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Sartori LGF, Nunes BM, Farah D, Oliveira LMD, Novoa CCT, Sartori MGF, Fonseca MCM. Mirabegron and Anticholinergics in the Treatment of Overactive Bladder Syndrome: A Meta-analysis. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:337-346. [PMID: 37494577 PMCID: PMC10371066 DOI: 10.1055/s-0043-1770093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
Abstract
OBJECTIVE To compare the use of mirabegron with anticholinergics drugs for the treatment of overactive bladder (OB). DATA SOURCE Systematic searches were conducted in EMBASE, PUBMED, Cochrane, and LILACS databases from inception to September 2021. We included RCTs, women with clinically proven OB symptoms, studies that compared mirabegron to antimuscarinic drugs, and that evaluated the efficacy, safety or adherence. DATA COLLECTION RevMan 5.4 was used to combine results across studies. We derived risk ratios (RRs) and mean differences with 95% CIs using a random-effects meta-analytic model. Cochrane Collaboration Tool and GRADE was applied for risk of bias and quality of the evidence. DATA SYNTHESIS We included 14 studies with a total of 10,774 patients. Fewer total adverse events was reported in mirabegron group than in antimuscarinics group [RR 0.93 (0.89-0.98)]. The risk of gastrointestinal tract disorders and dry mouth were lower with mirabegron [RR 0,58 (0.48-0.68); 9375 patients; RR 0.44 (0.35-0.56), 9375 patients, respectively]. No difference was reported between mirabegron and antimuscarinics drugs for efficacy. The adherence to treatment was 87.7% in both groups [RR 0.99 (0.98-1.00)]. CONCLUSION Mirabegron and antimuscarinics have comparable efficacy and adherence rates; however, mirabegron showed fewer total and isolated adverse events.
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Affiliation(s)
| | | | - Daniela Farah
- Department of Gynecology, Health Technologies Assessment Center, Universidade Federal de São Paulo, São Paulo, Brazil
- Department of Gynecology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Leticia Maria de Oliveira
- Department of Gynecology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | | | | | - Marcelo Cunio Machado Fonseca
- Department of Gynecology, Health Technologies Assessment Center, Universidade Federal de São Paulo, São Paulo, Brazil
- Department of Gynecology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Stoniute A, Madhuvrata P, Still M, Barron-Millar E, Nabi G, Omar MI. Oral anticholinergic drugs versus placebo or no treatment for managing overactive bladder syndrome in adults. Cochrane Database Syst Rev 2023; 5:CD003781. [PMID: 37160401 PMCID: PMC10167789 DOI: 10.1002/14651858.cd003781.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
BACKGROUND Around 16% of adults have symptoms of overactive bladder (OAB; urgency with frequency and/or urge incontinence), with prevalence increasing with age. Anticholinergic drugs are commonly used to treat this condition. This is an update of a Cochrane Review first published in 2002 and last updated in 2006. OBJECTIVES To assess the effects of anticholinergic drugs compared with placebo or no treatment for treating overactive bladder syndrome in adults. SEARCH METHODS We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 14 January 2020), and the reference lists of relevant articles. We updated this search on 3 May 2022, but these results have not yet been fully incorporated. SELECTION CRITERIA We included randomised or quasi-randomised trials in adults with overactive bladder syndrome that compared an anticholinergic drug alone with placebo treatment. DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligibility and extracted data from the included studies, including an assessment of the risk of bias. We assessed the certainty of the body of evidence using the GRADE approach. We processed data as described in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS We included 104 studies, 71 of which were new or updated for this version of the review. Although 12 studies did not report the number of participants, there were 47,106 people in the remainder of the included studies. The majority of the studies had insufficient information to allow judgement of risk of bias and we judged them to be unclear for all domains. Nine anticholinergic drugs were included in these studies: darifenacin; fesoterodine; imidafenacin; oxybutynin; propantheline; propiverine; solifenacin; tolterodine and trospium. No studies were found that compared anticholinergic drugs to no treatment. At the end of the treatment period, anticholinergics may slightly increase condition-specific quality of life (mean difference (MD) 4.41 lower, 95% confidence interval (CI) 5.28 lower to 3.54 lower (scale range -100 to 0); 12 studies, 6804 participants; low-certainty evidence). Anticholinergics are probably better than placebo in terms of patient perception of cure or improvement (risk ratio (RR) 1.38, 95% CI 1.15 to 1.66; 9 studies, 8457 participants; moderate-certainty evidence), and the mean number of urgency episodes per 24-hour period (MD 0.85 lower, 95% CI 1.03 lower to 0.67 lower; 23 studies, 16,875 participants; moderate-certainty evidence). Compared to placebo, anticholinergics may result in an increase in dry mouth adverse events (RR 3.50, 95% CI 3.26 to 3.75; 66 studies, 38,368 participants; low-certainty evidence), and may result in an increased risk of urinary retention (RR 3.52, 95% CI 2.04 to 6.08; 17 studies, 7862 participants; low-certainty evidence). Taking anticholinergics may be more likely to lead to participants withdrawing from the studies due to adverse events (RR 1.37, 95% CI 1.21 to 1.56; 61 studies, 36,943 participants; low-certainty evidence). However, taking anticholinergics probably reduces the mean number of micturitions per 24-hour period compared to placebo (MD 0.85 lower, 95% CI 0.98 lower to 0.73 lower; 30 studies, 19,395 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS The use of anticholinergic drugs by people with overactive bladder syndrome results in important but modest improvements in symptoms compared with placebo treatment. In addition, recent studies suggest that this is generally associated with only modest improvement in quality of life. Adverse effects were higher with all anticholinergics compared with placebo. Withdrawals due to adverse effects were also higher for all anticholinergics except tolterodine. It is not known whether any benefits of anticholinergics are sustained during long-term treatment or after treatment stops.
