Randomized controlled trial of cyclic and continuous therapy with trospium and solifenacin combination for severe overactive bladder in elderly patients with regard to patient compliance

Current and Emerging Pharmacological Targets and Treatments of Urinary Incontinence and Related Disorders

Overactive bladder syndrome with and without urinary incontinence and related conditions, signs, and disorders such as detrusor overactivity, neurogenic lower urinary tract dysfunction, underactive bladder, stress urinary incontinence, and nocturia are common in the general population and have a major impact on the quality of life of the affected patients and their partners. Based on the deliberations of the subcommittee on pharmacological treatments of the 7th International Consultation on Incontinence, we present a comprehensive review of established drug targets in the treatment of overactive bladder syndrome and the aforementioned related conditions and the approved drugs used in its treatment. Investigational drug targets and compounds are also reviewed. We conclude that, despite a range of available medical treatment options, a considerable medical need continues to exist. This is largely because the existing treatments are symptomatic and have limited efficacy and/or tolerability, which leads to poor long-term adherence. SIGNIFICANCE STATEMENT: Urinary incontinence and related disorders are prevalent in the general population. While many treatments have been approved, few patients stay on long-term treatment despite none of them being curative. This paper provides a comprehensive discussion of existing and emerging treatment options for various types of incontinence and related disorders.

Oral anticholinergic drugs versus placebo or no treatment for managing overactive bladder syndrome in adults

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.

Combination and Novel Pharmacologic Agents for OAB

PURPOSE OF REVIEW

To evaluate recent literature on combination and novel pharmacologic therapies for overactive bladder (OAB).

RECENT FINDINGS

Combination therapies demonstrating greater efficacy than monotherapy include combination anticholinergics, anticholinergic plus β-3 agonist, and anticholinergic with behavioral modification, percutaneous tibial nerve stimulation, or sacral neuromodulation. Promising novel therapies include new bladder selective anticholinergics, new β-3 agonists, and gabapentin. OAB is a symptom complex caused by dysfunction in the interconnected neural, muscular, and urothelial systems that control micturition. Although several therapeutic targets and treatment options exist, complete resolution is not always achieved, discontinuation rate for medical therapy is high, and few patients subsequently progress to third-line treatment options. Recent literature suggests combination therapy diversifying therapeutic targets is more effective than targeting a single pathway and novel treatments targeting additional pathways have promising results.

Pharmacological Management of Urinary Incontinence: Current and Emerging Treatment

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.

The clinical pharmacology of the medical treatment for overactive bladder in adults

INTRODUCTION

Overactive bladder is a prevalent symptom complex that affects the patient's quality of life. Any disruption between the neuronal micturition pathway can lead to bladder overactivity. Neurogenic causes, myogenic causes, aging, bladder outlet obstruction, sex, and psychological factors are some of the factors contributing to bladder overactivity. The complaint of any symptoms of OAB, which is highly prevalent and affects overall QOL, often needs therapeutic interventions. When conservative therapy methods fail, the addition of medications is recommended. The most commonly used agents for the treatment of OAB are antimuscarinic drugs. New classes of drugs, such as beta-3 agonists, have enriched our pharmacologic armamentarium.

AREAS COVERED

In this review, with a special focus on oral pharmacological treatments, we discussed the definition, etiology, symptoms, diagnosis, and management of OAB.

EXPERT OPINION

OAB is a multifactorial condition with every patient presenting with a different collection of symptoms and signs. Medical therapies should be given in conjunction with behavioral therapies. Using high or low doses, flexible doses, and stopping or changing the medications are interchangeable strategies based on the level of treatment efficacy and patient satisfaction.

The Analysis of the Effects of Executive Functions, Working Memory and Other Factors on Medication Adherence in Elderly Men with Benign Prostatic Hyperplasia and Overactive Bladder Symptoms

AIM

Evaluation of the executive function and working memory influence, as well as the general state of memory, on adherence to Benign Prostatic Hyperplasia (BPH) and overactive bladder symptoms treatment in elderly men.

BACKGROUND

The influence of the executive function and working memory on treatment adherence in older men with BPH has not been studied enough.

OBJECTIVE

To determine the level of influence of various factors on the treatment adherence in older men with BPH.

METHODS

The executive function and working memory evaluation, as well as a general memory assessment, were carried out using the Wisconsin Test, the Wechsler Memory Scale, and the California Verbal Test. Hierarchical and simultaneous regressions were calculated to study the effect of executive function and working memory.

