CNS)- sparing anticholinergic medications and compared to no medication exposure. A linear mixed effects model with time-dependent exposures evaluated the association between overactive bladder anticholinergic medication exposure and subsequent trajectories of cognitive z-scores. RESULTS We included 5,872 participants with a median follow-up of 6.4 years. Four hundred forty-three were exposed to traditional anticholinergic medications, 60 to CNS-sparing medications, and 5,369 had no exposure. On multivariable analyses, exposure to any anticholinergic overactive bladder medication was significantly associated with deterioration in longitudinal cognitive scores in the language and attention assessments compared to the control cohort. Traditional anticholinergic medication exposure was associated with worse attention scores than nonexposed participants. Exposure to CNS-sparing anticholinergic medications was associated with a deterioration in the language domain compared to those unexposed. Among women, traditional anticholinergic medication exposure was associated with worse global and visuospatial scores than nonexposed participants, but this association was not identified in the CNS-sparing group. CONCLUSION Exposure to anticholinergic overactive bladder medications was associated with small but significantly worse decline in cognitive scoring in the language and attention domains when compared to nonexposed individuals.
Collapse
|
3
|
Dmochowski RR. Letter to the Editor re: Is It Time to Rethink Our Approach to Overactive Bladder Treatment? UROGYNECOLOGY (PHILADELPHIA, PA.) 2024; 30:476-477. [PMID: 38683202 DOI: 10.1097/spv.0000000000001518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Affiliation(s)
- Roger R Dmochowski
- From the Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN
| |
Collapse
|
4
|
Ingram CF, Lincoln JA, Khavari R. Voiding Phase Dysfunction in Multiple Sclerosis: Contemporary Review of Terminology, Diagnosis, Management, and Future Directions. Urol Clin North Am 2024; 51:177-185. [PMID: 38609190 DOI: 10.1016/j.ucl.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
Lower urinary tract symptoms (LUTS) are highly prevalent in individuals with multiple sclerosis (MS). However, assessment of these symptoms is often hindered by vague definitions or absence of screening in asymptomatic patients. It is crucial to exercise caution when applying the non-neurogenic definition of urinary retention in this population. For men with MS experiencing persistent and treatment-resistant LUTS, urodynamic studies should be used to identify the underlying causes of symptoms. Although numerous therapies are presently accessible for managing LUTS in MS, there is a need for further investigation into emerging treatments such as percutaneous tibial nerve, and noninvasive brain stimulation.
Collapse
Affiliation(s)
| | - John A Lincoln
- Department of Neurology, McGovern Medical School, UT Health Neurosciences Neurology, 6431 Fannin Street, MSB 7.222, Houston, TX 77030, USA
| | - Rose Khavari
- Department of Urology, Houston Methodist Hospital, 6560 Fannin Street Suite 2100, Houston, TX 77030, USA.
| |
Collapse
|
5
|
Heesakkers JPFA, Toozs-Hobson P, Sutherland SE, Digesu A, Amundsen CL, McCrery RJ, De Wachter S, Kean ER, Martens F, Benson K, Ferrante KL, Cline KJ, Padron OF, Giusto L, Lane FL, Dmochowski RR. A prospective study to assess the effectiveness and safety of the BlueWind System in the treatment of patients diagnosed with urgency urinary incontinence. Neurourol Urodyn 2024. [PMID: 38634481 DOI: 10.1002/nau.25477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/21/2024] [Accepted: 04/08/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Overactive bladder (OAB) affects one in six adults in Europe and the United States and impairs the quality of life of millions of individuals worldwide. When conservative management fails, third-line treatments including tibial neuromodulation (TNM) is often pursued. TNM has traditionally been accomplished percutaneously in clinic. OBJECTIVE A minimally invasive implantable device activated by a battery-operated external wearable unit has been developed for the treatment of urgency urinary incontinence (UUI), mitigating the burden of frequent clinic visits and more invasive therapies that are currently commercially available. METHODS A prospective, multicenter, single-arm, open-label, pivotal study evaluated the safety and effectiveness of the device in adult females with UUI (i.e., wet OAB) (BlueWind Implantable Tibial Neuromodulation [iTNM] system; IDE number #G200013; NCT03596671). Results with the device were previously published under the name RENOVA iStim, which has been since renamed as the Revi™ System. Approximately 1-month post-implantation of the device, participants delivered therapy at their convenience and completed a 7-day voiding diary before visits 6- and 12-months post-treatment initiation. The primary efficacy and safety endpoints were the proportion of responders to therapy ( ≥ 50% improvement on average number of urgency-related incontinence episodes) and incidence of adverse events from implantation to 12-month post-activation. RESULTS A total of 151 participants, mean age 58.8 (SD: 12.5), were implanted; 144 and 140 completed the 6- and 12-month visits, respectively. The participants demonstrated mean baseline of 4.8 UUI/day (SD 2.9) and 10 voids/day (SD 3.3). Six and 12-months post-activation, 76.4% and 78.4% of participants, respectively, were responders to therapy in an intent-to-treat analysis. Of the 139 participants with completed 12-month diaries, 82% were responders, 50% were classified as "dry" (on at least 3 consecutive diary days), and 93.5% of participants reported that their symptoms improved. No implanted participant experienced an SAE related to the procedure or device. CONCLUSIONS iTNM, delivered and powered by a patient-controlled external wearable communicating with an implant, demonstrated clinically meaningful and statistically significant improvement in UUI symptoms and a high safety profile. This therapy highlights the value of patient-centric therapy for the treatment of UUI.
Collapse
Affiliation(s)
| | | | - Suzette E Sutherland
- Department of Urology, UW Medicine Pelvic Health Center, University of Washington, Seattle, Washington, USA
| | - Alex Digesu
- St Mary's Hospital, Imperial College NHS Trust, London, UK
| | - Cindy L Amundsen
- Department of Obstetrics and Gynecology, Division of Urogynecology and Reconstructive Pelvic Surgery, Duke University, Durham, North Carolina, USA
| | | | - Stefan De Wachter
- Department of Urology, ASTARC Faculty of Medicine and Health Sciences, University of Antwerp, Edegem, Belgium
| | - Emily R Kean
- Adult Pediatric Urology & Urogynecology, Omaha, Nebraska, USA
| | - Frank Martens
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kevin Benson
- Department of Obstetrics and Gynecology, FPMRS Division, Sanford Health, University of South Dakota School of Medicine, Sioux Falls, South Dakota, USA
| | | | - Kevin J Cline
- Louisiana State University Medical Center, Shreveport, Louisiana, USA
| | | | - Laura Giusto
- Chesapeake Urology Research Associates, Baltimore, Maryland, USA
| | - Felicia L Lane
- Urogynecology and Reconstructive Surgery, University of California, Irvine, Irvine, California, USA
| | | |
Collapse
|
6
|
Chancellor MB, Lucioni A, Staskin D. Oxybutynin-associated Cognitive Impairment: Evidence and Implications for Overactive Bladder Treatment. Urology 2024; 186:123-129. [PMID: 38296001 DOI: 10.1016/j.urology.2023.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/20/2023] [Accepted: 11/28/2023] [Indexed: 03/21/2024]
Abstract
Anticholinergic medications have long been a mainstay of overactive bladder (OAB) treatment. Oxybutynin, a first-generation anticholinergic, still accounts for more than half of all OAB medication prescriptions, despite associations with impaired memory and cognition, as well as mounting evidence that it may increase the risk of incident dementia. This review details the current literature regarding oxybutynin and cognition, including evidence from preclinical, clinical, and real-world studies that show that oxybutynin binds nonspecifically to muscarinic receptors in the brain and is associated with adverse cognitive outcomes. We also discuss society recommendations to reduce use of oxybutynin and other anticholinergics to treat OAB.
Collapse
Affiliation(s)
- Michael B Chancellor
- Corewell Health Beaumont University Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI.
| | | | | |
Collapse
|
7
|
Ferreira R, Otis-Chapados S, Alwashmi E, Bhojani N, Zorn KC, Chughtai B, Elterman DS. Sacral neuromodulation in the golden years: Treatment outcomes in elderly 75 years and older. Can Urol Assoc J 2024; 18:12-16. [PMID: 37931277 PMCID: PMC10841569 DOI: 10.5489/cuaj.8421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
INTRODUCTION Despite high prevalence and increased severity and burden of overactive bladder (OAB) and fecal incontinence (FI) in the elderly, sacral neuromodulation (SNM) is often overlooked as a potential treatment option for this demographic. In this study, we report the outcomes of SNM in patients aged 75 years or older at the time of surgery. METHODS We conducted a retrospective cohort study of patients who underwent SNM implantation between 2013 and 2022 performed by a single, high-volume urologist at a tertiary center. Success, complication, and adjunct therapy rates were analyzed by Fisher's or Wilcox rank-sum test as appropriate. We compared outcomes between patients aged 75-79 years and octogenarians. RESULTS Of 632 patients, 50 were ≥75 years. Patients had a mean age of 78.4±2.6 years and were predominantly female (84%). The indications for SNM were 66% OAB, 16% FI, 16% non-obstructive urinary retention, and 4% pelvic pain. Within the first year, 94% of patients reported satisfaction and improvement in symptoms, while 76% continued to experience improvement beyond one year. SNM insertion led to reduced oral medication use from 68% to 24% (p<0.0001). The complication rate was 16% and mostly included device pain. No significant difference was observed in treatment success, complication, or adjunct therapy rate between age groups. CONCLUSIONS SNM is a safe and effective option in well-selected patients over the age of 75 years. Treatment success rate is comparable to younger cohorts. Advanced age should not preclude third-line therapy options in this population.
Collapse
Affiliation(s)
- Roseanne Ferreira
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Emad Alwashmi
- Division of Urology, University Health Network, Toronto, ON, Canada
- Department of Surgery, College of Medicine, Qassim University, Qassim, Saudi Arabia
| | - Naeem Bhojani
- University of Montreal Hospital Center, Université de Montréal, Montreal, QC, Canada
| | - Kevin C. Zorn
- University of Montreal Hospital Center, Université de Montréal, Montreal, QC, Canada
| | - Bilal Chughtai
- New York Presbyterian Hospital-Weill Cornell, New York, NY, United States
| | - Dean S. Elterman
- Division of Urology, University Health Network, Toronto, ON, Canada
| |
Collapse
|
8
|
Bazinet A, Chartier-Kastler E. Unmet needs in the management of neurourological disorders within the last 50 years. World J Urol 2023; 41:3845-3850. [PMID: 37919517 DOI: 10.1007/s00345-023-04662-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 09/28/2023] [Indexed: 11/04/2023] Open
Abstract
PURPOSE This abstract aims to assess the evolution of neurogenic patient management over the past century, with a focus on persistent unmet needs in the field. We reflect on the history of neurourology and its key principles, highlighting urgent needs for research and progress. METHODS This review is based on a non-systematic search of MEDLINE databases. We explore the historical context, innovations, and challenges in neurological patient care, using keywords such as "Neurourology", "history" and "future", as well as specific treatment modalities. RESULT Several unmet needs in the field of neurourology have been identified. These include the need to strike a balance between spontaneous micturition and continence, the search for solutions to restore spontaneous micturition in patients with acontractile bladders, the imperative to improve and personalize renal and bladder function monitoring, mitigation of the side effects of long-term treatments, strategies to manage recurrent urinary tract infections, and efforts to overcome organizational barriers in patient care. CONCLUSION The care of neurological patients has made remarkable progress over the past 50 years. However, persistent unmet needs underline the need for ongoing research and collaboration to improve the quality of care in this field.
Collapse
Affiliation(s)
- Amélie Bazinet
- Urologie, Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75651, Paris Cedex 13, France.