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Affiliation(s)
- Akvile Stoniute
- Evidence Synthesis Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Priya Madhuvrata
- Obstetrics & Gynaecology, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
| | - Madeleine Still
- Evidence Synthesis Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Evelyn Barron-Millar
- Evidence Synthesis Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ghulam Nabi
- Section of Academic Urology, Division of Cancer Research, University of Dundee, Dundee, UK
| | - Muhammad Imran Omar
- Guidelines Office, European Association of Urology, Arnhem, Netherlands
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
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O'Connor E, Nic An Riogh A, Karavitakis M, Monagas S, Nambiar A. Diagnosis and Non-Surgical Management of Urinary Incontinence - A Literature Review with Recommendations for Practice. Int J Gen Med 2021; 14:4555-4565. [PMID: 34429640 PMCID: PMC8378928 DOI: 10.2147/ijgm.s289314] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 08/03/2021] [Indexed: 02/06/2023] Open
Abstract
Urinary incontinence (UI) is a bothersome symptom with population studies suggesting a prevalence of 13.1% in women and 5.4% in men. While a significant cohort of patients with this complaint may ultimately require surgical management to achieve complete continence, a number of non-surgical measures exist to improve symptoms and quality of life. A range of guidelines exist on this topic, including those published by the European Association of Urology (EAU), the International Continence Society (ICS), the American Urological Association (AUA) and the UK's National Institute for Health and Care Excellence (NICE). The aim of our study is to provide an overview of the initial assessment of patients with UI including history taking, examination and basic investigations. Our review outlines non-surgical management strategies for UI, including conservative measures, behavioral and physical therapies and drug treatment. We shall also examine the above guidelines and present a narrative overview of the literature surrounding the diagnosis and non-surgical management of urinary incontinence.
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Affiliation(s)
- Eabhann O'Connor
- Department of Urology, Beaumont University Hospital, Dublin, Ireland
| | | | - Markos Karavitakis
- Department of Urology, University General Hospital of Heraklion, University of Crete, Irakleio, Greece
| | - Serenella Monagas
- Department of Urology, San Agustín University Hospital, Avilés, Spain
| | - Arjun Nambiar
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne, UK
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Becher KF. [Urinary incontinence - Diagnostic and therapy options in the elderly]. MMW Fortschr Med 2019; 161:37-42. [PMID: 30721492 DOI: 10.1007/s15006-019-0130-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Klaus Friedrich Becher
- Abteilung Geriatrie und Frührehabilitation, Helios Hanseklinikum Stralsund, Große Parower Straße 47-53, D-18437, Stralsund, Deutschland.
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Becher KF. [Pharmacotherapy of urinary incontinence in the elderly]. Internist (Berl) 2016; 57:390-8. [PMID: 26886709 DOI: 10.1007/s00108-016-0026-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The prevalence and the incidence of Urinary Incontinence is growing. Women suffer predominantly from stress and mixed urinary incontinence and men from urge incontinence. In elderly people, the pathophysiological and the physiological change in the lower urinary tract system must be considered as well as an underlying multimorbidity. Stress urinary incontinence is among others caused by an insufficient urethral closure mechanism and urge incontinence is followed by unhibited detrusor contractions. Medical treatment is beside other important conservative options only one part of the treatment strategy in incontinence. Duloxetine, a serotonine-norepinephrine reuptake inhibitore can increase activity of the external urethral sphincter and is able to reduce incontinence episodes in up to 64 %. Antagonists of muscarinic receptors can reduce urgency, frequency and urge incontinence as well as increase bladder capacity significantly. In Germany, darifenacin, fesoterodin, oxybutynin, propiverine, solifenacin, tolterodine and trospium chloride are available to treat urge incontinence. The efficacy of these agents are almost comparable in the elderly with the exception of oxybutynin IR. However, tolerability is different and not well studied in the elderly population with the exception of fesoterodin. Side effects, especially dry mouth, dizziness and constipation often limit their use. None of the agents show ideal efficacy or tolerability in all patients. Last summer therefore a β3-agonist mirabegron was also introduced in Germany but was withdrawn.
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Affiliation(s)
- K F Becher
- Abteilung Geriatrie und Frührehabilitation, HELIOS Hanseklinikum Stralsund, Große Parower Str. 47-53, 18435, Stralsund, Deutschland.
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Abstract
INTRODUCTION Overactive bladder (OAB) is a common problem which can have disastrous effects on the quality of life of the sufferer. There are established treatments for the problem but they have significant adverse effects. Better drugs and new treatment modalities are necessary to deal with OAB. AREA COVERED Antimuscarinics, mirabegron and intravesical injection of botulinum toxin A are established treatments for OAB. Sacral neuromodulation is more invasive but has been successful in treating OAB. Phase II and III trials are in progress for newer β3-agonists and various combinations of antimuscarinics, β3-agonists and antidiuretics. Targeted secretion inhibitors (TSI) can increase efficacy and reduce adverse effects. Liposome integrated botulinum toxin A has an advantage of effective administration by intravesical instillation. Both medicines are in Phase II trials. Many other drugs which have promising results are discussed. EXPERT OPINION Newer antimuscarinics have better tolerability. Long-term data for mirabegron has shown that it is more effective in severe OAB. Combination drugs may prove to be more effective with less adverse effects. Emerging treatments with TSI, lipotoxin and gene therapy appear promising.
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Affiliation(s)
- Roopali Karmarkar
- a 1 Clinical Research Fellow, St Mary's Hospital, Imperial College, Urogynaecology Department , London, UK +44 0 79 83 41 40 71 ;
| | - Vik Khullar
- b 2 St Mary's Hospital, Imperial College, Urogynaecology Department , London, UK
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Nicholas RS, Friede T, Hollis S, Young CA. WITHDRAWN: Anticholinergics for urinary symptoms in multiple sclerosis. Cochrane Database Syst Rev 2015; 2015:CD004193. [PMID: 26043867 PMCID: PMC10666567 DOI: 10.1002/14651858.cd004193.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
This review has been withdrawn for the following reasons: ‐ a review author contravenes Cochrane's Commercial Sponsorship Policy. This policy ensures the independence of Cochrane reviews by making sure that there is no bias associated with commercial conflicts of interest in the conduct of Cochrane reviews. The author was employed by the biopharmaceutical company AstraZeneca and cannot say with certainty that the company did not produce or have any financial interest in the interventions in this review ‐ the review is substantially out of date To view the published versions of this article, please click the 'Other versions' tab. The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
- Richard S Nicholas
- Charing Cross HospitalWest London Neurosciences CentreFulham Palace RoadLondonUKW6 8RF
| | - Tim Friede
- Universitatsmedizin GöttingenAbteilung fur Innere Medizin 1GöttingenGermany
| | - Sally Hollis
- University of Nottinghamc/o Cochrane Skin GroupKing's Meadow CampusLenton LaneNottinghamUKNG7 2NR
| | - Carolyn A Young
- The Walton Centre NHS Foundation TrustLower LaneFazakerleyLiverpoolUKL9 7LJ
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Cameron AP, Jimbo M, Heidelbaugh JJ. Diagnosis and office-based treatment of urinary incontinence in adults. Part two: treatment. Ther Adv Urol 2013; 5:189-200. [PMID: 23904858 PMCID: PMC3721442 DOI: 10.1177/1756287213495100] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Urinary incontinence is a common problem in both men and women. In this review article we address treatment of the various forms of incontinence with conservative treatments, medical therapy, devices and surgery. The US Preventive Services Task Force, The Cochrane Database of Systematic Reviews, and PubMed were reviewed for articles focusing on urinary incontinence. Conservative therapy with education, fluid and food management, weight loss, timed voiding and pelvic floor physical therapy are all simple office-based treatments for incontinence. Medical therapy for incontinence currently is only available for urgency incontinence in the form of anticholinergic medication. Condom catheters, penile clamps, urethral inserts and pessaries can be helpful in specific situations. Surgical therapies vary depending on the type of incontinence, but are typically offered if conservative measures fail.
