Solifenacin-induced delirium and hallucinations

Safety and tolerability of solifenacin in children and adolescents with overactive bladder- a systematic review

BACKGROUND

Solifenacin is an anticholinergic that is used to treat overactive bladder syndrome (OAB) in children. It is important to ascertain the safety and tolerability of solifenacin in the paediatric population as solifenacin offers an alternative, is more bladder specific, and should have less anticholinergic side effects than other therapies.

OBJECTIVE

The aim of this study is to systematically evaluate the safety and tolerability of solifenacin in children and adolescents with OAB.

STUDY DESIGN

We included studies that reported the safety and tolerability of solifenacin in children and adolescents. All study types were included. Electronic searches were conducted in Ovid MEDLINE, Ovid Embase, TRIP, CINAHL and ICTRP on the 18th of January 2022. Risk of bias was assessed with the Cochrane Risk of Bias tool 2.0 (ROB-2) for randomised controlled trials (RCTs) and the Newcastle-Ottowa scale for cohort studies.

RESULTS

A total of twelve studies including two RCTs were included in this review. Results from the meta-analysis of RCTs showed the commonest side effects were constipation (RR 3.5, 95%CI 0.9-13.7) and dry mouth (RR 3.1 95%CI 0.2-53). In terms of tolerability, the effect estimate of ceasing solifenacin due to an adverse effect was 2.7 (95%CI 0.8-9.1). Within the cohort studies, out of the 779 patients 21.7% experienced side effects. The most common side effects were constipation (6.8%) and dry mouth/lips (6.0%) and 3.5% of patients ceased solifenacin due to adverse effects. Overall, the certainty of the evidence for side effects and tolerability were very low.

DISCUSSION

The reported incidence of side effects is low, and less than reported with oxybutynin use. However, the very low certainty of the evidence means the findings should be interpreted with caution. There is limited reporting of a prolonged QTc interval on ECG. Studies that described this only had an increase of QTc from baseline and not a clinically significant prolonged QTc that resulted in arrhythmias.

CONCLUSION

Solifenacin is an alternative anticholinergic for the treatment of OAB in children. However, given the paucity of good quality data on safety and tolerability it should be used cautiously in children with close monitoring for potential side effects.

Analysis of the nervous system and gastrointestinal adverse events associated with solifenacin in older adults using the US FDA adverse event reporting system

BACKGROUND

Antimuscarinics are the backbone of the pharmacological management of overactive bladder. Still, concerns have been raised over the nervous system (NS) adverse drug events (AEs) due to their dissimilarities to muscarinic receptor-subtype affinities.

OBJECTIVE

This study aimed to identify the nervous system and gastrointestinal adverse drug events (ADEs) associated with solifenacin use in older adults (≥65 years).

METHODS

A case/non-case analysis was performed on the reports submitted to the FDA Adverse Event Reporting System (FAERS) between 01/01/2004 and 30/06/2020. Cases were reports for solifenacin with ≥1 ADEs as preferred terms included in the Medical Dictionary of Regulatory Activities (MedDRA) system organ classes 'nervous system' or 'gastrointestinal' disorders. Non-cases were all other remaining reports for solifenacin. The case/non-cases was compared between solifenacin and other bladder antimuscarinics. Frequentist approaches, including the proportional reporting ratio (PRR) and reporting odds ratio (ROR), were used to measure disproportionality. The empirical Bayesian Geometric Mean (EBGM) score and information component (IC) value were calculated using a Bayesian approach. A signal was defined as the lower limit of 95% confidence intervals of ROR ≥ 2, PRR ≥ 2, IC > 0, EBGM > 1, for ADEs with ≥4 reports.

RESULTS

107 MedDRA preferred terms (PTs) comprising 970 ADE reports were retrieved for nervous system disorders associated with solifenacin. For gastrointestinal disorders, 129 MedDRA PTs comprising 1817 ADE reports were retrieved. Statistically significant results were found for 'altered state of consciousness': ROR = 9.71 (2.13-44.35), PRR = 9.69 (2.12-44.2) and IC = 1.29 (0.93-1.66).

CONCLUSIONS

The disproportionality reporting of 'altered state of consciousness', a previously unidentified ADE, was unexpected. Further monitoring of this ADE is needed to ensure patient safety, as this could be linked to poor balance and falls in older adults.