- Department of Urology, University of Montreal, Maisonneuve-Rosemont Hospital, Montreal, Canada.
| | - Emmanuel Chartier-Kastler
- Urologie, Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
| |
Collapse
|
9
|
Okita Y, Kitamura T, Komukai S, Zha L, Komatsu M, Narii N, Murata F, Megumi M, Gon Y, Kimura Y, Kiyohara K, Sobue T, Fukuda H. Association of anticholinergic drug exposure with the risk of dementia among older adults in Japan: The LIFE Study. Int J Geriatr Psychiatry 2023; 38:e6029. [PMID: 38041399 DOI: 10.1002/gps.6029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 11/12/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVES Several studies have investigated that anticholinergic drugs cause cognitive impairment. However, the risk of dementia associated with anticholinergics has not been extensively investigated in the super-aging society of Japan. We conducted this study to assess the association between anticholinergic drugs and the risk of dementia in older adults in Japan. METHODS This nested case-control study used data from the Longevity Improvement & Fair Evidence Study, which includes claim data in Japan from 2014 to 2020. We included 66,478 cases of diagnosed dementia and 328,919 matched controls aged ≥65 years, matched by age, sex, municipality, and cohort entry year. Primary exposure was the total cumulative anticholinergic drugs prescribed from cohort entry date to event date or matched index date, which was the total standardized daily doses for each patient, calculated by adding the total dose of different types of anticholinergic drugs in each prescription, divided by the World Health Organization-defined daily dose values. Odds ratios for dementia associated with cumulative exposure to anticholinergic drugs were calculated using conditional logistic regression adjusted for confounding variables. RESULTS The mean (standard deviation) age at index date was 84.3 (6.9), and the percentage of women was 62.1%. From cohort entry date to event date or matched index date, 18.8% of the case patients and 13.7% of the controls were prescribed at least one anticholinergic drug. In the multivariable-adjusted model, individuals with anticholinergic drugs prescribed had significantly higher odds of being diagnosed with dementia (adjusted odds ratio, 1.50 [95% confidence interval, 1.47-1.54]). Among specific types of anticholinergic drugs, a significant increase in risk was observed with the use of antidepressants, antiparkinsonian drugs, antipsychotics, and bladder antimuscarinics in a fully multivariable-adjusted model. CONCLUSIONS Several types of anticholinergic drugs used by older adults in Japan are associated with an increased risk of dementia. These findings suggest that the underlying risks should be considered alongside the benefits of prescribing anticholinergic drugs to this population.
Collapse
Affiliation(s)
- Yuki Okita
- Division of Environmental Medicine and Population Sciences, Department of Social Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Sho Komukai
- Biomedical Statistics, Department of Integrated Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Ling Zha
- Division of Environmental Medicine and Population Sciences, Department of Social Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Masayo Komatsu
- Division of Environmental Medicine and Population Sciences, Department of Social Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Nobuhiro Narii
- Division of Environmental Medicine and Population Sciences, Department of Social Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Fumiko Murata
- Department of Health Care Administration and Management, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Maeda Megumi
- Department of Health Care Administration and Management, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yasufumi Gon
- Department of Neurology, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Yasuyoshi Kimura
- Department of Neurology, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Kosuke Kiyohara
- Department of Food Science, Faculty of Home Economics, Otsuma Women's University, Chiyoda-ku, Japan
| | - Tomotaka Sobue
- Division of Environmental Medicine and Population Sciences, Department of Social Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Haruhisa Fukuda
- Department of Health Care Administration and Management, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| |
Collapse
|
10
|
Dmochowski RR, Newman DK, Rovner ES, Zillioux J, Malik RD, Ackerman AL. Patient and Clinician Challenges with Anticholinergic Step Therapy in the Treatment of Overactive Bladder: A Narrative Review. Adv Ther 2023; 40:4741-4757. [PMID: 37725308 PMCID: PMC10567877 DOI: 10.1007/s12325-023-02625-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/21/2023] [Indexed: 09/21/2023]
Abstract
Anticholinergics have been used in the treatment of overactive bladder (OAB), but their use is limited by poor tolerability and anticholinergic-related side effects. Increasingly, providers are discontinuing anticholinergic prescribing because of growing evidence of the association of anticholinergic use with increased risk of cognitive decline and other adverse effects. Newer medications for OAB, the β3-adrenergic receptor agonists mirabegron and vibegron, do not have anticholinergic properties and are typically well tolerated; however, many insurance plans have limited patient access to these newer OAB medications by requiring step therapy, meaning less expensive anticholinergic medications must be trialed and/or failed before a β3-agonist will be covered and dispensed. Thus, many patients are unable to easily access these medications. Step therapy and other drug utilization strategies (e.g., prior authorization) are often used to manage the growing costs of pharmaceuticals, but these policies do not always follow treatment guidelines and may harm patients as a result of treatment delays, discontinuations, or related increases in adverse events. Medical professionals have called for reform of drug utilization strategies through partnerships that include clinicians and policymakers. This narrative review discusses prescribing patterns for OAB treatment and the effect of switching between drugs, as well as the costs of step therapy and prior authorization on patients and prescribers.
Collapse
Affiliation(s)
- Roger R Dmochowski
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Diane K Newman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Eric S Rovner
- Department of Urology, Medical University of South Carolina, Charleston, SC, USA
| | - Jacqueline Zillioux
- Department of Urology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Rena D Malik
- Division of Urology, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - A Lenore Ackerman
- Departments of Urology and Obstetrics and Gynecology, Division of Pelvic Medicine and Reconstructive Surgery, David Geffen School of Medicine, University of California, Los Angeles, 10833 Le Conte Avenue, Box 951738, Los Angeles, CA, 90095-1738, USA.
| |
Collapse
|
11
|
Bishara D. Anticholinergic action is rarely a good thing. Ther Adv Psychopharmacol 2023; 13:20451253231195264. [PMID: 37701892 PMCID: PMC10493059 DOI: 10.1177/20451253231195264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/11/2023] [Indexed: 09/14/2023] Open
Abstract
The evidence for the risks associated with anticholinergic agents has grown considerably in the last two decades. Not only are they associated with causing peripheral side effects such as dry mouth, blurred vision and constipation, but they can also cause central effects such as cognitive impairment; and more recently, they have consistently been linked with an increased risk of dementia and death in older people. This paper reviews the evidence for the associations of anticholinergic agents and the risk of dementia and increased mortality in dementia.
Collapse
|
12
|
Wang J, Ritchey ME, Reynolds K, Carbonneau M, Carrera A, Goti N, Horn JR, Girman CJ. Assessment of Codispensing Patterns of Mirabegron and Prespecified CYP2D6 Substrates in Patients with Overactive Bladder. Drugs Real World Outcomes 2023; 10:439-446. [PMID: 37219800 PMCID: PMC10491567 DOI: 10.1007/s40801-023-00370-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Patients with overactive bladder (OAB) experience sudden, intense urges to urinate, which may include urge urinary incontinence and nocturia. Pharmacotherapy includes β3-adrenergic receptor agonists such as mirabegron; however, mirabegron contains a label warning for cytochrome P450 (CYP) 2D6 inhibition, making coadministration with CYP2D6 substrates require monitoring and dose adjustment to avoid unintended increases in substrate concentration. OBJECTIVE To understand the codispensing patterns of mirabegron among patients using ten predefined CYP2D6 substrates with and before mirabegron dispensing. METHODS This retrospective claims database analysis used the IQVIA PharMetrics® Plus Database to assess codispensing of mirabegron with ten predefined CYP2D6 substrate groups identified on the basis of medications most frequently prescribed in the United States, those with high susceptibility to CYP2D6 inhibition, and those with evidence for exposure-related toxicity. Patients had to be ≥ 18 years old before initiation of the CYP2D6 substrate episode that overlapped with mirabegron. The cohort entry period was November 2012 to September 2019, and the overall study period was 1 January 2011 to 30 September 2019. Comparisons of patient profiles at dispensing were made between time periods with and before mirabegron use in the same patient. Descriptive statistics were used to assess the number of exposure episodes, total duration of exposure, and median duration of exposure of CYP2D6 substrate dispensing with and before mirabegron. RESULTS CYP2D6 substrate exposure periods totaling ≥ 9000 person-months were available before overlapping exposure to mirabegron for all ten CYP2D6 substrate cohorts. Median codispensing duration for chronically administered CYP2D6 substrates was 62 (interquartile range [IQR] 91) days for citalopram/escitalopram, 71 (105) days for duloxetine/venlafaxine, and 75 (115) days for metoprolol/carvedilol; median codispensing duration for acutely administered CYP2D6 substrates was 15 (33) days for tramadol and 9 (18) days for hydrocodone. CONCLUSIONS In this claims database analysis, the dispensing patterns of CYP2D6 substrates with mirabegron displayed frequent overlapping of exposure. Thus, a need exists to better understand the outcomes experienced by patients with OAB who are at increased risk for drug‒drug interactions when taking multiple CYP2D6 substrates concurrently with a CYP2D6 inhibitor.
Collapse
Affiliation(s)
| | | | - Kamika Reynolds
- CERobs Consulting, LLC, Chapel Hill, NC, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Adam Carrera
- Urovant Sciences, 5281 California Ave, Suite 100, Irvine, CA, 92617, USA.
| | - Noelia Goti
- Urovant Sciences, 5281 California Ave, Suite 100, Irvine, CA, 92617, USA
| | - John R Horn
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA
| | | |
Collapse
|
13
|
Müderrisoglu AE, de la Rosette JJMCH, Michel MC. Potential side effects of currently available pharmacotherapies in male lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Expert Opin Drug Saf 2023; 22:1213-1224. [PMID: 38064204 DOI: 10.1080/14740338.2023.2293206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 12/06/2023] [Indexed: 12/20/2023]
Abstract
INTRODUCTION The drug classes of α1-adrenoceptor antagonists, 5α-reductase inhibitors, and phosphodiesterase type 5 inhibitors are guideline-recommended treatments of lower urinary tract symptoms suggestive of benign prostatic hyperplasia; muscarinic receptor antagonists and β3-adrenoceptor agonists are also recommended if storage symptoms are insufficiently addressed with one of the other three drug classes. AREAS COVERED We provide a narrative review (no formalized literature searches performed) of the tolerability of these drug classes with emphasis on the more recently introduced medications, on combination treatment, and on more lately emerging risks. EXPERT OPINION/COMMENTARY The tolerability profiles are distinct between drug classes but, with few exceptions, similar within a drug class. Within a drug, formulations with longer duration of action tend to have better tolerability. Efficacy gains using combination treatment at least partly come at a cost of lesser tolerability. Greater susceptibility to experience adverse events based on age, comorbidities, and comedications appears conceptually important but remains under-investigated in this therapeutic area.
Collapse
Affiliation(s)
- A Elif Müderrisoglu
- Department of Medical Pharmacology, Istanbul Medipol University, Istanbul, Turkiye
| | | | - Martin C Michel
- Department of Pharmacology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| |
Collapse
|
14
|
Poonawalla IB, Xu Y, Gaddy R, James A, Ruble M, Burns S, Dixon SW, Suehs BT. Anticholinergic exposure and its association with dementia/Alzheimer's disease and mortality in older adults. BMC Geriatr 2023; 23:401. [PMID: 37391728 PMCID: PMC10311860 DOI: 10.1186/s12877-023-04095-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/07/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND Use of anticholinergic (ACH) medications is associated with increased risk of cognitive decline in the elderly. However, little is known about this association from a health plan perspective. METHODS This retrospective cohort study used the Humana Research Database to identify individuals with at least one ACH medication dispensed in 2015. Patients were followed until incidence of dementia/Alzheimer's disease, death, disenrollment or end of December 2019. Multivariate Cox regression models were used to assess the association between ACH exposure and study outcomes, adjusting for demographics and clinical characteristics. RESULTS A total of 12,209 individuals with no prior ACH use or dementia/Alzheimer's disease diagnosis were included. As ACH polypharmacy increased (i.e., from no ACH exposure, to one, two, three, and four or more ACH medications), there was a stair-step increase in the incidence rate of dementia/Alzheimer's disease (15, 30, 46, 56 and 77 per 1,000 person-years of follow-up) and in the incidence of mortality (19, 37, 80, 115 and 159 per 1,000 person-years of follow-up). After adjusting for confounders, ACH exposure to one, two, three and four or more ACH medications was associated with a 1.6 (95% CI 1.4-1.9), 2.1 (95% CI 1.7-2.8), 2.6 (95% CI 1.5-4.4), and 2.6 (95% CI 1.1-6.3) times, respectively, increased risk of a dementia/Alzheimer's disease diagnosis compared to periods of no ACH exposure. ACH exposure to one, two, three and four or more medications was associated with a 1.4 (95% CI 1.2-1.6), 2.6 (95% CI 2.1-3.3), 3.8 (95% CI 2.6-5.4), and 3.4 (95% CI 1.8-6.4) times, respectively, increased risk of mortality compared to periods of no ACH exposure. CONCLUSIONS Reducing ACH exposure may potentially minimize long-term adverse effects in older adults. Results suggest populations which may benefit from targeted interventions to reduce ACH polypharmacy.