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Affiliation(s)
- Anne P Cameron
- University of Michigan Department of Urology, 3875 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5330, USA
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Madhuvrata P, Cody JD, Ellis G, Herbison GP, Hay-Smith EJC. Which anticholinergic drug for overactive bladder symptoms in adults. Cochrane Database Syst Rev 2012; 1:CD005429. [PMID: 22258963 DOI: 10.1002/14651858.cd005429.pub2] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Around 16% to 45% of adults have overactive bladder symptoms (urgency with frequency and/or urge incontinence - 'overactive bladder syndrome'). Anticholinergic drugs are common treatments. OBJECTIVES To compare the effects of different anticholinergic drugs for overactive bladder symptoms. SEARCH METHODS We searched the Cochrane Incontinence Group Specialised Trials Register (searched 8 March 2011) and reference lists of relevant articles. SELECTION CRITERIA Randomised trials in adults with overactive bladder symptoms or detrusor overactivity that compared one anticholinergic drug with another, or two doses of the same drug. DATA COLLECTION AND ANALYSIS Two authors independently assessed eligibility, trial quality and extracted data. Data were processed as described in the Cochrane Reviewers' Handbook. MAIN RESULTS Eighty six trials, 70 parallel and 16 cross-over designs were included (31,249 adults). Most trials were described as double-blind, but were variable in other aspects of quality. Crossover studies did not present data in a way that could be included in the meta-analyses. Twenty nine collected quality of life data (the primary outcome measure) using validated measures, but only fifteen reported useable data.Tolterodine versus oxybutynin: There were no statistically significant differences for quality of life, patient reported cure or improvement, leakage episodes or voids in 24 hours, but fewer withdrawals due to adverse events with tolterodine (Risk Ratio (RR) 0.52, 95% confidence interval (CI) 0.40 to 0.66, data from eight trials), and less risk of dry mouth (RR 0.65, 95% CI 0.60 to 0.71, data from ten trials).Solifenacin versus tolterodine: There were statistically significant differences for quality of life (standardised mean difference (SMD) -0.12, 95% CI -0.23 to -0.01, data from three trials), patient reported cure/improvement (RR 1.25, 95% CI 1.13 to 1.39, data from two trials), leakage episodes in 24 hours (weighted mean difference (WMD) -0.30, 95% CI -0.53 to -0.08, data from four studies) and urgency episodes in 24 hours (WMD -0.43, 95% CI -0.74 to -0.13, data from four trials), all favouring solifenacin. There was no difference in withdrawals due to adverse events and dry mouth, but after sensitivity analysis the dry mouth (RR 0.69, 95% CI 0.51 to 0.94) was statistically significantly lower with solifenacin when compared to Immediate Release (IR) tolterodine.Fesoterodine versus extended release tolterodine: Three trials contributed to the meta analyses. There were statistically significant differences for quality of life (SMD -0.20, 95% CI -0.27 to -0.14), patient reported cure/improvement (RR 1.11, 95% CI 1.06 to 1.16), leakage episodes (WMD -0.19, 95% CI -0.30 to -0.09), frequency (WMD -0.27, 95% CI -0.47 to -0.06) and urgency episodes (WMD -0.44, 95% CI -0.72 to -0.16) in 24 hours, all favouring fesoterodine, but those taking fesoterodine had higher risk of withdrawal due to adverse events (RR 1.45, 95% CI 1.07 to 1.98) and higher risk of dry mouth (RR 1.80, 95% CI 1.58 to 2.05) at 12 weeks.Different doses of tolterodine: The standard recommended starting dose (2 mg twice daily) was compared with two lower (0.5 mg and 1 mg twice daily), and one higher dose (4 mg twice daily). The effects of 1 mg, 2 mg and 4 mg doses were similar for leakage episodes and micturitions in 24 hours, with greater risk of dry mouth with 2 and 4 mg doses at two to 12 weeks.Different doses of solifenacin: The standard recommended starting dose of 5 mg once daily was compared to 10 mg: while frequency and urgency were less (better) with 10 mg compared to 5 mg, there was a higher risk of dry mouth with 10 mg solifenacin at four to 12 weeks.Different doses of fesoterodine:The recommended starting dose of 4mg once daily was compared to 8 and 12 mg. The clinical efficacy (patient reported cure, leakage episodes, micturition per 24 hours) of 8 mg was better than 4 mg fesoterodine but with a higher risk of dry mouth with 8 mg.There was no statistically significant difference between 4 and 12 mg in the efficacy but the dry mouth was significantly higher with 12 mg at eight to 12 weeks.Extended versus immediate release preparations of oxybutynin and/or tolterodine: There were no statistically significant differences for cure/improvement, leakage episodes or micturitions in 24 hours, or withdrawals due to adverse events, but there were few data. Overall, extended release preparations had less risk of dry mouth at two to 12 weeks.One extended release preparation versus another: There was less risk of dry mouth with oral extended release tolterodine than oxybutynin (RR 0.75, 95% CI 0.59 to 0.95), but no difference between transdermal oxybutynin and oral extended release tolterodine although some people withdrew due to skin reaction at the transdermal patch site at 12 weeks. AUTHORS' CONCLUSIONS Where the prescribing choice is between oral immediate release oxybutynin or tolterodine, tolterodine might be preferred for reduced risk of dry mouth. With tolterodine, 2 mg twice daily is the usual starting dose, but a 1 mg twice daily dose might be equally effective, with less risk of dry mouth. If extended release preparations of oxybutynin or tolterodine are available, these might be preferred to immediate release preparations because there is less risk of dry mouth.Between solifenacin and immediate release tolterodine, solifenacin might be preferred for better efficacy and less risk of dry mouth. Solifenacin 5 mg once daily is the usual starting dose, this could be increased to 10 mg once daily for better efficacy but with increased risk of dry mouth.Between fesoterodine and extended release tolterodine, fesoterodine might be preferred for superior efficacy but has higher risk of withdrawal due to adverse events and higher risk of dry mouth.There is little or no evidence available about quality of life, costs, or long-term outcome in these studies. There were insufficient data from trials of other anticholinergic drugs to draw any conclusions.