Theophylline for Spinal Cord Injury Associated Bradycardia

BACKGROUND

Spinal cord injury (SCI) related bradycardia occurs frequently in patients with high cervical spine injuries. In patients with SCI-related symptomatic bradycardia, a variety of agents have been used to improve heart rate and reduce the need for vasopressor therapy. The literature concerning the use of theophylline in this disease state is sparse.

OBJECTIVE

The primary objective of this study was to evaluate and describe the use of theophylline for SCI-related symptomatic bradycardia.

METHODS

This was a retrospective case series of patients with SCI-related symptomatic bradycardia who were treated with theophylline. Patients were evaluated based on clinical response to theophylline. Patients were classified as a responder if vasopressors were discontinued or the number of bradycardia episodes decreased following the initiation of theophylline.

RESULTS

A total of twenty-six patients were included in the study. 17 (65.4%) patients were classified as responders, 5 (19.2%) patients were classified as non-responders, and 4 (15.4%) of patients were classified as undetermined. 11 patients (43.31%) were discharged on theophylline with 7 of these patients (41.2%) classified as responders. There were no significant differences between those classified as responders and those who were not.

CONCLUSION AND RELEVANCE

This case series suggest that theophylline could be used as adjunctive therapy in patients with bradycardia secondary to acute SCI who achieve an adequate response to theophylline.

The risk of delirium and falls or fractures with the use of overactive bladder anticholinergic medications

OBJECTIVE

To determine if OAB anticholinergics have an increased risk of delirium or falls/fractures relative to OAB beta-3 agonist medications.

METHODS

This was a retrospective, cohort study using linked administrative data from the universal healthcare system of Ontario, Canada. Participants were all residents >66 years of age who newly initiated an OAB medication between January 2016 and March 2020. Coprimary outcomes were evidence of a hospital visit with delirium, or for a fall/fracture. We used matching weights to make the three exposure groups (beta-3 agonist, oxybutynin, or newer OAB anticholinergics) comparable across 82 baseline characteristics. We examined both the risk during the first 30 days (logistic regression) and the risk during continuous usage (proportional hazards).

RESULTS

We identified 103 024 older adults who started OAB medications. With matching weights, all measured variables were similar. The 30-day incidence of delirium was 0.31%, and fall/fracture was 1.07%; there was no significantly increased risk of either delirium (oxybutynin users OR 1.28 [95% CI 0.84-1.96], newer OAB anticholinergic users OR 0.92 [95% CI 0.58-1.46]) or falls/fractures (oxybutynin users OR 1.19 [95% CI 0.95-1.49], newer OAB anticholinergic users OR 1.14 [95% CI 0.91-1.43]) compared to beta-3 agonist users. With continuous usage, there was an increased HR of delirium among users of newer anticholinergics (HR 1.13, 95% CI 1.02-1.26) and an increased HR for fall/fracture among oxybutynin users (HR 1.13, 95% CI 1.02-1.24).

CONCLUSIONS

Compared to beta-3 agonists, the continuous use of oxybutynin is associated with a significantly increased risk of fall/fracture, and newer OAB anticholinergics are associated with a significantly increased risk of delirium.

Solifenacin-induced acute psychosis: a case report

Solifenacin is a muscarinic receptor antagonist that has been used to treat overactive bladder since 2004. It has a great affinity for the detrusor M3 receptor, which must be stimulated for bladder muscle contraction, and demonstrates the most selective profile to the bladder of the muscarinic receptor subtypes. It is thought that urinary antimuscarinic agents, due to their passage to the central nervous system and lipophilic properties, may cause central nervous system symptoms in some rare cases. A case report of a 42-year-old male patient who had an acute psychotic attack as a result of solifenacin treatment for overactive bladder is presented in this article.

Electron Donor-Acceptor Properties of Different Muscarinic Ligands: On the Road to Control Schizophrenia

Schizophrenia is a severe neuropsychiatric disorder that deteriorates perception, affection, and cognitive mental functions. The current treatments are mainly focused on the dopamine system, but the so-named dopamine hypothesis of schizophrenia fails to explain all the symptoms. Previous studies have shown that there is a reciprocal relationship between muscarinic acetylcholine receptors and dopamine receptor function. Some muscarinic ligands show antidopaminergic activity, and therefore, they should have some antipsychotic efficacy. In this work, conceptual density functional theory is employed to analyze the properties of acetylcholine's agonists, partial agonists, or antagonists. The aim is to establish a classification of the antipsychotic-like or pro-psychotic activities of these molecules based on the electron-donor and electron-acceptor properties. Most of the agonists and antagonists are better electron donors and worse electron acceptors than partial agonists. We found that acetylcholine antagonists that clinically promote psychotic symptoms are good electron-donor molecules, and acetylcholine agonists that clinically relieve symptoms of psychosis are good electron donors. These results represent a further advance on the road to understanding the charge-transfer properties of drugs used as possible treatments for schizophrenia.