Collapse
Affiliation(s)
- Insiya B Poonawalla
- Humana Healthcare Research, Humana Inc., 500 W Main St, Louisville, KY, 40202, USA.
| | - Yihua Xu
- Humana Healthcare Research, Humana Inc., 500 W Main St, Louisville, KY, 40202, USA
| | - Rainelle Gaddy
- Humana Pharmacy Solutions, Humana Inc., 500 W Main St, Louisville, KY, 40202, USA
| | - Alex James
- Humana Pharmacy Solutions, Humana Inc., 500 W Main St, Louisville, KY, 40202, USA
| | - Matt Ruble
- Humana Pharmacy Solutions, Humana Inc., 500 W Main St, Louisville, KY, 40202, USA
| | - Salina Burns
- Humana Pharmacy Solutions, Humana Inc., 500 W Main St, Louisville, KY, 40202, USA
| | - Suzanne W Dixon
- Humana Healthcare Research, Humana Inc., 500 W Main St, Louisville, KY, 40202, USA
| | - Brandon T Suehs
- Humana Healthcare Research, Humana Inc., 500 W Main St, Louisville, KY, 40202, USA
| |
Collapse
|
15
|
Naseri A, Sadigh-Eteghad S, Seyedi-Sahebari S, Hosseini MS, Hajebrahimi S, Salehi-Pourmehr H. Cognitive effects of individual anticholinergic drugs: a systematic review and meta-analysis. Dement Neuropsychol 2023; 17:e20220053. [PMID: 37261256 PMCID: PMC10229087 DOI: 10.1590/1980-5764-dn-2022-0053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 11/11/2022] [Accepted: 11/26/2022] [Indexed: 06/02/2023] Open
Abstract
Anticholinergics (ACs) are among the most prescribed drugs. Investigating the impaired cognitive domains due to individual ACs usage is associated with controversial findings. Objective The objective of this study was to investigate the effects of individual ACs on different aspects of cognitive function based on clinical trial studies. Methods This systematic review was conducted following the PRISMA statement. A systematic search was performed in Embase, PubMed, Cochrane Library, Scopus, and Web of Science databases. Risk of bias (RoB) was assessed by the Joanna Briggs Institute checklists and the meta-analysis was performed using the CMA software. Results Out of 3,026 results of searching, 138 studies were included. A total of 38 studies that assess the cognitive impacts of scopolamine were included in the meta-analysis. Included studies reported cognitive effects of scopolamine, mecamylamine, atropine, biperiden, oxybutynin, trihexyphenidyl, benzhexol, and dicyclomine; however, glycopyrrolate, trospium, tolterodine, darifenacin, fesoterodine, tiotropium, and ipratropium were not associated with cognitive decline. Based on the meta-analyses, scopolamine was associated with reduced recognition (SDM -1.84; 95%CI -2.48 to -1.21; p<0.01), immediate recall (SDM -1.82; 95%CI -2.35 to -1.30; p<0.01), matching to sample (SDM -1.76; 95%CI -2.57 to -0.96; p<0.01), delayed recall (SDM -1.54; 95%CI -1.97 to -1.10; p<0.01), complex memory tasks (SDM -1.31; 95%CI -1.78 to -0.84; p<0.01), free recall (SDM -1.18; 95%CI -1.63 to -0.73; p<0.01), cognitive function (SDM -0.95; 95%CI -1.46 to -0.44; p<0.01), attention (SDM -0.85; 95%CI -1.38 to -0.33; p<0.01), and digit span (SDM -0.65; 95%CI -1.21 to -0.10; p=0.02). There was a high RoB in our included study, especially in terms of dealing with possible cofounders. Conclusion The limitations of this study suggest a need for more well-designed studies with a longer duration of follow-up on this topic to reach more reliable evidence.
Collapse
Affiliation(s)
- Amirreza Naseri
- Tabriz University of Medical Sciences, Student Research Committee, Tabriz, Iran
| | - Saeed Sadigh-Eteghad
- Tabriz University of Medical Sciences, Neurosciences Research Center, Tabriz, Iran
| | | | | | - Sakineh Hajebrahimi
- Tabriz University of Medical Sciences, Research Center for Evidence-Based Medicine, Iranian EBM Center: A Joanna Briggs Institute Center of Excellence, Tabriz, Iran
| | - Hanieh Salehi-Pourmehr
- Tabriz University of Medical Sciences, Research Center for Evidence-Based Medicine, Iranian EBM Center: A Joanna Briggs Institute Center of Excellence, Tabriz, Iran
| |
Collapse
|
16
|
Carr DN, Macharia A, Hacker MR, Winkelman WD. Despite Recommendations, Anticholinergics Account for the Majority of Prescriptions to Treat Overactive Bladder in the United States. UROGYNECOLOGY (PHILADELPHIA, PA.) 2023; 29:497-503. [PMID: 36730660 PMCID: PMC10134866 DOI: 10.1097/spv.0000000000001301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
IMPORTANCE There are significant associations between anticholinergic medication use and an increased risk of cognitive impairment and dementia. Many experts now advocate minimizing the use of anticholinergic medications to treat overactive bladder (OAB) in elderly women. OBJECTIVE The aim of this study was to describe temporal and geographic trends in the pharmacologic treatment of OAB for patients 65 years or older across the United States. STUDY DESIGN The U.S. Centers for Medicare & Medicaid Services publishes annual Medicare Provider Utilization and Payment Data. The data set includes the number of unique Part D beneficiaries 65 years or older with at least 1 claim for a drug and the number of 30-day fills dispensed. The database also includes the U.S. state and rural-urban commuting area designation of the prescriber. RESULTS From 2013 to 2019, Medicare Part D beneficiaries 65 years or older received 47.7 million 30-day fills for the treatment of OAB. In 2013, anticholinergics represented 98% of the total 30-day fills (5.6 million) for OAB. The use of β3 agonists was nearly 24 times greater in 2019 than in 2013. Geographic variation in prescribing practices was evident. CONCLUSIONS The number of anticholinergics dispensed for the treatment of OAB remained relatively stable, and there was a substantial increase in the use of β3 agonists. Percentages of anticholinergics dispensed varied among states. More patients are being treated for OAB; however, anticholinergics comprised the majority of prescriptions for treatment in 2019.
Collapse
Affiliation(s)
| | - Annliz Macharia
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center
| | | | | |
Collapse
|
17
|
Bhide AA, Digesu GA, Swift S. Overactive bladder medication - do we need to revisit trospium chloride for our elderly patients? Int Urogynecol J 2023; 34:961-962. [PMID: 37099160 DOI: 10.1007/s00192-023-05559-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2023] [Indexed: 04/27/2023]
Affiliation(s)
- Alka A Bhide
- St Mary's Hospital, Imperial College NHS Trust, London, UK
| | - G A Digesu
- St Mary's Hospital, Imperial College NHS Trust, London, UK.
| | - Steven Swift
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC, 29425, USA
| |
Collapse
|
18
|
Snyder D, Mujais S. Comment on: Pharmacist-driven interventions to de-escalate urinary antimuscarinics in the Programs of All-Inclusive Care for the Elderly. J Am Geriatr Soc 2023; 71:994-996. [PMID: 36582170 DOI: 10.1111/jgs.18204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 11/16/2022] [Indexed: 12/31/2022]
Abstract
See the Reply by David Bankes and Jacques Turgeon.
Collapse
Affiliation(s)
- Daniel Snyder
- Medical Affairs, Urovant Sciences, Irvine, California, USA
| | - Salim Mujais
- Clinical Development, Urovant Sciences, Irvine, California, USA
| |
Collapse
|
19
|
Patient perceived improvement and medication resumption rates after intradetrusor onabotulinumtoxina for idiopathic urgency urinary incontinence. Int Urogynecol J 2023; 34:745-749. [PMID: 35657395 DOI: 10.1007/s00192-022-05252-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 05/10/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Intradetrusor onabotulinumtoxinA (BTX-A) is a third-line therapy for overactive bladder (OAB), however several gaps exist in periprocedural care. Prior studies have demonstrated BTX-A efficacy at 2-3 weeks, but there are limited data documenting when patients should begin to note symptom improvement. The primary aim of this study was to evaluate patient-reported temporal improvement in symptoms, with secondary aim to evaluate medication resumption rates, following initial BTX-A injection. METHODS A prospective, single-arm cohort study of patients with non-neurogenic urgency incontinence undergoing initial BTX-A injection was performed. Intradetrusor 100 units BTX-A was administered in standard 20-site template. Patients discontinued OAB medication(s) at BTX-A injection and completed a daily Patient Global Impression of Improvement (PGI-I) diary for 3 weeks. Data were collected at 1 month, including final satisfaction score, medication resumption rates, and adverse outcomes. RESULTS Fifty-one patients were included, with 25 patients (49%) actively taking an OAB medication. Median time to first improvement was 3 days, at least "much better" (PGI-I <2) was 5 days, and maximal improvement was 7 days. Twenty of 25 patients (80%) opted to remain off OAB medications at 1 month based on symptomatic improvement following injection. Adverse outcomes included urinary tract infection in three patients (6%) and symptomatic incomplete emptying requiring temporary intermittent catheterization in two patients (4%). CONCLUSIONS Median time to first and maximal improvement was 3 and 7 days, respectively, following initial 100 units BTX-A. Eighty percent of patients on medications opted to remain off at 1 month. These data may help further counsel patient expectations following initial BTX-A therapy.
Collapse
|
20
|
Zillioux J, Lewis KC, Hettel D, Goldman HB, Vasavada SP, Gill BC. Cognitive impairment does not impact sacral neuromodulation implant rates for overactive bladder. Neurourol Urodyn 2023; 42:623-630. [PMID: 36701189 DOI: 10.1002/nau.25138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/02/2023] [Accepted: 01/16/2023] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To evaluate the impact of cognitive impairment (CI) diagnoses on sacral neuromodulation (SNM) outcomes in older patients. MATERIALS AND METHODS We completed a retrospective review of all patients aged ≥55 years who underwent test-phase SNM (peripheral nerve evaluation (PNE) or stage 1) for overactive bladder (OAB) between 2014 and 2021 within a large multi-regional health system. Patient demographics, relevant comorbidities, CI diagnoses (dementia or mild CI), and SNM procedures were recorded. Logistic regression modeling was performed to evaluate the impact of CI on SNM implantation rates. RESULTS Five-hundred and ten patients underwent SNM test phase (161 PNE, 349 Stage 1) during the study period. The mean age was 71.0(8.5) years, and most (80.6%) were female. Overall, 52(10.1%) patients had a CI diagnosis at the time of SNM, and 30 (5.8%) were diagnosed at a median of 18.5 [9.25, 39.5] months after SNM. Patients with CI diagnoses were older, with more comorbidities, and were more likely to undergo PNE. Univariable comparison found no difference in implantation rate based on pre-SNM CI (85.4% vs. 76.9%, p = 0.16). Multivariable analysis identified PNE (OR 0.43, 95% CI 0.26-0.71), age (OR 0.96, 95%CI 0.93-0.98), and prior beta-3 agonist use (OR 0.60, 95% CI 0.37-0.99) but not CI or dementia as independent negative predictors of implantation. Implanted patients had a median follow-up of 25 [12.0, 55.0] months. Explant and revision rates did not differ according to CI. CONCLUSION Patients with OAB and CI diagnoses proceed to SNM implant at rates similar to patients without CI diagnoses. A diagnosis of CI should not necessarily exclude patients from SNM therapy for refractory OAB.