RESULTS

After the end of the study, the symptoms of hyperactive bladder significantly decreased, the symptoms of evacuation did not change significantly, and the cognitive status of the patients remained unchanged. The predictor variables significantly influencing adherence of elderly men to BPH and overactive bladder (OAB) treatment are executive function and working memory composite (β = .33, p < .05), severe symptoms of lower urinary tract (-.34, p < .05), and age (-.27, p < .05).

CONCLUSION

The status of executive function and working memory, as well as the age and severity of the pathological symptoms of the lower urinary tract, should be taken into account when predicting the risks of rejecting BPH and OAB treatment in elderly patients.

A new tool for self-evaluation of adherence to antimuscarinic drugs treatment in patients with urinary incontinence

Abstract objective

To evaluate the validity of the Medication Adherence Self-Report Inventory (MASRI) questionnaire in determining antimuscarinic drugs adherence in patients with urinary incontinence (UI).

Patients and methods

In all, 629 patients [355 (56.4%) women and 274 (43.6%) men], aged 18-65 years, were included. All patients were prescribed antimuscarinic drugs and treatment adherence was tested at the start, and after 4, 8 and 12 weeks using the MASRI. The standard of external monitoring was the Brief Medication Questionnaire (BMQ) and visual count of the remaining pills. The functional status of the lower urinary tract was tested using voiding diaries and uroflowmetry.

Results

The correlation between indicators of adherence according to the MASRI and screen mode of the BMQ was r = 0.84 (P ≤ 0.01), r = 0.72 (P ≤ 0.01), r = 0.7 (P ≤ 0.05) at 4, 8 and 12 weeks of follow-up, respectively, which indicated a satisfactory competitive validity. In the study of the discriminant validity, we found that non-adherent patients were correctly identified according to the MASRI in 96.2%, 96.9% and 96.2% of cases at 4, 8 and 12 weeks of follow-up, respectively. The values of the positive likelihood ratio (7.92, 10.81, and 12.8 at 4, 8 and 12 weeks of follow-up, respectively) were quite acceptable for the adherence forecast. The receiver operating characteristic analysis revealed a failure of the null hypothesis of the excess/insufficient discrimination power of the MASRI. The correlation between the percentage of non-adherent patients and the percentage of patients with impaired lower urinary tract function according to uroflowmetry data was r = 0.55 (P ≤ 0.05) at 4 weeks; r = 0.59 (P ≤ 0.05) at 8 weeks; and r = 0.62 (P ≤ 0.01) at 12 weeks.

Conclusion

The MASRI questionnaire is highly constructive, competitive, has discriminant validity, and is suitable for self-assessment of treatment adherence in patients with UI taking antimuscarinics. Using the MASRI is less costly and faster compared with other assessment tools.

Comparison of objective and subjective factors in the adherence to antimuscarinics when treating overactive bladder in employed persons

Background

This study examines subjective reasons for the refusal of treatment and the state of objective status markers of various factors influencing the resistance of patients when treating overactive bladder by antimuscarinic drugs (AMs).

Methods

The socioeconomic and medical parameters were studied in 2465 patients aged 18-60 years (1446 women (58.7%), 1019 men (41.3%); mean age was 52.1) taking AMs during the year. The study control was carried out by studying passport data, employers' income certificates, patients' ambulatory medical records, the use of OABq-SF and MOS SF-36 questionnaires, voiding diaries and uroflowmetry.

Results

The average time to reach the 30-day break in the AM administration was 177 days. During the 12-month follow up, 74.7% of patients discontinued their participation. In total, 35.9% of patients stated medical reasons for the refusal of AM treatment; in 31.9% of individuals in the group the deviation of objective health status markers from average sample values was established. Economic reasons for the refusal were given by 20.4% of patients; in 18.5% of individuals economic status markers were different from average sample values. In 24.1% of cases of refusal of treatment, patients indicated social and psychological reasons; objective social and psychological status markers were altered in 35.9%.

Conclusions

The percentage of patients indicating economic and medical reasons for the refusal of AM treatment is statistically uniform with respect to the percentage of patients with objective disturbances of health and economic statuses. The percentage of patients indicating social and psychological factors as a reason for the refusal of treatment was significantly lower than the percentage of patients with altered social and psychological status markers. These results can be used in practical healthcare when predicting adherence to AM use.