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Affiliation(s)
- Priya Madhuvrata
- Obstetrics & Gynaecology, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield,
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Nicholas R, Young C, Friede T. Bladder symptoms in multiple sclerosis: a review of pathophysiology and management. Expert Opin Drug Saf 2011; 9:905-15. [PMID: 20569078 DOI: 10.1517/14740338.2010.501793] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
IMPORTANCE OF THE FIELD The use of anticholinergic medication in bladder dysfunction such as overactive bladder syndrome (OAB) is widespread. However, the benefits and risks of anticholinergics in multiple sclerosis (MS) are unclear because in MS the damage to normal urinary function is both more diffuse and increases with disease progression, and the risk of CNS side effects is higher. AREAS COVERED IN THIS REVIEW The pathophysiology of urinary dysfunction in MS and the efficacy and side effects of anticholinergics is assessed. The review analyzed randomized controlled trials and observational studies using anticholinergics involving persons with a confirmed diagnosis of MS having urinary symptoms. Finally a pragmatic approach to managing urinary symptoms in MS is discussed. WHAT THE READER WILL GAIN The published data provide limited evidence for the efficacy of anticholinergics in MS. The complexity of treating urinary symptoms in the context of other therapies and the changing neurological background seen in MS is comprehensively analyzed. TAKE HOME MESSAGE Anticholinergics could be helpful in particular phases of MS. However, there is inadequate evidence currently available on the use of anticholinergics in MS, and further research on the management of the MS neuropathic bladder is warranted.
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Affiliation(s)
- Richard Nicholas
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, Department of Neurosciences, London, UK.
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Abstract
Enuresis is defined as nocturnal bed wetting for at least 2 nights per month in children older than 5 years. At this age the prevalence of enuresis is about 15-20%. More than 50% of these children show day time symptoms, such as frequency, urgency and incontinence (non-monosymptomatic enuresis). The other children are asymptomatic during day time and wet the bed during the night time (monosymptomatic enuresis). The main pathogenetic factors are nycturia, detrusor overactivity and reduced arousability. Psychological and psychiatric aspects, genetics and obstipation play an additional role in the etiology. Basic diagnostic investigations are mandatory before treatment. Clinical history, physical examination, sonography of the urinary tract, urinalysis and bladder diary are prerequisites before any therapeutic steps are taken. The cornerstones of primary enuresis therapy are general lifestyle advice, pharmacotherapy and alarm devices. Therapy-resistant children deserve further evaluation and a multidisciplinary therapy approach. After careful evaluation specific therapy is efficient in approximately 80% of patients.
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Affiliation(s)
- M Riccabona
- Abteilung für Kinderurologie, Krankenhaus der Barmherzigen Schwestern Linz, Seilerstätte 4, Linz, Austria.
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Neveus T, Eggert P, Evans J, Macedo A, Rittig S, Tekgül S, Vande Walle J, Yeung C, Robson L. Evaluation of and Treatment for Monosymptomatic Enuresis: A Standardization Document From the International Children's Continence Society. J Urol 2010; 183:441-7. [DOI: 10.1016/j.juro.2009.10.043] [Citation(s) in RCA: 175] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Indexed: 10/20/2022]
Affiliation(s)
- Tryggve Neveus
- Nephrology Unit, Uppsala University Children's Hospital, Uppsala, Sweden
| | - Paul Eggert
- Klinik für Allgemeine Pädiatrie der Christian-Albrechts-Universität, Kiel, Germany
| | - Jonathan Evans
- Nottingham University Hospitals National Health Service Trust Queens Medical Centre Campus, Nottingham, United Kingdom
| | - Antonio Macedo
- Pediatric Urology Section, Federal University of São Paulo, São Paulo, Brazil
| | - Søren Rittig
- Department of Pediatrics, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | - Serdar Tekgül
- Section of Paediatric Urology, Department of Urology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Johan Vande Walle
- Pediatric Nephrology Unit, Ghent University Hospital, Ghent, Belgium
| | - C.K. Yeung
- Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
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Behavioral intervention versus pharmacotherapy or their combinations in the management of overactive bladder dysfunction. Adv Urol 2009:345324. [PMID: 20029638 PMCID: PMC2796220 DOI: 10.1155/2009/345324] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Accepted: 11/07/2009] [Indexed: 11/30/2022] Open
Abstract
Overactive bladder syndrome (OAB) refers to individuals with the following symptoms: urinary urgency, increased urinary frequency, and urge incontinence. These symptoms are not life threatening but can cause embarrassment and significantly impact quality of life. There are numerous treatment options for OAB, including behavioral therapy, traditional pharmacological therapy or a combination of the two. These options are considered the mainstay of treatment for OAB. We carried out a comprehensive systematic review of the available literature on the effectiveness of behavioral intervention, anticholinergic drugs, and their combination in the management of adults with overactive bladder, with emphasis on results from clinical trials and primary literature. Each treatment intervention is efficacious, and the choice should be based on the patient's severity of symptoms, tolerability, compliance and satisfaction with the treatment. Based on available literature, management of OAB using a combination of behavioral therapy and drug intervention is the most efficacious in terms of patient satisfaction, perceived improvement, and reduction of bladder symptoms. It is also the most practical and cost effective for optimal management of patients with OAB. Pharmacological treatment, in addition to behavioral therapy, remains important in the management of adults with OAB syndrome.