Collapse
Affiliation(s)
- Jacqueline Zillioux
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kevin C Lewis
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Daniel Hettel
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Howard B Goldman
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Sandip P Vasavada
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Bradley C Gill
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| |
Collapse
|
21
|
Manunta A, Peyronnet B, Olivari-Philiponnet C, Chartier-Kastler E, Saussine C, Phé V, Robain G, Denys P, Even A, Samson E, Grise P, Karsenty G, Hascoet J, Castel-Lacanal E, Charvier K, Guinet-Lacoste A, Chesnel C, Amarenco G, Haffner F, Haddad M, Le Normand L, Perrouin-Verbe MA, Perrouin-Verbe B, De Seze M, Ruffion A, Gamé X. [Guidelines on the urological management of the adult patient with spinal dysraphism (spina bifida)]. Prog Urol 2023; 33:178-197. [PMID: 36609138 DOI: 10.1016/j.purol.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 12/10/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Improved life expectancy and prenatal screening have changed the demographics of spina bifida (spinal dysraphism) which has presently become a disease of adulthood. Urinary disorders affect almost all patients with spinal dysraphism and are still the leading cause of mortality in these patients. The aim of this work was to establish recommendations for urological management that take into account the specificities of the spina bifida population. MATERIALS AND METHODS National Diagnosis and Management Guidelines (PNDS) were drafted within the framework of the French Rare Diseases Plan at the initiative of the Centre de Référence Maladies Rares Spina Bifida - Dysraphismes of Rennes University Hospital. It is a collaborative work involving experts from different specialties, mainly urologists and rehabilitation physicians. We conducted a systematic search of the literature in French and English in the various fields covered by these recommendations in the MEDLINE database. In accordance with the methodology recommended by the authorities (Guide_methodologique_pnds.pdf, 2006), proposed recommendations were drafted on the basis of this literature review and then submitted to a review group until a consensus was reached. RESULTS Bladder dysfunctions induced by spinal dysraphism are multiple and varied and evolve over time. Management must be individually adapted and take into account all the patient's problems, and is therefore necessarily multi-disciplinary. Self-catheterisation is the appropriate micturition method for more than half of the patients and must sometimes be combined with treatments aimed at suppressing any neurogenic detrusor overactivity (NDO) or compliance alteration (anticholinergics, intra-detrusor botulinum toxin). Resort to surgery is sometimes necessary either after failure of non-invasive treatments (e.g. bladder augmentation in case of NDO resistant to pharmacological treatment), or as a first line treatment in the absence of other non-invasive alternatives (e.g. aponeurotic suburethral tape or artificial urinary sphincter for sphincter insufficiency; urinary diversion by ileal conduit if self-catheterisation is impossible). CONCLUSION Spinal dysraphism is a complex pathology with multiple neurological, orthopedic, gastrointestinal and urological involvement. The management of bladder and bowel dysfunctions must continue throughout the life of these patients and must be integrated into a multidisciplinary context.
Collapse
Affiliation(s)
- A Manunta
- Centre de référence Spina Bifida-Dysraphismes, CHU Pontchaillou, Rennes, France
| | - B Peyronnet
- Centre de référence Spina Bifida-Dysraphismes, CHU Pontchaillou, Rennes, France.
| | | | - E Chartier-Kastler
- Service d'Urologie, GH Pitié-Salpétrière, APHP, Paris, France; Sorbonne Université, Paris, France; Service de médecine physique et réadaptation, Hôpital Raymond-Poincaré, APHP, Garches, France
| | - C Saussine
- Service d'urologie, les hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - V Phé
- Service d'urologie, Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Paris, France
| | - G Robain
- Service de médecine physique et réadaptation, Hôpital Rotschild, APHP, Paris, France
| | - P Denys
- Service de médecine physique et réadaptation, Hôpital Raymond-Poincaré, APHP, Garches, France; Faculté de médecine Paris Ouest, Université de Versailles-Saint-Quentin-en-Yvelines, Garches, France
| | - A Even
- Service de médecine physique et réadaptation, Hôpital Raymond-Poincaré, APHP, Garches, France; Faculté de médecine Paris Ouest, Université de Versailles-Saint-Quentin-en-Yvelines, Garches, France
| | - E Samson
- Centre de référence Spina Bifida-Dysraphismes, CHU Pontchaillou, Rennes, France
| | - P Grise
- Service d'urologie, CHU Rouen, Rouen, France
| | - G Karsenty
- Aix-Marseille Université, urologie et transplantation rénale, Hôpital La Conception, AP-HM, Marseille, France
| | - J Hascoet
- Centre de référence Spina Bifida-Dysraphismes, CHU Pontchaillou, Rennes, France
| | - E Castel-Lacanal
- CHU Toulouse, service de médecine physique et de réadaptation et ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - K Charvier
- Service de médecine physique et réadaptation, Hôpital Henry-Gabrielle, Hospices civils de Lyon, Saint-Genis-Laval, France
| | - A Guinet-Lacoste
- Sorbonne Université, GRC 001, GREEN Groupe de recherche clinique en neuro-urologie, AP-HP, Hôpital Tenon, 75020 Paris, France
| | - C Chesnel
- Sorbonne Université, GRC 001, GREEN Groupe de recherche clinique en neuro-urologie, AP-HP, Hôpital Tenon, 75020 Paris, France; Service de neuro-urologie et explorations périnéales, Hôpital Tenon, AP-HP, Paris, France
| | - G Amarenco
- Sorbonne Université, GRC 001, GREEN Groupe de recherche clinique en neuro-urologie, AP-HP, Hôpital Tenon, 75020 Paris, France; Service de neuro-urologie et explorations périnéales, Hôpital Tenon, AP-HP, Paris, France
| | - F Haffner
- ASBH, Association nationale Spina Bifida et Handicaps associés, 94420 Le Plessis Trevise, France
| | - M Haddad
- Service de chirurgie viscérale et urologie pédiatrique, AP-HM, Marseille, France
| | - L Le Normand
- Service d'urologie, CHU de Nantes, Nantes, France
| | | | - B Perrouin-Verbe
- Service de médecine physique et réadaptation, CHU de Nantes, Nantes, France
| | - M De Seze
- Spécialiste en médecine physique et de réadaptation, Clinique St.-Augustin, Bordeaux, France
| | - A Ruffion
- Service d'urologie, Hospices civils de Lyon, Lyon, France
| | - X Gamé
- Département d'urologie, transplantation rénale et andrologie, CHU Rangueil, Université Paul-Sabatier, Toulouse, France
| |
Collapse
|
22
|
Monaghan TF, Weiss JP, Wein AJ, Rahman SN, Lazar JM, Bliwise DL, Everaert K, Lemack GE, Cornu JN, Drake MJ, Chapple CR, Hashim H, Blaivas JG, Dmochowski RR. Sleep Disorders, Comorbidities, Actions, Lower Urinary Tract Dysfunction, and Medications ("Sleep C.A.L.M.") in the evaluation and management of nocturia: A simple approach to a complex diagnosis. Neurourol Urodyn 2023; 42:562-572. [PMID: 36655726 DOI: 10.1002/nau.25128] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Nocturia arises from a fundamental mismatch between nocturnal urine production, storage capacity, and sleep architecture, which may be driven by abnormalities of the genitourinary tract, but also by sleep disorders, medical diseases, patient actions/lifestyle factors, or medications. This article introduces a novel system for organizing the complex differential diagnosis for nocturia, as proposed by an international collective of practicing urologists, physician specialists, and sleep experts: "Sleep CALM"-Sleep Disorders, Comorbidities, Actions, Lower Urinary Tract Dysfunction, and Medications. METHODS Narrative review of current evidence regarding the relevance of each "Sleep CALM" factor to nocturia pathogenesis, evaluation, and management. RESULTS Nocturia and sleep disorders are highly intertwined and often bidirectional, such that nocturnal awakenings for reasons other than a sensation of bladder fullness should not be used as grounds for exclusion from nocturia treatment, but rather leveraged to broaden therapeutic options for nocturia. Nocturia is an important potential harbinger of several serious medical conditions beyond the genitourinary tract. Urologists should have a low threshold for primary care and medical specialty referral for medical optimization, which carries the potential to significantly improve nocturnal voiding frequency in addition to overall health status. Adverse patient actions/lifestyle factors, lower urinary tract dysfunction, and medication use commonly coexist with disordered sleep and comorbid medical conditions, and may be the primary mediators of nocturia severity and treatment response, or further exacerbate nocturia severity and complicate treatment. CONCLUSION "Sleep CALM" provides a memorable and clinically relevant means by which to structure the initial patient history, physical exam, and clinical testing in accordance with current best-practice guidelines for nocturia. Although not intended as an all-encompassing diagnostic tool, the "Sleep CALM" schema may also be useful in guiding individualized ancillary testing, identifying the need for specialty referral and multidisciplinary care, and uncovering first-line treatment targets.
Collapse
Affiliation(s)
- Thomas F Monaghan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jeffrey P Weiss
- Department of Urology, SUNY Downstate Health Sciences University, Brooklyn, New York, USA
| | - Alan J Wein
- Division of Urology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Syed N Rahman
- Department of Urology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jason M Lazar
- Department of Medicine, Division of Cardiovascular Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, USA
| | - Donald L Bliwise
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Karel Everaert
- Department of Human Structure and Repair, Faculty of Medicine and Health Science, Ghent University, Ghent, Belgium
| | - Gary E Lemack
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jean-Nicolas Cornu
- Department of Urology, Charles Nicolle University Hospital, Rouen, France
| | - Marcus J Drake
- Department of Urology, Imperial College London, Imperial College Healthcare NHS Trust, London, UK
| | - Christopher R Chapple
- Department of Urology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Hashim Hashim
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Jerry G Blaivas
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Roger R Dmochowski
- Department of Urological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
23
|
Game X, Dmochowski R, Robinson D. Mixed urinary incontinence: Are there effective treatments? Neurourol Urodyn 2023; 42:401-408. [PMID: 36762411 PMCID: PMC10092712 DOI: 10.1002/nau.25065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 09/06/2022] [Accepted: 10/07/2022] [Indexed: 11/10/2022]
Abstract
The aim of this debate article is to discuss whether effective treatments are available for mixed urinary incontinence (MUI). Because patients with MUI have both stress and urgency urinary incontinence (SUI and UUI) episodes and current treatment guidelines currently recommend treating the predominant symptom first, this article presents standard and emerging treatments for both SUI and UUI before discussing how well these treatments meet the medical needs of patients with MUI. Standard treatments presented include noninvasive options such as lifestyle changes and pelvic floor exercises, pharmacological agents, and surgery. Treatment of all three types of urinary incontinence (UI) is usually initiated with noninvasive options, after which treatment options diverge based on UI subtype. Multiple pharmacological agents have been developed for the treatment of UUI and overactive bladder, whereas surgery remains the standard option for SUI and stress-predominant MUI. The divide between UUI and SUI options seems to be propagated in emerging treatments, with most novel pharmacological agents still targeting UUI and even having SUI and stress-predominant MUI as exclusion criteria for participation in clinical trials. Considering that current treatment options focus almost exclusively on treating the predominant symptom of MUI and that emerging pharmacological treatments exclude patients with stress-predominant MUI during the development phase, effective treatments for MUI are lacking both in standard and emerging practice. Ideally, agents with dual mechanisms of action could provide symptom benefit for both the stress and urgency components of MUI.