Effectiveness of a new tool for self-evaluation of adherence to antimuscarinic drug treatment in older patients of both sexes with urge incontinence

AIM

The present study was a comparison of the validity of the Medication Adherence Self-Report Inventory (MASRI) questionnaire with other methods of assessing adherence to antimuscarinic drugs treatment in older patients with urge incontinence.

METHODS

The experiment involved 733 men and women aged >65 years who had noted no less than one urge incontinence episode per day. At the beginning of the experiment, and after 4, 8 and 12 weeks, their adherence to treatment was monitored using the MASRI.

RESULTS

The construct validity of the tool was confirmed by data on the correlation of the percentage of non-adherent patients according to the MASRI and the percentage of patients having a belief barrier on the Brief Medication Questionnaire screen (r = 0.89, P ≤ 0.01; r = 0.91, P ≤ 0.01; and r = 0.91, P ≤ 0.05 at the 4th, 8th and 12th week of the follow up). The hypothesis of competitive validity was supported by comparing the percentage of non-adherent patients according to the MASRI and the number of missed doses on the Brief Medication Questionnaire screen (r = 0.94, P ≤ 0.01; r = 0.85, P ≤ 0.05; and r = 0.7, P ≤ 0.05), and according to a visual count of pills. The area under the curve at the 4th, 8^th , and 12th week was 0.95 ± 0.04, 0.92 ± 0.03 and 0.94 ± 0.04, respectively.

CONCLUSION

The MASRI questionnaire has high validity, and is effective for evaluating adherence to treatment among older patients with urge incontinence taking antimuscarinic drugs. Using the MASRI would imply lower costs and greater availability of diagnostics, and it is the tool of choice in clinical practice. Geriatr Gerontol Int 2018; 18: 115-122.

Self-assessment of treatment compliance with antimuscarinic drugs and lower urinary tract condition among women with urinary incontinence

AIM

Our aim was to determine the efficiency of the Medication Compliance Self-Report Inventory (MASRI) in self-reporting antimuscarinic drug treatment compliance among women with urinary incontinence (UI).

MATERIALS AND METHODS

The study assessed 347 women aged 18-65 (averaging 49.7) years with more than one urinary incontinence (UI) episode per day. Treatment compliance was tested at the beginning and at weeks 4, 8, and 12 using the MASRI, the Brief Medication Questionnaire (BMQ), and visual pill counts. The MASRI's constructive, concurrent, and discriminate validity was studied in comparison with an external standard that uses the chi-square and Spearman coefficient. Receiver operating characteristic (ROC) analysis was performed to identify optimum MASRI cutoffs that would predict noncompliance. Furthermore, the functional condition of the lower urinary tract was tested using voiding diaries, uroflowmetry, and cystometry.

RESULT

The correlation between the percentage of noncompliant women according to the MASRI, and individuals with a belief barrier with respect to the BMQ screen was r = 0.81 (p ≤0.05), r = 0.84 (p ≤0.05), and r = 0.79 (p ≤0.05). The correlation between the percentage of noncompliant women according to the MASRI and of women who missed >20% of their doses according to the Regimen Screen of the BMQ was r = 0.79, p ≤0.05, r = 0.82, p ≤0.01, r = 0.77, and p ≤0.05 at the control points. Finally, the percentage of noncompliant patients who self-reported correctly according to the MASRI data compared with the BMQ was 95.6%, 95.7%, and 96.6% at the control points.

CONCLUSION

The MASRI entails acceptable validity for accurately predicting treatment compliance with antimuscarinic drugs among women who have had UI for >3 months.

Long-term adherence to antimuscarinic drugs when treating overactive bladder in the older: Subjective reason and objective factors

Purpose

Comparison of subjective reasons for the refusal of antimuscarinic treatment and the state of objective economic, social, psychological and health status markers in the elderly with overactive bladder.

Materials and Methods

One thousand seven hundred thirty-six (1,736) patients participated in the experiment: 1,036 or 59.7% of women, and 700 or 40.3% of men aged over 60 years (average age, 68.1 years) who took antimuscarinic (AM) drugs during the year. The control of objective parameters was carried out by studying patients' medical records, the use of overactive bladder questionnaire short form and Medical Outcomes Study 36-item Shor-Form Health Survey, voiding diaries, uroflowmetry, as well as income certificates from the Tax Inspectorate, support documentation for expenses on drugs.