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Abstract
BACKGROUND Multiple Sclerosis (MS) is the commonest physically disabling chronic neurological disease affecting young people. Urinary symptoms are present in about 68% of people with MS but their basis has a number of potential aetiologies that can change with time. OBJECTIVES To assess the absolute and comparative efficacy, tolerability and safety of anticholinergic agents in MS patients. SEARCH STRATEGY We searched the Cochrane Multiple Sclerosis Group Specialised Trials Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue1), MEDLINE (January 1966 to January 2008), EMBASE (January 1974 to January 2008), supplemented with search of reference lists, personal communication with authors and relevant drug manufacturers. SELECTION CRITERIA Randomised trials and cross-over trials (blinded and unblinded) that are either placebo-controlled or comparing two or more treatments. DATA COLLECTION AND ANALYSIS All four review authors independently assessed eligibility and trial quality, and extracted data. Data were processed as described in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS Our search strategy identified 33 articles of which thirty were excluded. Three single centre trials were included. No details were given regarding randomisation and blinding in the first two trials but side effects were frequent with all treatments.The first (Hebjorn 1977) was a double blind randomised crossover trial. Thirty four persons with MS received three drugs Methantheline Bromide, Flavoxate Chloride and Meladrazine Tartrate each for 14 days, washout periods were not mentioned. Median volume measurements at the first bladder contraction were statistically significant at a 5% level for Methantheline Bromide only compared to no treatment.The second (Gajewski 1986) was a prospective parallel group randomised study. Thirty four persons with MS were treated for 6-8 weeks with Oxybutynin (19 subjects) or Propantheline (15 subjects). For frequency, nocturia, urgency, and urge incontinence differences in symptom grade in favour of Oxybutynin were found. However, only for frequency the difference was statistically significant at 5% level.The third (Fader 2007) was a double blind crossover trial. Sixty four persons with MS received oral Oxybutynin or intravesical Atropine for 14 days. Details of randomisation and blinding were given. There was no significant difference between the two treatments in any efficacy outcome measure. Side effects and QOL scores showed significant differences in favour of atropine. AUTHORS' CONCLUSIONS From the available evidence we cannot advocate the use of anticholinergics in MS.
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Affiliation(s)
- Richard S Nicholas
- West London Neurosciences Centre, Charing Cross Hospital, Fulham Palace Road, London, UK, W6 8RF.
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Bulat T, Castle SC, Rutledge M, Quigley P. Clinical practice algorithms: Medication management to reduce fall risk in the elderly—Part 4, Anticoagulants, anticonvulsants, anticholinergics/bladder relaxants, and antipsychotics. ACTA ACUST UNITED AC 2008; 20:181-90. [DOI: 10.1111/j.1745-7599.2008.00311.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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17
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Abstract
Overactive bladder is a common and distressing problem. Standard therapy is directed towards modifying the detrusor motor sensitivity and response via anticholinergic medication. Currently available medications are reviewed and alternative targets for treatment are presented.
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Affiliation(s)
- Rebecca J McCrery
- Division of Voiding Dysfunction & Female Urology, Scott Department of Urology, Baylor College of Medicine, Houston, Texas, USA
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Dmochowski RR, Nitti V, Staskin D, Luber K, Appell R, Davila GW. Transdermal oxybutynin in the treatment of adults with overactive bladder: combined results of two randomized clinical trials. World J Urol 2005; 23:263-70. [PMID: 16151816 DOI: 10.1007/s00345-005-0012-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2005] [Accepted: 05/16/2005] [Indexed: 10/25/2022] Open
Abstract
The safety and efficacy of oxybutynin transdermal delivery system (oxybutynin-TDS) versus placebo in adults with urge and mixed urinary incontinence was investigated using combined results from double-blind stages of 2 phase 3 clinical trials. Study 1: placebo-controlled, parallel-group comparison of 3 oxybutynin-TDS doses in 12-week double-blind and open-label periods, followed by a 28-week open-label extension. Study 2 was a 12-week randomized, double-blind, placebo-controlled comparison of oxybutynin-TDS versus long-acting tolterodine and placebo, followed by a 52-week open-label extension. Efficacy analysis included 241 patients receiving oxybutynin-TDS, 244 receiving placebo. Most participants were Caucasian women (92%). Approximately 60% received prior anticholinergic therapy. Primary outcome was determined by changes from baseline to end of treatment in frequency of incontinence episodes, frequency of urination, and void volume. Oxybutynin-TDS was significantly more effective than placebo in reducing median daily incontinence episodes (-3.0 vs placebo -2.0; P=.00004) and daily urinary frequency (-2.0 vs -1.0; P=.0023), and in increasing void volume (25 mL vs 5.5 mL; P<.00001). Overall rates of anticholinergic adverse events (AEs) were 12.8% for oxybutynin-TDS and 11.0% for placebo (P=0.5421). The most common systemic anticholinergic AEs were dry mouth (7.0% for oxybutynin-TDS vs 5.3% for placebo) and constipation (2.1% vs 2.0%). Application site erythema occurred in 7.0% of participants who received oxybutynin-TDS (3.7% discontinuation rate); pruritus occurred in 16.1% (3.3% discontinuation rate). Transdermal oxybutynin was shown to be efficacious, with a proven safety profile. It may be utilized for patients with overactive bladder as a treatment option that could enhance compliance.
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Affiliation(s)
- Roger R Dmochowski
- Department of Urologic Surgery, Vanderbilt University, Nashville, TN 37235, USA.
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19
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Miller KL. Stress Urinary Incontinence in Women: Review and Update on Neurological Control. J Womens Health (Larchmt) 2005; 14:595-608. [PMID: 16181016 DOI: 10.1089/jwh.2005.14.595] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Female stress urinary incontinence (SUI) is a common disease that involves leakage of urine during coughing, sneezing, or other increases in intraabdominal pressure. Treatments for SUI include pelvic floor muscle training, electrical stimulation, surgery, and off-label alpha-adrenergic agonists that stimulate contraction of the urethral smooth muscle. None of these treatments is universally or completely effective, and because drug therapy with the alpha- adrenergic agonists phenylpropanolamine and ephedrine can cause serious pressor adverse effects, the former has been banned in the United States, and the latter is under scrutiny. The central nervous system (CNS) affects reflexes that control urine storage and micturition, and norepinephrine and serotonin play a key role in maintaining storage capability by means of contraction of the external striated muscle of the urethral sphincter. Duloxetine hydrochloride, which inhibits reuptake of both of these neurotransmitters, has been shown to promote striated urethral sphincter contraction in animal models and to reduce the incidence of involuntary urine release in women with SUI without interfering with micturition. CONCLUSION Neuromodulation of noradrenergic and serotonergic neurotransmitters with such drugs as duloxetine provides an additional treatment option for women with SUI.