Collapse
Affiliation(s)
- Xavier Game
- Department of Urology, CHU Rangueil, Toulouse, France
| | - Roger Dmochowski
- Department of Urology, Vanderbilt University, Nashville, Tennessee, USA
| | - Dudley Robinson
- Department of Urogynaecology, Kings College Hospital, London, UK
| |
Collapse
|
24
|
Abstract
PURPOSE OF REVIEW Up to half of postmenopausal women experience genitourinary symptoms secondary to hormone deficiency, and there is little consensus on the use of vaginal hormone therapy (VHT) for lower urinary tract symptoms (LUTS) in these patients. This is a review of the scientific literature in the last decade evaluating the use of VHT for disorders of the lower urinary tract including overactive bladder (OAB), stress urinary incontinence (SUI), recurrent urinary tract infections (UTI), and interstitial cystitis/bladder pain syndrome (ICS/BPS). RECENT FINDINGS Vaginal estrogen therapy improves OAB symptoms in postmenopausal women, but results are mixed when VHT is used in combination with other treatments. There is inconclusive or limited data for the use of VHT to treat SUI and IC/BPS. Vaginal estrogen and prasterone (DHEA) therapies have demonstrated efficacy as treatment modalities for patients who experience recurrent UTIs. VHT preparations show efficacy for the treatment of certain LUTS and can be considered in carefully selected patients when clinically indicated.
Collapse
|
25
|
Efficacy and Safety of Vibegron for the Treatment of Overactive Bladder in Women: A Subgroup Analysis From the Double-Blind, Randomized, Controlled EMPOWUR Trial. UROGYNECOLOGY (HAGERSTOWN, MD.) 2023; 29:48-57. [PMID: 36384907 DOI: 10.1097/spv.0000000000001258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE The international phase 3 EMPOWUR trial demonstrated efficacy and safety of vibegron, a newer β 3 -adrenergic receptor agonist, in adults with overactive bladder (OAB). Women are disproportionately affected by OAB, especially those with bothersome symptoms, such as urge urinary incontinence (UUI). OBJECTIVE This subgroup analysis from EMPOWUR assessed efficacy and safety of vibegron in women. STUDY DESIGN In EMPOWUR, patients with OAB were randomized 5:5:4 to 12 weeks of treatment with once-daily vibegron 75 mg, placebo, or tolterodine 4-mg extended release. Efficacy end points included change from baseline at week 12 in mean daily number of micturitions, UUI episodes, and urgency episodes. Safety was assessed through adverse events (AEs). RESULTS Of the patients included in the analysis, 1286 (84.9%) were women (vibegron, n = 463; placebo, n = 459; tolterodine, n = 364). At week 12, women receiving vibegron showed significant reductions (95% confidence intervals of least squares mean differences does not include 0) from baseline versus placebo in mean daily micturitions, UUI episodes, and urgency episodes, with least squares mean differences (95% confidence intervals) of -0.5 (-0.8 to -0.2), -0.7 (-1.0 to -0.4), and -0.8 (-1.3 to -0.4), respectively. Treatment-emergent AE incidence was similar with vibegron (39%) and placebo (35%); the most common AE with incidence higher with vibegron (4.3%) than placebo (2.6%) was headache. CONCLUSIONS In this subgroup analysis, women receiving vibegron showed significant reductions in key efficacy end points versus placebo and favorable safety profile, consistent with the overall results from EMPOWUR, suggesting that vibegron is efficacious and safe for the treatment of OAB in this patient population.
Collapse
|
26
|
Evidence-Informed, Interdisciplinary, Multidimensional Action Plan to Advance Overactive Bladder Research and Treatment Initiatives: Directives From State-of-the-Science Conference on Overactive Bladder and Cognitive Impairment. UROGYNECOLOGY (HAGERSTOWN, MD.) 2023; 29:S20-S39. [PMID: 36548637 DOI: 10.1097/spv.0000000000001274] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
ABSTRACT This article outlines an evidence-informed, interdisciplinary, multidimensional, comprehensive action plan for the American Urogynecologic Society to improve care of women with overactive bladder (OAB) while minimizing treatment-related adverse events, including cognitive impairment. It is a "call to action" to advance basic, translational, and clinical research and summarizes initiatives developed at the State-of-the-Science Conference on OAB and Cognitive Impairment to (1) develop framework for a new OAB treatment approach in women, (2) define research gaps and future research priorities, (3) champion health equity and diversity considerations in OAB treatment, (4) foster community and promote education to remove stigma surrounding OAB and urinary incontinence, and (5) elevate visibility and impact of OAB, by creating partnerships through education and engagement with health care professionals, industry, private and public payers, funding agencies, and policymakers.
Collapse
|
27
|
Wu SY, Jhang JF, Liu HH, Chen JT, Li JR, Chiu B, Chen SL, Kuo HC. Long-Term Surveillance and Management of Urological Complications in Chronic Spinal Cord-Injured Patients. J Clin Med 2022; 11:7307. [PMID: 36555924 PMCID: PMC9785560 DOI: 10.3390/jcm11247307] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/02/2022] [Accepted: 12/07/2022] [Indexed: 12/13/2022] Open
Abstract
Bladder dysfunction is a common complication after chronic spinal cord injury (SCI). Patients may experience renal function loss, urinary tract infection (UTI), urolithiasis, bladder cancer, and even life-threatening events such as severe sepsis or renal failure. Suitable patient care may prevent UTI and urinary incontinence, decrease medication use, and preserve renal function. As the primary goal is to preserve renal function, management should be focused on facilitating bladder drainage, the avoidance of UTI, and the maintenance of a low intravesical pressure for continence and complete bladder emptying. Currently, several bladder management options are available to SCI patients: (1) reflex voiding; (2) clean intermittent catheterization; (3) indwelling catheterization. The target organ may be the bladder or the bladder outlet. The purposes of intervention include the following: (1) increasing bladder capacity and/or decreasing intravesical pressure; (2) increasing bladder outlet resistance; (3) decreasing bladder outlet resistance; (4) producing detrusor contractility; (5) urinary diversion. Different bladder management methods and interventions may have different results depending on the patient's lower urinary tract dysfunction. This review aims to report the current management options for long-term bladder dysfunction in chronic SCI patients. Furthermore, we summarize the most suitable care plans for improving the clinical outcome of SCI patients.
Collapse
Affiliation(s)
- Shu-Yu Wu
- Department of Urology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 23142, Taiwan
- Department of Urology, School of Medicine, Tzu Chi University, Hualien 97004, Taiwan
| | - Jia-Fong Jhang
- Department of Urology, School of Medicine, Tzu Chi University, Hualien 97004, Taiwan
- Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97002, Taiwan
| | - Hsin-Ho Liu
- Department of Urology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung 42743, Taiwan
| | - Jian-Ting Chen
- Division of Urology, Department of Surgery, Yuanlin Christian Hospital, Changhua 51053, Taiwan
| | - Jian-Ri Li
- Department of Urology, Taichung Veterans General Hospital, Taichung 40705, Taiwan
| | - Bin Chiu
- Department of Urology, Far Eastern Memorial Hospital, New Taipei City 22000, Taiwan
| | - Sung-Lang Chen
- Department of Urology, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
- Department of Urology, School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
| | - Hann-Chorng Kuo
- Department of Urology, School of Medicine, Tzu Chi University, Hualien 97004, Taiwan
- Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97002, Taiwan
| |
Collapse
|
28
|
CYP2D6 Substrate Dispensing Among Patients Dispensed Mirabegron: An Administrative Claims Analysis. Drugs Real World Outcomes 2022; 10:119-129. [PMID: 36456851 PMCID: PMC9944153 DOI: 10.1007/s40801-022-00339-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Overactive bladder (OAB) is characterized by the presence of bothersome urinary symptoms. Pharmacologic treatment options for OAB include anticholinergics and β3-adrenergic agonists. Use of β3-adrenergic agonists may result in similar treatment efficacy with a decreased side effect profile compared with anticholinergics because high anticholinergic burden is associated with cardiovascular and neurologic side effects. However, the β3-adrenergic agonist mirabegron, one of two approved drugs within this class, is a moderate cytochrome P450 (CYP) 2D6 inhibitor, and coadministration of drugs that are CYP2D6 substrates with mirabegron may lead to adverse drug effects. OBJECTIVE The aim of this study was to quantify how often CYP2D6 substrates were dispensed in patients receiving mirabegron among adults of any age and among those ≥ 65 years of age. METHODS In this retrospective descriptive analysis, a deidentified administrative claims database in the United States, IQVIA PharMetrics® Plus, was used to identify dispensing claims for CYP2D6 substrates and mirabegron from November 2012 to September 2019. Prevalence of CYP2D6 substrate dispensing was assessed in patients dispensed mirabegron among all adults ≥ 18 years old and additionally among a cohort of those ≥ 65 years old. Patient baseline profiles at the time of mirabegron and CYP2D6 substrate codispensing and at the time of mirabegron dispensing were compared. CYP2D6 substrates were categorized as those with the potential for increased risk of QT prolongation, with anticholinergic properties, with narrow therapeutic index (NTI), contraindicated or having a black box warning when used with CYP2D6 inhibitors, or used for depression or other psychiatric disease. Dispensing data and patient profiles were summarized descriptively. RESULTS Overall, 68.5% of adults ≥ 18 years old dispensed mirabegron had overlapping dispensings for one or more CYP2D6 substrate; 60.6% and 53.6% had overlapping dispensings for CYP2D6 substrates with anticholinergic properties or risk of QT prolongation, respectively. CYP2D6 substrates with NTI, contraindicated with CYP2D6 inhibitors, or for psychiatric use were codispensed in 17.7%, 16.6%, and 38.0% of adult mirabegron users, respectively. Mirabegron users receiving one or more concurrent CYP2D6 substrate were more likely to be older, have more comorbidities and baseline polypharmacy, and have increased healthcare resource utilization compared with those without concurrent CYP2D6 substrates. Commonly codispensed CYP2D6 substrates included hydrocodone, oxycodone, tramadol, metoprolol, and tamsulosin. Findings were similar for patients in the older cohort (≥ 65 years old), with 72.1% receiving overlapping CYP2D6 substrates. CONCLUSIONS Codispensing of CYP2D6 substrates, especially those with anticholinergic properties or risk of QT prolongation, was common among adults and older adults receiving mirabegron. Results highlight the need for improved awareness of CYP2D6 substrate prescribing among patients receiving pharmacologic treatment for OAB that inhibits the CYP2D6 pathway.
Collapse
|
29
|
Duperrouzel C, Martin C, Mendell A, Bourque M, Carrera A, Mack A, Nesheim J. Healthcare and economic burden of anticholinergic use in adults with overactive bladder: a systematic literature review. J Comp Eff Res 2022; 11:1375-1394. [PMID: 36354285 DOI: 10.2217/cer-2022-0160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Aim: To determine the economic burden associated with anticholinergic medication use in adults with overactive bladder (OAB) in the USA. Methods: A systematic literature review was conducted to identify articles assessing healthcare resource utilization (HCRU) and costs associated with anticholinergic use in adults with OAB. Results: From the 34 articles identified, increased anticholinergic burden, switching anticholinergic treatments and potentially inappropriate anticholinergic use were associated with increased HCRU and/or costs. However, studies comparing patients with OAB receiving anticholinergics to individuals with untreated OAB or without OAB reported a mix of increases and decreases in HCRU and costs. Conclusion: Additional controlled studies assessing the economic impact of anticholinergics in OAB are needed and may enable optimization of economic and potentially patient outcomes.