Results

Fifty-two point six percent (52.6%) of patients preserved adherence to treatment during the first 6 months, 30.1% – during the follow-up period. The average time of reaching a 30-day break in the AM drugs administration was 174 days. In 36.5% of cases of the refusal of treatment, patients referred to medical reasons for the refusal, in 31.6% of cases disturbance was established in objective health status markers (differences were significant in 30% of the follow-up time). The percentage of refusals of treatment for social and psychological reasons (13.2%) was significantly lower (p≤0.05), than the percentage of individuals with statuses altered objectively (21.9%).

Conclusions

A significant share of elderly patients taking AM drugs when treating overactive bladder is inclined to overestimate the importance of health factors influencing their decisions and to underestimate the importance of social and psychological factors, and an urologist should take it into account for the efficacy evaluation.

The effective tool for self-assessment of adherence to treatment in patients with benign prostatic obstruction and overactive bladder symptoms

PURPOSE

Study of validity of the Medication Adherence Self-Report Inventory (MASRI) for use in clinical practice to treat patients with benign prostatic obstruction (BPO) accompanied with overactive bladder (OAB) symptoms.

METHODS

During 12 weeks of the randomized study, 452 patients with BPO and OAB symptoms (mean age of 61.3 (12.7)) were studied for adherence to the treatment with Tamsulosin, Solifenacin and Trospium using the MASRI. External monitoring instruments included the Brief Medication Questionnaire (BMQ) and the visual remaining pill count. The state of the prostate gland and the lower urinary tract was monitored using questionnaires I-PSS, OAB Awareness Tool, uroflowmetry and voiding diaries.

RESULT

Correlation between the percentage of men non-adherent to treatment (MASRI) and the percentage of patients having a belief barrier on the screen of the BMQ was r = 0.89, p ≤0.05, r = 0.92, p ≤0.01, r = 0.85, p ≤0.05, a number of missed doses on the Regimen Screen of the BMQ was r = 0.79; p ≤0.05; r = 0.81; p ≤0.05; r = 0.75, p ≤0.05, a number of non-adherent patients according to the BMQ was r = 0.83 (p ≤0.05), r = 0.88 (p ≤0.05), r = 0.79, p ≤0.05, the results of the pill count were r = 0.65-0.76; p ≤0.05-0.01. These data confirm high validity of the MASRI.

CONCLUSION

The MASRI is a valid tool for rapid assessment of adherence to treatment of patients with BPO and OAB receiving Tamsulosin and antimuscarinic drugs and may be recommended for use in clinical practice.

Treatment compliance of working persons to high-dose antimuscarinic therapies: a randomized trial

AIM

The aim of this work was to study the factors affecting the stability of working patients in antimuscarinic (AM) drug treatment.

BACKGROUND

The prevalence of urge urinary incontinence (UUI) is an average of between 8.2% and 16.0% of the population. UUI is a condition that adversely affects the health-related quality of life. The first-line therapy in managing UUI is AM treatment.

METHODS

In 1006 patients between 18 and 60 years old (627 women, 379 men, mean age 69.4) who received AM treatment for one year, the possible demographic, socioeconomic and health factors influencing compliance were studied. Also, the functional state of the lower urinary tract (LUT) was studied in this randomized, prospective survey. The study instruments were the documents of employers, tax offices, outpatient records, OABq-SF (overactive bladder - short form) questionnaires, MOS SF-36 (Medical Outcomes Study short form-36), voiding charts, and uroflowmetry data.

RESULTS

The compliance to AM treatment within 6 months was retained in 49.5% patients; during the year, in 32.3% of patients. The average time for reaching the 30-day break in taking trospium was 194 days. In the course of the experiment it was revealed that compliance to AM treatment was significantly higher in patients taking solifenacin and trospium in high dosages (p ⩽ 0.01, p ⩽ 0.05), suffering from severe symptoms of urgency (p ⩽ 0.01), and having a low level of side effects (p ⩽ 0.01). A satisfactory level of compliance is characteristic of patients with a high level of monthly and annual income (p ⩽ 0.01, p ⩽ 0.01), a low percentage of expenses to AM (p ⩽ 0.05), and rarely changing employers (p ⩽ 0.05). In addition, the compliance to treatment is higher in older adults (p ⩽ 0.05), living in the urban district (p ⩽ 0.01), and working in educational (p ⩽ 0.05) and health (p ⩽ 0.01) institutions, having a high level of the indices of Social Functioning (p ⩽ 0.05), Role-Emotional (p ⩽ 0.05), and Mental Health (p ⩽ 0.01).

CONCLUSION

As a result of this study, under the control of the objective functional state of LUT, the influence of various factors on the patients' stability in the treatment with AM drugs was revealed.