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Affiliation(s)
- Karen L Miller
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, 30 North 1900 East, Salt Lake City, UT 84132, USA.
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20
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Hay-Smith J, Herbison P, Ellis G, Morris A. Which anticholinergic drug for overactive bladder symptoms in adults. Cochrane Database Syst Rev 2005:CD005429. [PMID: 16034974 DOI: 10.1002/14651858.cd005429] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Around 16% to 45% of adults have overactive bladder symptoms (urgency with frequency and/or urge incontinence - 'overactive bladder syndrome'). Anticholinergic drugs are common treatments. OBJECTIVES To compare the effects of different anticholinergic drugs for overactive bladder symptoms. SEARCH STRATEGY We searched the Cochrane Incontinence Group specialised trials register (searched 17 January 2002) and reference lists of relevant articles. A search for full publications of abstracts identified in January 2002 was completed in July 2003. SELECTION CRITERIA Randomised trials in adults with overactive bladder symptoms or detrusor overactivity that compared one anticholinergic drug with another, or two doses of the same drug. DATA COLLECTION AND ANALYSIS Two authors independently assessed eligibility, trial quality and extracted data. Data were processed as described in the Cochrane Reviewers' Handbook. MAIN RESULTS Forty nine trials, 39 parallel and 10 cross-over designs were included (11,332 adults). Most trials were described as double-blind, but were variable in other aspects of quality. Crossover studies did not present data in a way that could be included in the meta-analysis.Four trials collected quality of life data (the primary outcome measure) using validated measures; none reported useable data. Oxybutynin versus tolterodine: There were no statistically significant differences for patient perceive improvement, leakage episodes or voids in 24 hours, but fewer withdrawals due to adverse events (RR 0.57, 95% CI 0.43 to 0.75), and less risk of dry mouth (RR 0.60, 95% CI 0.54 to 0.66), with tolterodine. Different doses tolterodine: The usual recommended starting dose (2 mg twice daily) was compared with two lower (0.5 mg and 1 mg twice daily), and one higher dose (4 mg twice daily). The effect of 1 mg, 2 mg and 4 mg doses was similar for leakage episodes and micturitions in 24 hours, with greater risk of dry mouth with 2 and 4 mg doses.Extended versus immediate release preparations of oxybutynin and/or tolterodine: There were no statistically significant differences for cure/improvement, leakage episodes or micturitions in 24 hours, or withdrawals due to adverse events, but there were few data. Overall, extended release preparations had less risk of dry mouth. One extended release preparation versus another: There was less risk of dry mouth with oral extended release tolterodine than oxybutynin (RR 0.75, 95% CI 0.59 to 0.95), but no difference between transdermal oxybutynin and oral extended release tolterodine although some people withdrew due to skin reaction at the trandermal patch site. AUTHORS' CONCLUSIONS Where the prescribing choice is between oral immediate release oxybutynin or tolterodine, tolterodine might be preferred for reduced risk of dry mouth. With tolterodine, 2 mg twice daily is the usual starting dose, but a 1 mg twice daily dose might be equally effective with less risk of dry mouth. If extended release preparations of oxybutynin or tolterodine are available, these might be preferred to immediate release preparations because there is less risk of dry mouth. There is little or no evidence available about quality of life, costs, or long-term outcome in these studies. There were insufficient data from trials of other anticholinergic drugs to draw any conclusions.
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Affiliation(s)
- J Hay-Smith
- Rehabilitation Teaching and Research Unit, Department of Medicine, Wellington School of Medicine and Health Sciences, University of Otago, PO Box 7343, Wellington South, Wellington, New Zealand.
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21
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Chu FM, Dmochowski RR, Lama DJ, Anderson RU, Sand PK. Extended-release formulations of oxybutynin and tolterodine exhibit similar central nervous system tolerability profiles: a subanalysis of data from the OPERA trial. Am J Obstet Gynecol 2005; 192:1849-54; discussion 1854-5. [PMID: 15970828 DOI: 10.1016/j.ajog.2005.03.036] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This study was undertaken to compare the central nervous system (CNS) tolerability profiles of the extended-release formulations of oxybutynin chloride and tolterodine tartrate in the treatment of women with overactive bladder (OAB), as observed in the OPERA (Overactive bladder: Performance of Extended Release Agents) trial. STUDY DESIGN The OPERA trial was a randomized, double-blind, active-control comparison of the efficacy and safety of extended-release oxybutynin (10 mg/d) and extended-release tolterodine (4 mg/d) given to 790 women with OAB for 12 weeks. The incidence of reported CNS events was compared between the treatment groups by using the Fisher exact test. RESULTS The incidence of CNS adverse events was 9% and 8% for the oxybutynin and tolterodine treatment groups, respectively. The difference between groups was not statistically significant. All reported CNS adverse events were rated as mild or moderate in severity. There were no serious treatment-related adverse events in either group, and discontinuation because of a CNS adverse event was infrequent. CONCLUSION The extended-release formulations of oxybutynin and tolterodine were observed to be associated with a similar low incidence of CNS adverse events, which were mostly mild or moderate in severity.
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22
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Abstract
Pharmacological treatment for overactive bladder has centred around the interruption of the detrusor activity that is central to urge and incontinence symptoms. The majority of patients with this disorder are treated with antimuscarinic agents. These drugs have been demonstrated to improve urgency, frequency of micturition and urge incontinence, all of which are primary symptoms of overactive bladder; however, they are also commonly associated with anticholinergic adverse effects, most notably dry mouth. Attempts to increase tolerability have included the development of advanced formulations that regulate release of the active ingredient and the development of pharmacological agents that target the desired bladder receptors more specifically and accurately. Although all agents provide good efficacy, tolerability is greatly affected by the formulation used to deliver the active pharmacological agent, as well as the specificity of the targeted receptors. Clinical trials involving a transdermal formulation of oxybutynin have shown that this delivery method may be associated with a lower incidence of anticholinergic adverse events compared with both the immediate-release and the extended-release oral formulations of traditional agents, as well as the most recently approved agents - trospium chloride, solifenacin and darifenacin. Much is still being learned about the function and specificity of muscarinic receptors, which will support the development of agents with sustained efficacy and enhanced tolerability compared with the available formulations to date. These include the S-isomer of oxybutynin, as well as selective muscarinic M2 receptor antagonists.