Collapse
|
30
|
Zillioux J, Slopnick EA, Vasavada SP. Third-line therapy for overactive bladder in the elderly: Nuances and considerations. Neurourol Urodyn 2022; 41:1967-1974. [PMID: 35645033 PMCID: PMC9796112 DOI: 10.1002/nau.24965] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Overactive bladder (OAB) disproportionally affects older adults in both incidence and severity. OAB pharmacotherapy is often problematic in the elderly due to polypharmacy, adverse side effect profiles and contraindications in the setting of multiple comorbidities, and concerns regarding the risk of incident dementia with anticholinergic use. The burden of OAB in older patients coupled with concerns surrounding pharmacotherapy options should motivate optimization of nonpharmacologic therapies in this population. At the same time, several aspects of aging may impact treatment efficacy and decision-making. This narrative review critically summarizes current evidence regarding third-line OAB therapy use in the elderly and discusses nuances and treatment considerations specific to the population. METHODS We performed an extensive, nonsystematic evidence assessment of available literature via PubMed on onabotulinumtoxinA (BTX-A), sacral neuromodulation, and percutaneous tibial nerve stimulation (PTNS) for OAB, with a focus on study in elderly and frail populations. RESULTS While limited, available studies show all three third-line therapies are efficacious in older populations and there is no data to support one option over another. BTX-A likely has a higher risk of urinary tract infection and retention in older compared to younger populations, especially in the frail elderly. PTNS incurs the lowest risk, although adherence is poor, largely due to logistical burdens. CONCLUSION Advanced age and frailty should not preclude third-line therapy for refractory OAB, as available data support their efficacy and safety in these populations. Ultimately, treatment choices should be individualized and involve shared decision-making.
Collapse
Affiliation(s)
- Jacqueline Zillioux
- Department of UrologyGlickman Urological and Kidney Institute, Cleveland ClinicClevelandOhioUSA
| | - Emily A. Slopnick
- Department of UrologyGlickman Urological and Kidney Institute, Cleveland ClinicClevelandOhioUSA
| | - Sandip P. Vasavada
- Department of UrologyGlickman Urological and Kidney Institute, Cleveland ClinicClevelandOhioUSA
| |
Collapse
|
31
|
King J, Walker A, Aikin D, Haag-Molkenteller C, Kankam M. Pharmacokinetics and Safety of Vibegron 75 mg Administered as an Intact or Crushed Tablet in Healthy Adults. Clin Pharmacol Drug Dev 2022; 11:1349-1355. [PMID: 36104302 DOI: 10.1002/cpdd.1169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 08/19/2022] [Indexed: 01/27/2023]
Abstract
Oral pharmacotherapy for overactive bladder, a condition that increases with age, includes anticholinergics and β3 -adrenergic receptor agonists. Older adults, including those with dysphagia, may have difficulty swallowing tablets. In this phase 1 study in healthy adults, we assessed the pharmacokinetic profile of the β3 -adrenergic receptor agonist vibegron administered as a single 75-mg dose as an intact tablet versus crushed and mixed with applesauce. Additional end points included safety (assessed by adverse events), perception of taste (assessed via questionnaire), and stability over 4 hours after crushing and mixing in applesauce (assessed by chromatography). Overall, 30 participants were randomized, and 29 were included in the pharmacokinetic analysis. Crushing a vibegron tablet and mixing with applesauce decreased vibegron maximum observed plasma concentration and area under the plasma concentration-time curve from time 0 to infinity by ≈30% and ≈10%, respectively; however, these decreases were not considered clinically significant. Treatment-emergent adverse events were reported in 16 (53.3%) participants. Approximately half of participants reported the vibegron and applesauce mixture tasted as expected; of those reporting the taste was different than expected, 50% reported the taste as bitter. The mixture was stable for 4 hours in applesauce. The results of this study showed that crushing and administering vibegron with applesauce may be an appropriate option for patients with overactive bladder and swallowing difficulties.
Collapse
Affiliation(s)
| | | | | | | | - Martin Kankam
- Altasciences Clinical Kansas, Inc (formerly Vince & Associates Clinical Research, Inc), Overland Park, KS, USA
| |
Collapse
|
32
|
Kennelly M, Wielage R, Shortino D, Thomas E, Mudd PN. Long-term efficacy and safety of vibegron versus mirabegron and anticholinergics for overactive bladder: a systematic review and network meta-analysis. Drugs Context 2022; 11:dic-2022-4-2. [PMID: 36303599 PMCID: PMC9576010 DOI: 10.7573/dic.2022-4-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/18/2022] [Indexed: 11/07/2022] Open
Abstract
Background Few randomized controlled trials evaluate the long-term efficacy and safety of pharmacotherapy for overactive bladder (OAB). This network meta- analysis compares the long-term (52-week) efficacy and safety of vibegron, mirabegron and anticholinergics for the treatment of OAB. Methods A systematic literature review and network meta-analysis were conducted following PRISMA guidelines using MEDLINE, Embase and Cochrane Central Register of Controlled Trials and terms related to OAB. Efficacy outcomes included change from baseline to week 48–52 in mean daily total urinary incontinence (UI) episodes, mean daily number of micturitions and volume voided/micturition. Efficacy outcomes were analysed using Bayesian models. Commonly reported adverse events (AEs) are described. Results Of 2098 hits retrieved, 5 publications and 1 study report describing 5 unique randomized controlled trials were included in the analyses. Mean (95% credible interval) change from baseline in total UI episodes for vibegron 75 mg (−2.2; −2.9 to −1.5) showed a significantly greater reduction than mirabegron 50 mg (−1.3; −1.9 to −0.8) and tolterodine 4 mg extended release (−1.6; −2.1 to −1.1). No significant differences were observed between vibegron and comparators for daily micturitions or volume voided/micturition. Within the manuscripts, the 4 most common AEs (range) for anticholinergics included dry mouth (5.2–90.0%), constipation (7.7–65.0%), blurred vision (3.8–35.0%) and hypertension (8.6–9.6%); the 4 most commonly reported AEs for β3-adrenergic agonists included hypertension (8.8–9.2%), urinary tract infection (5.9–6.6%), headache (5.5%) and nasopharyngitis (4.8–5.2%). Conclusion Vibegron was associated with significantly greater improvement in daily total UI episodes at 52 weeks than mirabegron and tolterodine. When reported, the most common AE for anticholinergics was dry mouth and for β3-adrenergic agonists was hypertension. Hypertension incidence was similar between drug classes.
Collapse
|
33
|
Chen JV, Gahn JC, Nesheim J, Mudd PN. Budget Impact Analysis of Vibegron for the Treatment of Overactive Bladder in the USA. PHARMACOECONOMICS 2022; 40:979-988. [PMID: 35881325 PMCID: PMC9522665 DOI: 10.1007/s40273-022-01163-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/29/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Overactive bladder (OAB) is associated with considerable clinical and economic burden. Treatment of patients with OAB using anticholinergics is limited by tolerability issues and increased anticholinergic burden, which is associated with increased risk of dementia and falls/fractures. This analysis assessed the budget impact of introducing the β3-adrenergic agonist vibegron for the treatment of patients with OAB from US commercial payor and Medicare perspectives. METHODS A budget impact model (BIM) with a 5-year time horizon was developed using a top-down, prevalence-based approach and projected market shares for 1-million-member US commercial and Medicare plans. The BIM included vibegron, mirabegron, and anticholinergics, incorporating changes in clinical outcomes (efficacy, drug-drug interactions, anticholinergic burden (ACB), OAB-related comorbidities, and adverse events (AEs)). Costs per member per month (PMPM) and per treated member per month (PTMPM) were determined. One-way sensitivity analyses quantified the impact of changes in key variables. RESULTS The introduction of vibegron was associated with a modest increase in PMPM cost over 5 years of $0.12 (range for years 1‒5, $0.01‒$0.26) for commercial payors and $0.24 ($0.01‒$0.52) for Medicare (PTMPM cost: $2.70 ($0.17‒$4.85) and $3.15 ($0.19‒$5.82), respectively). Costs were partially offset by savings related to decreased third-line treatment use, yearly decreases in AE and comorbidity incidence, reduced drug-drug interactions, and reduced ACB associated with vibegron introduction. PMPM costs were most sensitive to vibegron market share assumptions, OAB prevalence, and vibegron persistence at 1 month for private payors and Medicare and additionally vibegron persistence at 12 months for Medicare. CONCLUSIONS Vibegron may address unmet needs in treating OAB and is a useful addition to health plans while minimizing risks of anticholinergic AEs, ACB, and drug-drug interactions, which may partially offset increased pharmacy costs.
Collapse
Affiliation(s)
| | - James C Gahn
- Medical Decision Modeling, Indianapolis, IN, USA
| | - Jeffrey Nesheim
- Urovant Sciences, 5281 California Ave, Suite 100, Irvine, CA, 92617, USA.
| | - Paul N Mudd
- Urovant Sciences, 5281 California Ave, Suite 100, Irvine, CA, 92617, USA
| |
Collapse
|
34
|
Onur R, Bayrak Ö, Coşkun B, Tahra A, Ocakoglu G, Buyuran G, Mega E, Gungor Ugurlucan F, Ozturk GB. Clinical preferences and treatment attitudes among urologists, gynecologists, and geriatricians: An independent online questionnaire survey for comparison of treatment choices in the management of overactive bladder. Neurourol Urodyn 2022; 41:1914-1923. [DOI: 10.1002/nau.25050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/30/2022] [Accepted: 09/08/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Rahmi Onur
- Department of Urology, School of Medicine Marmara University Istanbul Turkey
| | - Ömer Bayrak
- Department of Urology, School of Medicine Gaziantep University Gaziantep Turkey
| | - Burhan Coşkun
- Department of Urology, School of Medicine Uludag University Bursa Turkey
| | - Ahmet Tahra
- Department of Urology, School of Medicine Istanbul Medeniyet University Istanbul Turkey
| | - Gokhan Ocakoglu
- Department of Bioistatistic, School of Medicine Uludag University Bursa Turkey
| | - Gorkem Buyuran
- Department of Urology, School of Medicine Gaziantep University Gaziantep Turkey
| | - Ertunc Mega
- Department of Gynecology and Obstetrics Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital Istanbul Turkey
| | - Funda Gungor Ugurlucan
- Department of Obstetrics and Gynecology, Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Gulistan Bahat Ozturk
- Department of Geriatrics, Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| |
Collapse
|
35
|
Tan ECK, Lexomboon D, Häbel H, Fastbom J, Eriksdotter M, Johnell K, Sandborgh-Englund G. Validating a model for medication-related dental outcomes in older people. Oral Dis 2022; 28:1697-1704. [PMID: 33780083 DOI: 10.1111/odi.13864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/07/2021] [Accepted: 03/24/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To externally validate a model for medication-related dental outcomes in (a) a general older population with dementia and (b) a matched population without dementia. SUBJECTS AND METHODS This validation study used population-based data from seven Swedish national registers (2008-2017). Individuals aged 60+ with dementia were matched to those without dementia on age, gender, and county of residence at the date of diagnosis (index date). The exposure was continuous use of xerogenic medications during the 3-year period before index date. The primary outcome was the number of tooth extraction and restorative procedures within 3 years after index date. RESULTS A total of 334,220 individuals were included in the final sample. In the dementia cohort, the use of urological drugs (incidence rate ratio [IRR] 1.08, 95% CI 1.03-1.13), respiratory medicines (IRR 1.10, 95% CI 1.04-1.17), and proton-pump inhibitors (IRR 1.09, 95% CI 1.05-1.13) was associated with the primary outcome. In the non-dementia cohort, respiratory medicines (IRR 1.03, CI 1.00-1.05), proton-pump inhibitors (IRR 1.06, CI 1.04-1.08), opioids (IRR 1.05, CI 1.03-1.07), and antidepressants (IRR 1.06, CI 1.04-1.08) were associated with the primary outcome. CONCLUSIONS Although there were differences in prescription patterns, the model performed similarly in both those with and without dementia.