Mirabegron in the Treatment of Overactive Bladder: Safety and Efficacy in the Very Elderly Patient

Lower urinary tract symptoms, including urgency, urgency incontinence, frequency, and nocturia, are highly prevalent in older adults and are associated with significant morbidity and impairment in quality of life. When conservative measures such as bladder training fail to improve symptoms, pharmacological management is recommended by national and international guidelines. Mirabegron, an agonist of the β3 adrenergic receptor, demonstrates similar efficacy to the anticholinergic drugs without the risk of anticholinergic effects, but experience and evidence in the very elderly population are limited. This narrative review examines the current evidence base for mirabegron in very elderly adults.

Anticholinergics for Overactive Bladder in Frail and Medically Complex Older People: The Case For

Overactive bladder (OAB) is a common, troublesome condition affecting the lives of many older people. When pharmacotherapy is considered, antimuscarinics remain the mainstay for treatment. Bladder antimuscarinics are effective in the relief of symptoms for OAB and treatment leads to significant improvements in quality of life for those with the condition. However, many older people (> 65 years) with OAB are in later life (> 75 years) and a proportion of these will either be medically complex, with multiple comorbid conditions, or frail. This article discusses the evidence for OAB treatment in the frail or medically complex elderly, outlines where caution should be exercised, giving examples from the recent literature, and advocates for an active approach for this group, who are often left without any treatment.

Delirium following fesoterodine treatment for urgency incontinence in an 89-year old man

We describe the case of an 89-year-old man who developed delirium following the introduction of fesoterodine to treat his urgency incontinence. The patient started experiencing visual hallucinations approximately five days after starting fesoterodine 4 mg once daily. Delirium resolved after fesoterodine was stopped. Despite the apparent safe cognitive profile due to its pharmacodynamic properties, fesoterodine should be used with caution in the elderly, frail population.

Oral pharmacotherapy for overactive bladder in older patients: mirabegron as a potential alternative to antimuscarinics

OBJECTIVE

Overactive bladder (OAB) is a particular challenge to treat in older adults with co-morbid conditions taking multiple medications. Antimuscarinics (e.g., solifenacin, fesoterodine) and β3-adrenergic receptor agonists (mirabegron) are similarly efficacious; however, antimuscarinics may be associated with side effects that result in poor persistence and contribute to anticholinergic burden, particularly in those taking other medications with anticholinergic properties. With a mechanism of action distinct from antimuscarinics, mirabegron has a different tolerability profile and does not contribute to anticholinergic burden. The objective of this review was to compare and contrast the tolerability profiles of antimuscarinics and mirabegron in older patients to inform practice.

METHODS

Prospective trials or retrospective subgroup analyses of antimuscarinics for the treatment of OAB in older patients were identified through a search of PubMed. Tolerability data and results of subgroup analyses of mirabegron in patients aged ≥65 and ≥75 years from a pooled analysis of three trials each of 12 weeks and a 1 year trial are described.

RESULTS

Anticholinergic adverse events (AEs) including dry mouth and constipation were more frequent with antimuscarinics versus mirabegron. In patients aged ≥65 years, dry mouth occurred with a six-fold higher incidence with tolterodine extended-release (ER) 4 mg than with mirabegron 25 mg or 50 mg over 12 weeks, and a three-fold higher incidence with tolterodine ER than mirabegron 50 mg over 1 year. Mirabegron had a low incidence of central nervous system effects. A systematic review of the cardiovascular safety profile of mirabegron has not identified any clinically significant effects on blood pressure or pulse rate at therapeutic doses amongst patients aged ≥65 years.

CONCLUSIONS

Mirabegron has a more favorable tolerability profile than antimuscarinics amongst older patients and may provide an improved benefit-to-risk ratio and therefore be considered as an alternative to antimuscarinics for older patients.