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Affiliation(s)
- Roger Dmochowski
- Department of Urologic Surgery, Vanderbilt University, Nashville, Tennessee 37232, USA.
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23
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DuBeau CE, Khullar V, Versi E. ?Unblinding? in randomized controlled drug trials for urinary incontinence: Implications for assessing outcomes when adverse effects are evident. Neurourol Urodyn 2005; 24:13-20. [PMID: 15570576 DOI: 10.1002/nau.20083] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
AIMS To determine whether women with urinary incontinence (UI) can identify their allocation in a randomized controlled trial (RCT) of tolterodine (TOL), and whether correct identification is associated with outcomes and adverse effects (AEs). METHODS Exploratory analysis of a randomized, double-blind, placebo (PLC)-controlled trial of TOL 4 mg daily for 8 weeks in 743 women with urge-predominant mixed UI. Patient perception of their randomization was assessed at trial end. Main outcome measures were 7-day bladder diaries, patient perception of improvement, and UI-specific quality of life (QoL). RESULTS TOL produced a significant decrease in urge UI episodes compared to PLC (78% vs. 51%, P = 0.0001). Fifty-one percent of women correctly identified their randomization (58% on TOL vs. 37% on PLC, P < 0.001). Women who assumed they took TOL had better bladder diary outcomes than those who assumed they took PLC. Within each assumption group, patient perception outcomes were similar, regardless of actual randomization. QoL improved in all domains except general health for women on TOL. In women who assumed they took TOL, significant drug benefit was evident in three domains. Moderate-severe dry mouth was higher in those who assumed they took TOL (7.3% vs. 0%, P < 0.0001). CONCLUSIONS Greater than fifty percent of women in this RCT of antimuscarinic treatment were "unblinded" to their randomization. Patient assumption of randomization was associated with bladder diary and perception outcomes, specific QoL domains, and dry mouth. Efficacy of urge incontinence drugs should be considered in the context of patient assumptions, expectations, and "unblinding" by easily evident side effects.
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Affiliation(s)
- Catherine E DuBeau
- Section of Geriatrics, University of Chicago, Chicago, Illinois 60637, USA.
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24
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Knight-Klimas TC. Current Management of Urinary Incontinence. J Pharm Pract 2004. [DOI: 10.1177/0897190004263216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Urinary incontinence is an underreported, underdiagnosed, and undertreated condition erroneously thought by many patients to be a normal part of aging. This article briefly discusses transient urinary incontinence and then focuses on the different types of established incontinence. Specifically, the article discusses preferred terminology associated with urinary incontinence and describes the different types, causes, nonpharmacologic options, and pharmacologic options for managing overactive bladder syndrome, stress incontinence, and overflow incontinence. It briefly discusses mixed urinary incontinence and functional incontinence. The role of the pharmacist in working with patients, caregivers, and other health care professionals to optimize management of urinary incontinence is discussed throughout.
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25
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Landis JR, Kaplan S, Swift S, Versi E. Efficacy of Antimuscarinic Therapy for Overactive Bladder With Varying Degrees of Incontinence Severity. J Urol 2004; 171:752-6. [PMID: 14713803 DOI: 10.1097/01.ju.0000103540.71683.e5] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We analyze the efficacy of tolterodine extended release (ER) for overactive bladder in patients with severe incontinence. MATERIALS AND METHODS Patients with urinary frequency (8 micturitions or greater per 24 hours), urge incontinence (5 episodes or greater a week) and symptoms of overactive bladder for 6 months or greater were randomized to treatment with 4 mg tolterodine ER once daily or placebo for 12 weeks. Severe incontinence was defined as 21 episodes or greater per week at baseline. Changes in the number of incontinence episodes per week and micturition frequency after 12 weeks were compared between treatments. RESULTS A total of 986 patients were eligible for this post-hoc analysis. After 12 weeks tolterodine ER produced a significant absolute median reduction in incontinence episodes per week compared to placebo (9.0 vs 5.0, p <0.0001). For patients with severe incontinence at baseline median absolute and percentage reductions in incontinence episodes per week were significantly greater with tolterodine ER than placebo (21.0 vs 9.5, p <0.0001; 67.6% vs 29.8%, p = 0.022). Micturition frequency decreased (p <0.02) and volume voided per micturition (p <0.0001) increased significantly more with tolterodine ER compared with placebo in these patients. For patients with nonsevere incontinence at baseline median reductions in incontinence episodes per week were also significantly greater with tolterodine ER than placebo (6.0 vs 4.0, p <0.0001; 71.4% vs 38.5%, p = 0.026). CONCLUSIONS Patients with more severe incontinence at baseline achieved greater absolute reductions in incontinence with tolterodine compared to those with less severe symptoms. The degree of improvement, as measured by percent change, was comparable across the entire range of baseline incontinence severity strata. Benefits of antimuscarinic therapy may be greater in these patients than previously reported.
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Affiliation(s)
- J Richard Landis
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Phiadelphia, 19104-6021, USA.