Collapse
Affiliation(s)
- Edwin C K Tan
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW, Australia
- Department of Neurobiology, Care Sciences and Society, Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University, Parkville, Vic., Australia
| | | | - Henrike Häbel
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Johan Fastbom
- Department of Neurobiology, Care Sciences and Society, Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Maria Eriksdotter
- Department of Neurobiology, Care Sciences and Society, Division of Clinical Geriatrics, Karolinska Institutet, Huddinge, Sweden
- Theme Aging, Karolinska University Hospital, Huddinge, Sweden
| | - Kristina Johnell
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Gunilla Sandborgh-Englund
- Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
- Academic Center for Geriatric Dentistry, Stockholm, Sweden
| |
Collapse
|
36
|
Staskin D. Clinical direction in the pharmacological and device management of refractory overactive bladder: the urge to develop new treatments. Expert Opin Pharmacother 2022; 23:1475-1477. [PMID: 36045592 DOI: 10.1080/14656566.2022.2117609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- David Staskin
- Division of Urology, St. Elizabeth's Medical Center, Steward Health, Tufts University School of Medicine, Boston, MA, USA
| |
Collapse
|
37
|
Stefanacci RG, Yeaw J, Shah D, Newman DK, Kincaid A, Mudd PN. Impact of Urinary Incontinence Related to Overactive Bladder on Long-Term Care Residents and Facilities: A Perspective From Directors of Nursing. J Gerontol Nurs 2022; 48:38-46. [PMID: 35771072 DOI: 10.3928/00989134-20220606-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The current study assessed the impact of urinary incontinence (UI) on residents, staff, care processes, and quality measures in long-term care (LTC) settings. A 70-question quantitative online survey was sent to directors of nursing (DONs) who had worked for ≥1 year in a ≥100-bed facility (≥80% LTC beds). Of the 62% of residents with UI, 40% were always incontinent, and 81% used incontinence products for UI. Overall, 59% of DONs reported that UI management contributes to certified nursing assistant turnover. Approximately 36% of resident falls occurred while trying to get to the bathroom. LTC quality measures reported as significantly impacted by UI included urinary tract infection and falls with major injury. Only 14% of residents with UI were treated with medication. Most (75%) DONs were unaware of any link between anticholinergic medications and risk of cognitive side effects. These results highlight the need for improved UI treatment, awareness, and management in this population. [Journal of Gerontological Nursing, 48(7), 38-46.].
Collapse
|
38
|
Sun P, Wang Z, Wu T, Zuo S, Huang X, Cui Z, Zhang D. Injectable, Adhesive, and Self-Healing Composite Hydrogels Loaded With Oxybutynin Hydrochloride for the Treatment of Overactive Bladder in Rats. Front Bioeng Biotechnol 2022; 10:906835. [PMID: 35832402 PMCID: PMC9272884 DOI: 10.3389/fbioe.2022.906835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/11/2022] [Indexed: 12/04/2022] Open
Abstract
Object: The aim of this study was to prepare injectable, adhesive, and self-healing composite hydrogels loaded with oxybutynin hydrochloride and verify its function in the treatment of overactive bladder. Method: The ultraviolet (UV) absorption of oxybutynin (Oxy) in the solution was detected using a UV spectrophotometer at 233 nm, and the cumulative drug release was calculated using Origin software. L929 mouse fibroblasts were used to test cell adhesion to OCP50 and OCP100 hydrogels. Both FT-IR and NMR overactive bladder demonstrated that Dex was oxidized to PDA with aldehyde groups. Urodynamic examinations were performed 24 h after intraperitoneal injection in the rat model. The relative expression levels of Orai1 and STIM1 were detected by western blot (WB) and QPCR. Results: After loading Oxy, the shear adhesion under the wet conditions of OCP50 and OCP100 was higher than CP50 and CP100 (p < 0.05), and both were suitable for intravaginal administration. After 72 h of release, oxybutynin released 82.8% in OCP100 hydrogel and 70% in OCP50. Compared to the model, OCP50, CP100, and OCP100 relieved the overactive bladder and inhibited the expression of Orail and STIM1. Conclusions: Oxybutynin hydrogel could provide relief to overactive bladder by decreasing the expression of Orail and STIM1 in rats.
Collapse
Affiliation(s)
- Peng Sun
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Zheng Wang
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Tong Wu
- Department of Chemotherapy, Shandong Second Provincial General Hospital, Shandong Provincial ENT Hospital, Jinan, China
| | - Shishuai Zuo
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xiaoyu Huang
- Department of Urology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Zilian Cui
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Urology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Dong Zhang
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Urology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- *Correspondence: Dong Zhang,
| |
Collapse
|
39
|
Sayner AM, Rogers F, Tran J, Jovanovic E, Henningham L, Nahon I. Transcutaneous Tibial Nerve Stimulation in the Management of Overactive Bladder: A Scoping Review. Neuromodulation 2022; 25:1086-1096. [DOI: 10.1016/j.neurom.2022.04.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 03/31/2022] [Accepted: 04/06/2022] [Indexed: 12/28/2022]
|
40
|
Michel MC, Madersbacher S. [Medical treatment of male lower urinary tract symptoms: what's new?]. Aktuelle Urol 2022; 53:240-245. [PMID: 35193150 DOI: 10.1055/a-1749-4556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Decades after the introduction of 5α-reductase inhibitors and α1-adrenoceptor antagonists, new data of practical relevance related to their desired and adverse effects continues to emerge. Some of these novel findings are to be taken seriously but are insufficiently established, for instance associations between drug use and depression or dementia. Multiple combination treatments have been tested. While combination treatment was often statistically superior to monotherapy, the difference was mostly in the range of 1 IPSS point, which raises doubts on the clinical relevance of the findings at the group level. The new evidence enables further personalisation of the treatment of male lower urinary tract dysfunction, but also makes individual risk-benefit considerations more complex.
Collapse
Affiliation(s)
- Martin C. Michel
- Pharmacology, Johannes Gutenberg University Hospital Mainz, Mainz, Germany
| | - Stephan Madersbacher
- Urologie, Kaiser Franz Josef Krankenhaus, Sigmund Freud Privatuniversität, Wien, Austria
| |
Collapse
|
41
|
Enemchukwu EA, Subak LL, Markland A. Barriers and facilitators to overactive bladder therapy adherence. Neurourol Urodyn 2022; 41:1983-1992. [PMID: 35510540 DOI: 10.1002/nau.24936] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/13/2022] [Accepted: 03/23/2022] [Indexed: 12/25/2022]
Abstract
AIMS To provide an overview of the barriers and facilitators to overactive bladder (OAB) therapy initiation and adherence. METHODS A PubMed and Embase literature search was conducted to identify barriers to OAB therapy adherence. RESULTS OAB therapy adherence is associated with improvements in urinary symptoms, and quality of life with reductions in annual costs for OAB-related expenditures. However, adherence rates to behavioral therapies are as low as 32% at 1 year, only 15%-40% of treated patients remain on oral medications at 1 year due to several factors (e.g., inadequate efficacy, tolerability, and cost), and 5%-10% of OAB patients progress to advanced therapies. While some common barriers to therapy adherence are often fixed (e.g., costs, lack of efficacy, time, side effects, treatment fatigue), many are modifiable (e.g., lack of knowledge, poor relationships, negative experiences, poor communication with providers). Patient-centered care may help address some modifiable barriers. Emerging data demonstrate that patient-centered care in the form of treatment navigators improves OAB therapy adherence and progression to advanced therapies in the appropriate patient. CONCLUSIONS There are numerous modifiable barriers to OAB therapy adherence. A patient-centered lens is needed to elicit patient goals, establish realistic treatment expectations, and tailor therapy to improve therapy adherence, optimize outcomes, and reduce healthcare expenditures. Further research is needed to develop and study low-cost, scalable solutions.
Collapse
Affiliation(s)
- Ekene A Enemchukwu
- Department of Urology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Leslee L Subak
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Alayne Markland
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| |
Collapse
|
42
|
|
43
|
Brucker BM, King J, Mudd Jr PN, McHale K. Selectivity and Maximum Response of Vibegron and Mirabegron for β3-Adrenergic Receptors. Curr Ther Res Clin Exp 2022; 96:100674. [PMID: 35693456 PMCID: PMC9184556 DOI: 10.1016/j.curtheres.2022.100674] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/06/2022] [Indexed: 11/24/2022] Open
Abstract
Background The β3-adrenergic agonists vibegron and mirabegron have shown favorable safety profiles and efficacy for the treatment of overactive bladder. However, β-adrenergic receptors are also found outside the bladder, which could lead to off-target activity. Objective This study assessed the selectivity of vibegron and mirabegron for β-adrenergic receptors and the maximal effect and potency for β3-adrenergic receptors. Methods Functional cellular assays were performed using Chinese hamster ovary-K1 cells expressing β1-, Chinese hamster ovary cells expressing β2-, and human embryonic kidney 293 cells expressing β3-adrenergic receptors. Cells were incubated with vibegron, mirabegron, or control (β1 and β3, isoproterenol; β2, procaterol). Responses were quantified using homogeneous time-resolved fluorescence of cyclic adenosine monophosphate and were normalized to the respective control. Half-maximal effective concentration and maximum response values were determined by nonlinear least-squares regression analysis. Results Activation of β3-adrenergic receptors with vibegron or mirabegron resulted in concentration-dependent β3-adrenergic receptor responses. Mean (SEM) half-maximal effective concentration values at β3-adrenergic receptors were 2.13 (0.25) nM for vibegron and 10.0 (0.56) nM for mirabegron. At a concentration of 10 µM, β3-adrenergic activity relative to isoproterenol was 104% for vibegron and 88% for mirabegron. Maximum response at β3-adrenergic receptors was 99.2% for vibegron and 80.4% for mirabegron. β1-adrenergic activity was 0% and 3% for vibegron and mirabegron, respectively; β2-adrenergic activity was 2% and 15%, respectively. Conclusions Vibegron showed no measurable β1 and low β2 activity compared with mirabegron, which showed low β1 and some β2 activity. Both showed considerable selectivity at β3-adrenergic receptors; however, vibegron demonstrated near-exclusive β3 activity and a higher maximum β3 response.
Collapse
|
44
|
Mur J, Russ TC, Cox SR, Marioni RE, Muniz‐Terrera G. Association between anticholinergic burden and dementia in UK Biobank. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2022; 8:e12290. [PMID: 35434252 PMCID: PMC9005668 DOI: 10.1002/trc2.12290] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/11/2022] [Accepted: 03/03/2022] [Indexed: 11/20/2022]
Abstract
Background Previous studies on the relationship between anticholinergic drugs and dementia have reported heterogeneous results. This variability could be due to different anticholinergic scales and differential effects of distinct classes of drugs. Methods Using Cox proportional hazards models, we computed the association between annual anticholinergic burden (AChB) and the risk of dementia in UK Biobank with linked general practitioner prescription records between the years 2000 and 2015 (n = 171,775). Results AChB according to most anticholinergic scales (standardized odds ratio range: 1.027-1.125) and the slope of the AChB trajectory (hazard ratio = 1.094; 95% confidence interval: 1.068-1.119) were predictive of dementia. However, the association between AChB and dementia held only for some classes of drugs, especially antidepressants, antiepileptics, and antidiuretics. Discussion The heterogeneity in previous findings may partially be due to different effects for different classes of drugs. Future studies should establish differences in more detail and further examine the practicality of a general measure of AChB relating to the risk of dementia.