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26
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Hughes DA, Dubois D. Cost-effectiveness analysis of extended-release formulations of oxybutynin and tolterodine for the management of urge incontinence. PHARMACOECONOMICS 2004; 22:1047-1059. [PMID: 15524493 DOI: 10.2165/00019053-200422160-00002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
INTRODUCTION Oxybutynin and tolterodine are two drugs widely used for the management of overactive bladder and urge urinary incontinence. The once-daily, extended-release formulations benefit from being well tolerated and efficacious. However, their costs, compared with generic immediate-release (IR) oxybutynin, are significantly greater. This study compared the cost effectiveness of oxybutynin extended-release (Oxy-XL), tolterodine extended-release (Tol-ER), tolterodine immediate-release (Tol-IR) and oxybutynin immediate-release (Oxy-IR). STUDY DESIGN A cost-effectiveness model. METHODS A systematic review that identified appropriate randomised clinical trials provided evidence on efficacy. Empirical models of drug effects (number of incontinent-free weeks) and persistence (proportion of patients still on therapy) were constructed in order to determine clinical effectiveness which was combined with cost data (direct medical costs to the UK NHS, year 2001 values) to calculate the drugs' cost-effectiveness from the perspective of the NHS. Univariate sensitivity analyses were conducted to test the robustness of the results. PATIENTS Hypothetical cohort of patients with urge incontinence associated with overactive bladder. MAIN OUTCOME MEASURES AND RESULTS The incremental cost per incontinent-free week for Oxy-IR (versus no treatment) ranged from pound sterling 2.58 to pound sterling 16.59. Oxy-XL and Tol-ER were more effective than Oxy-IR but at additional costs per incontinent-free week. Tol-IR did not appear to be a cost-effective option as it was less effective and more costly than the extended-release formulations. Uncertainty surrounding the health and cost consequences of early discontinuation affected these results, although the model results were robust to parameter uncertainty. CONCLUSION Oxy-IR, Oxy-XL and Tol-ER appear to be cost-effective options for the management of urge incontinence from the NHS perspective. A decision among the treatments depends on the acceptable cost per additional incontinent-free week.
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Affiliation(s)
- Dyfrig A Hughes
- Centre for the Economics of Health, IMSCaR, University of Wales, Bangor, Wales.
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Abstract
OBJECTIVE To identify drugs associated with the complaint of dry mouth. MATERIALS AND METHODS MEDLINE was searched for papers 1980-2002 using keywords, oral, mouth, salivary, drugs, dry mouth and xerostomia, and relevant secondary references were hand-searched. RESULTS Evidence was forthcoming for a number of xerogenic drugs, especially antimuscarinic agents, some sympathomimetic agents, and agents affecting serotonin and noradrenaline uptake, as well as a miscellany of other drugs such as appetite suppressants, protease inhibitors and cytokines. CONCLUSION Dry mouth has a variety of possible causes but drugs--especially those with anticholinergic activity against the M3 muscarinic receptor--are the most common cause of reduced salivation.
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Affiliation(s)
- C Scully
- International Centres for Excellence in Dentistry and Department of Oral Medicine, Eastman Dental Institute for Oral Health Care Sciences, University of London, London, UK.
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Abstract
To store and expel urine at appropriate intervals, the lower urinary tract requires extensive input and control from the peripheral autonomic, somatic, and central nervous systems. Neurological disorders, such as cerebrovascular disease and Parkinson's disease, often cause functional disturbances of the lower urinary tract.
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Affiliation(s)
- Mike B Siroky
- Boston University School of Medicine, 80 East Concord Street, Boston, MA 02118, USA.
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Abstract
Oxybutynin is a muscarinic receptor antagonist, which has been available for a number of years in its original immediate-release (IR) formulation. While oxybutynin IR has proven effective for the treatment of overactive bladder, its extended use can be limited by adverse effects, particularly dry mouth. An extended-release (ER) formulation of oxybutynin based on the OROS system has recently become available, which allows once daily administration. In direct comparison to oxybutynin IR, oxybutynin ER has an increased oral bioavailability for the parent compound oxybutynin which is accompanied by a reduced bioavailability for the active metabolite N-desethyl-oxybutynin. The latter has been implicated in mediating a major part of the adverse effects of oxybutynin treatment. Two double-blind, placebo-controlled, randomised studies in patients with overactive bladder have demonstrated that oxybutynin ER has a similar efficacy as oxybutynin IR but with improved tolerability. This is in line with clinical pharmacological studies demonstrating a smaller impairment of saliva production with oxybutynin ER than with oxybutynin IR. Thus, the ER formulation of oxybutynin maintains the therapeutic benefits and concomitantly improves tolerability.
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Affiliation(s)
- Martin C Michel
- Department of Medicine, University of Essen, Essen, Germany.
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Abstract
Recent pharmacologic treatment for detrusor overactivity has resulted in more favorable side effect profiles, not only because of the use of different drug delivery systems for older drugs but perhaps also due to the improved bladder selectivity of newer antimuscarinic agents. These developments translate into higher patient compliance and better long-term results with the newer agents over generic immediate-release oxybutynin for the treatment of the overactive bladder.
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Affiliation(s)
- H Henry Lai
- Scott Department of Urology, Baylor College of Medicine, 6560 Fannin Street, Suite 2100, Houston, TX 77030, USA
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Dmochowski R, Kell S, Staskin D. Oxybutynin chloride: alterations in drug delivery and improved therapeutic index. Expert Opin Pharmacother 2002; 3:443-54. [PMID: 11934349 DOI: 10.1517/14656566.3.4.443] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Oxybutynin chloride (Ditropan, Alza) is widely regarded as the most efficient antimuscarinic agent for the treatment of bladder detrusor dysfunction resulting in urinary urgency, frequency and urge incontinence. Oxybutynin metabolism occurs primarily in the proximal gastrointestinal tract and the hepatic circulation and is mediated by the cytochrome P450 3A4 isozyme. The major degradation products are desethyloxybutynin, which possesses pharmacological activity, and phenylcyclohexylglycolic acid, which is metabolically inert. A major limitation to long-term compliance with immediate-release oxybutynin remains the necessity for twice- or thrice-daily dosing regimens to provide sustained pharmacological efficacy. Side effects induced by cytochrome P450 metabolism of oxybutynin into the primary metabolite desethyloxybutynin within the gut wall substantially affect the tolerability of the compound within the individual. The oral osmotic delivery system provides unique advantages for drug delivery and substantially alters the tolerability profile of the oxybutynin chloride compound. This extended-release formulation consists of a two component core encapsulated by a semi-permeable membrane. The osmotic gradient between the surrounding environment and the inner core of the delivery system remains constant and water absorption within the capsule is controlled by the semipermeable membrane causing a controlled release of drug, which is sustained over 24 h. Herein are reviewed the various pre- and post-approval trials which have documented the overall therapeutic index of the oral osmotic oxybutynin (Ortho-McNeil Pharmaceuticals). Subsequent post-market surveillance issues are reviewed as are new developments in oxybutynin delivery.
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Affiliation(s)
- Roger Dmochowski
- Department of Urologic Surgery, Room A1302, Medical Center North, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
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