Collapse
Affiliation(s)
- Jure Mur
- Lothian Birth Cohorts GroupDepartment of PsychologyUniversity of EdinburghEdinburghUK
- Centre for Genomic and Experimental MedicineInstitute of Genetics and Molecular MedicineUniversity of EdinburghEdinburghUK
- Alzheimer Scotland Dementia Research CentreUniversity of EdinburghEdinburghUK
| | - Tom C. Russ
- Alzheimer Scotland Dementia Research CentreUniversity of EdinburghEdinburghUK
- Edinburgh Dementia PreventionUniversity of EdinburghEdinburghUK
- Division of PsychiatryCentre for Clinical Brain ScienceUniversity of EdinburghEdinburghUK
| | - Simon R. Cox
- Lothian Birth Cohorts GroupDepartment of PsychologyUniversity of EdinburghEdinburghUK
| | - Riccardo E. Marioni
- Centre for Genomic and Experimental MedicineInstitute of Genetics and CancerUniversity of EdinburghEdinburghUK
| | - Graciela Muniz‐Terrera
- Edinburgh Dementia PreventionUniversity of EdinburghEdinburghUK
- Division of PsychiatryCentre for Clinical Brain ScienceUniversity of EdinburghEdinburghUK
| |
Collapse
|
45
|
Nakagomi H, Mitsui T, Shimura H, Ihara T, Kira S, Sawada N, Takeda M. Mirabegron for overactive bladder in frail patients 80 years or over (HOKUTO study). BMC Urol 2022; 22:40. [PMID: 35313873 PMCID: PMC8939141 DOI: 10.1186/s12894-022-00989-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 03/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We assessed the efficacy and safety of mirabegron, a β3-adrenoceptor agonist, in older adults (≥ 80 years old) with overactive bladder (OAB). METHODS OAB patients aged ≥ 80 years were enrolled in this prospective, single-arm observational study. OAB was diagnosed based on the OAB symptom score (OABSS); i.e., a total score of ≥ 3 points and an urgency score of ≥ 2 points. Patients who received 50 mg mirabegron once daily were evaluated at the baseline and at 4, 8, and 12 weeks. The changes from the baseline in the OABSS, International Prostate Symptom Score (IPSS), OAB questionnaire (OAB-q) score, and Vulnerable Elders Survey (VES-13) score were determined. Adverse events, laboratory tests, 12-lead electrocardiography, the QT interval according to Fridericia's formula (QTcF), uroflowmetry, the post-void residual urine volume (PVR), and the Mini-Mental State Examination (MMSE) score were used to assess safety. RESULTS Forty-three patients (median age: 84 years, range: 80-96 years) were examined. They had high rates of comorbidities and polypharmacy. Mirabegron significantly improved in total score of the OABSS, including urgency and urge incontinence. The total IPSS, IPSS quality-of-life (QOL) index, and OAB-q scores also significantly improved. Mirabegron improved in the VES-13 score. There were no significant changes in laboratory test values, uroflowmetry findings, PVR, the QTcF, or MMSE score. Two patients (4.7%) withdrew from the study after experiencing adverse events. CONCLUSIONS Mirabegron was well tolerated and significantly improved in OAB symptoms, and QOL in older patients. Trial registration The present clinical study was approved by University of Yamanashi Institutional Review Board prior to study initiation (ID1447) and was retrospectively registered with the UMIN Clinical Trials Registry (UMIN-CTR), Japan (UMIN000045996) on Nov 6, 2021.
Collapse
Affiliation(s)
- Hiroshi Nakagomi
- Department of Urology, University of Yamanashi Graduate School of Medical Sciences, 1110 Shimokato, Chuo City, Yamanashi, 409-3898, Japan
| | - Takahiko Mitsui
- Department of Urology, University of Yamanashi Graduate School of Medical Sciences, 1110 Shimokato, Chuo City, Yamanashi, 409-3898, Japan.
| | - Hiroshi Shimura
- Department of Urology, University of Yamanashi Graduate School of Medical Sciences, 1110 Shimokato, Chuo City, Yamanashi, 409-3898, Japan
| | - Tatsuya Ihara
- Department of Urology, University of Yamanashi Graduate School of Medical Sciences, 1110 Shimokato, Chuo City, Yamanashi, 409-3898, Japan
| | - Satoru Kira
- Department of Urology, University of Yamanashi Graduate School of Medical Sciences, 1110 Shimokato, Chuo City, Yamanashi, 409-3898, Japan
| | - Norifumi Sawada
- Department of Urology, University of Yamanashi Graduate School of Medical Sciences, 1110 Shimokato, Chuo City, Yamanashi, 409-3898, Japan
| | - Masayuki Takeda
- Department of Urology, University of Yamanashi Graduate School of Medical Sciences, 1110 Shimokato, Chuo City, Yamanashi, 409-3898, Japan
| |
Collapse
|
46
|
Frankel J, Staskin D, Varano S, Kennelly MJ, Jankowich RA, Haag-Molkenteller C. An Evaluation of the Efficacy and Safety of Vibegron in the Treatment of Overactive Bladder. Ther Clin Risk Manag 2022; 18:171-182. [PMID: 35264853 PMCID: PMC8901416 DOI: 10.2147/tcrm.s310371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 02/13/2022] [Indexed: 11/23/2022] Open
Abstract
Pharmacologic treatment for overactive bladder (OAB), which is characterized by bothersome symptoms such as urgency and urge urinary incontinence (UUI), includes anticholinergics and β3-adrenergic receptor agonists. Anticholinergics are associated with adverse effects including dry mouth, constipation, cognitive impairment, and increased risk of dementia. Therefore, the drug class of β3-adrenergic receptor agonists may represent an effective, safe treatment option. Vibegron, a β3-adrenergic receptor agonist, was approved for use in Japan (2018) and the United States (2020). Over the past 3 years, 2 phase 3 trials (EMPOWUR, EMPOWUR extension) have been conducted with once-daily vibegron 75 mg for the treatment of OAB, and additional secondary and subgroup analyses have detailed the efficacy and safety of vibegron. In the international phase 3 EMPOWUR trial, treatment with vibegron was associated with significant improvements compared with placebo in efficacy outcomes of micturition frequency, UUI episodes, urgency episodes, and volume voided as early as week 2 that were sustained throughout the 12-week trial. The 40-week EMPOWUR extension study, following the 12-week treatment period, demonstrated sustained efficacy in patients receiving vibegron for 52 weeks. Treatment with vibegron was also associated with improvements in patient-reported measures of quality of life. Across studies, vibegron was generally safe and well tolerated. A separate, dedicated ambulatory blood pressure monitoring study showed that treatment with vibegron was not associated with clinically meaningful effects on blood pressure or heart rate. Across all studies, vibegron was efficacious, safe, and well tolerated and thus represents a valuable treatment option for patients with OAB. Here, nearly 1 year after US approval, we review the published data on efficacy and safety of vibegron 75 mg for the treatment of OAB.
Collapse
Affiliation(s)
- Jeffrey Frankel
- Seattle Urology Research Center, Seattle, WA, USA
- Correspondence: Jeffrey Frankel, PO Box 1192, Mercer Island, WA 98040, USA, Tel +1 206 972 2775, Email
| | - David Staskin
- Tufts University School of Medicine, Boston, MA, USA
| | | | | | | | | |
Collapse
|
47
|
Dmochowski RR. Response letter to comments on "Increased risk of incident dementia following use of anticholinergic agents: A systematic literature review and meta-analysis". Neurourol Urodyn 2021; 41:518-519. [PMID: 34859488 DOI: 10.1002/nau.24843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/21/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Roger R Dmochowski
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
48
|
Gandi C, Sacco E. Pharmacological Management of Urinary Incontinence: Current and Emerging Treatment. Clin Pharmacol 2021; 13:209-223. [PMID: 34858068 PMCID: PMC8630428 DOI: 10.2147/cpaa.s289323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/05/2021] [Indexed: 12/16/2022] Open
Abstract
Pharmacological management of urinary incontinence (UI) is currently based on antimuscarinic and beta-3-agonist drugs. Botulinum toxin A detrusor injections represent an effective but more invasive alternative. This review covers the latest developments of the currently available drugs and the emerging compounds for the treatment of UI. Evidence shows that new antimuscarinics and beta-3-agonists with improved safety profiles may offer unique options to patients intolerant to currently available drugs. Combination therapy proved to be a non-invasive alternative for patients refractory to first-line monotherapy. Exciting advances are ongoing in the research to improve the efficacy/tolerability profile of botulinum toxin, through innovative routes of administration. Several new agents emerged from preclinical studies, some of which have now entered the clinical phase of development and could represent, in the coming years, a new way for the treatment of UI. Recent evidence on the existence of different overactive bladder phenotypes could be the key to tailored treatment. Rather than discovering new molecules, reaching the ability to identify the right drug for the right patient could be the real gamechanger of the future.
Collapse
Affiliation(s)
- Carlo Gandi
- Department of Urology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University School of Medicine, Rome, Italy
| | - Emilio Sacco
- Department of Urology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University School of Medicine, Rome, Italy
| |
Collapse
|
49
|
Kennelly MJ, Rhodes T, Girman CJ, Thomas E, Shortino D, Mudd PN. Efficacy of Vibegron and Mirabegron for Overactive Bladder: A Systematic Literature Review and Indirect Treatment Comparison. Adv Ther 2021; 38:5452-5464. [PMID: 34537953 PMCID: PMC8520873 DOI: 10.1007/s12325-021-01902-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/24/2021] [Indexed: 01/05/2023]
Abstract
Background In the absence of head-to-head trials, we performed an indirect treatment comparison of the β3-adrenergic agonists vibegron and mirabegron in the treatment of overactive bladder (OAB). Methods PubMed, Embase, and Cochrane Library were searched for articles related to phase 3, double-blind, controlled trials of vibegron 75 mg and mirabegron 25/50 mg in patients with OAB. Efficacy outcomes included change from baseline at weeks 4, 12, and 52 in mean daily number of total urinary incontinence episodes and micturitions and mean volume voided/micturition. Effect size was computed as placebo-subtracted change from baseline (weeks 4, 12) or active control (tolterodine)-subtracted change from baseline (week 52) for each treatment group. Adverse events (AEs) are presented descriptively. Results After removal of duplicates, 49 records were identified, and after screening 9 met inclusion criteria for analysis. Vibegron showed significantly greater reduction in mean daily number of total incontinence episodes than mirabegron 25 mg at week 4, mirabegron 50 mg (weeks 4, 52), and tolterodine (weeks 4, 12) (P < 0.05, each) and significantly greater improvement in volume voided versus mirabegron 25 mg (week 12), mirabegron 50 mg (weeks 12, 52), and tolterodine (week 4) (P < 0.05, each). Confidence intervals of point estimates overlapped zero for all other comparisons of vibegron and mirabegron (25 or 50 mg) or tolterodine, indicating no significant differences between treatments for these time/endpoints. Urinary tract infection, hypertension, and dry mouth were the most commonly occurring AEs for vibegron, mirabegron, and tolterodine, respectively, in the short-term trials; hypertension was the most commonly occurring AE with all three treatments in the long-term trials. Conclusions Vibegron was associated with significant improvement in total incontinence episodes versus mirabegron at 4 and 52 weeks and volume voided at 12 and 52 weeks. Improvement in micturitions was similar between vibegron and mirabegron or tolterodine. Incidence of AEs was generally comparable between vibegron and mirabegron. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-01902-8.
Collapse
Affiliation(s)
- Michael J Kennelly
- Department of Urology, Obstetrics and Gynecology, Carolinas Medical Center, 2001 Vail Ave, Suite 360, Charlotte, NC, 28207, USA.
| | | | | | | | | | | |
Collapse
|
50
|
Stewart LH. Time to change our target in the treatment of OAB. Neurourol Urodyn 2021; 41:513. [PMID: 34633692 DOI: 10.1002/nau.24821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/11/2021] [Accepted: 08/30/2021] [Indexed: 11/08/2022]
|