Tolterodine use for symptoms of overactive bladder

WITHDRAWN: Anticholinergics for urinary symptoms in multiple sclerosis

This review has been withdrawn for the following reasons: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‐ the review is substantially out of date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The editorial group responsible for this previously published document have withdrawn it from publication.

Pharmacotherapy of overactive bladder syndrome

Urinary incontinence is a common and distressing condition that is known to adversely affect quality of life. Overactive bladder (OAB) is the term used to describe the symptom complex of urgency with or without urge incontinence, usually with frequency and nocturia. Drug therapy, in addition to behavioral modification, remains integral in the management of women with OAB, and the development of new drugs, treatment regimens and methods of delivery should improve patient compliance and acceptability. Developments over the last 10 years have led to the launch of several new drugs for the treatment of OAB that may offer greater efficacy while minimizing adverse effects. This article critically reviews the current pharmacological treatment of OAB in addition to providing a rationale for treatment.

Pharmacological approach to overactive bladder and urge urinary incontinence in women: an overview

Besides life-style changes, electrical stimulation or surgery, pharmacological treatment is becoming the first-choice approach in women suffering from lower urinary tract symptoms (LUTS), including urge urinary incontinence (UUI) and overactive bladder (OAB). Several drugs for the treatment of bladder storage and voiding disorders are currently available and, in the near future, novel compounds with higher specificity for the lower urinary tract receptors will be accessible. This will bring optimization of therapy, reducing side effects and increasing compliance, especially in patients with comorbidities and in women. The purpose of this paper is to give an overview on the pharmacotherapy of two common inter-correlated urological conditions, UUI and OAB. The study was conducted by analyzing and comparing the data of the recent international literature on this topic. Advances in the discovery of pharmacological options have dramatically improved the quality of life of patients affected by incontinence, but further studies are needed to increase the effectiveness and safety of the therapies used in this field.

Does conservative management really benefit patients with OAB?

The benefit that patients with overactive bladder (OAB) experience with conservative management is an important aspect in the evaluation of this therapy. The first-line options include behavioral interventions, and several techniques are available. Clinical research indicates amelioration of individual symptoms with these techniques, but few studies have shown a positive effect on health-related quality-of-life parameters. After failure of behavioral therapy or in combination with a training program, pharmacological therapy with anticholinergics is the next step. Extensive clinical research into different pharmacological compounds has shown significant effects on the symptomatic elements of OAB. The clinical relevance and the effects on quality-of-life parameters with pharmacological therapy have also been evaluated and show a significant effect on specific aspects. Recently, clinical research in conservative management of patients with OAB has focused more on evaluating patients' perceptions of their condition and the effects of treatment with patient-reported outcome instruments. Future studies should include these tools in the evaluation of any therapy in OAB.

Cost Effectiveness of Controlled-Release Oxybutynin Compared with Immediate-Release Oxybutynin and Tolterodine in the Treatment of Overactive Bladder in the UK, France and Austria

OBJECTIVE

To estimate the cost effectiveness of controlled-release (CR) oxybutynin compared with immediate-release (IR) oxybutynin and tolterodine in the treatment of overactive bladder (OAB) in Austria, France and the UK.

DESIGN AND SETTING

This was a modelling study on the management of patients with OAB who were >/=18 years of age, and had urge or mixed incontinence with a primary-urge component. The study was performed from the perspective of payers (i.e. the National Health Service [NHS] in the UK, Social Security in France and the Sick Funds in Austria) and patients.

METHODS

Clinical outcomes attributable to managing OAB were obtained from the published literature, and resource utilisation estimates were derived from a panel of clinicians. Using decision analytical techniques, three decision models were constructed depicting the management of OAB with CR oxybutynin, IR oxybutynin and tolterodine over 6 months in the UK, France and Austria. The models were used to estimate the cost effectiveness of CR oxybutynin relative to the other two anticholinergic drugs in each of the three countries and the expected direct patient costs and indirect societal costs (at 2000/2001 prices).

MAIN OUTCOME MEASURES AND RESULTS

Starting OAB treatment with CR oxybutynin instead of either IR oxybutynin or tolterodine in the UK and Austria was found to be a potentially dominant strategy, since it improves clinical outcome at a lower cost, from the payers' perspective. In France, starting OAB treatment with CR oxybutynin instead of either the IR formulation or tolterodine was found to be a potentially cost-effective strategy from the payer's perspective. The expected 6-monthly direct costs to patients were euro230, euro720-920 and euro970-1000 in the UK, France and Austria, respectively. In the UK and Austria, these costs were broadly consistent between initial treatments. However, in France, tolterodine-treated patients would be expected to incur 28% more expenditure than patients treated with the other two drugs. Transportation emerged as the primary cost driver, accounting for at least 60% of patients' out-of-pocket expenditure, in all three countries. Irrespective of the initial treatment, patients would be expected to miss 1-2 days of work over 6 months as a result of their OAB. This equates to an expected lost productivity cost of euro84, euro250 and euro98 in the UK, France and Austria, respectively.

CONCLUSION

Starting OAB treatment with CR oxybutynin is expected to be a clinically more effective strategy than starting with either IR oxybutynin or tolterodine, and potentially the most cost-effective strategy in all three countries.

Standard Pharmacological Treatment and New Therapies for Overactive Bladder

The prevalence of overactive bladder (OAB) in adult males varies from 10.2% to 17.4%, and in females from 7.7 to 31.3. 16.5% of the adult population presents symptoms consistent with OAB; of these, 37.2% are actually affected. The OAB has a significant effect on the quality of life. Initial treatment includes behavioral therapy, physiotherapy and antimuscarinic drugs. In patients where behavioral modifications fail, treatment is associated with antimuscarinics. The antimuscarinic agents used to treat OAB showed some efficacy, but adverse events too, such as dry mouth, constipation, headache and blurred vision. In selected cases unresponsive to antimuscarinic therapy, it is possible to use second-line treatments represented by sacral neuromodulation and botulinum toxin type A both for idiopathic detrusor overactivity, where it is still an experimental treatment, and for neurogenic cases with 2011 FDA approval. Surgical options represent the last choice for selected cases.

Bladder symptoms in multiple sclerosis: a review of pathophysiology and management

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.

Anticholinergics for urinary symptoms in multiple sclerosis

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.

Management of overactive bladder syndrome

Overactive bladder (OAB) syndrome is the term used to describe the symptom complex of urinary urgency with or without urge incontinence, usually with frequency and nocturia. Drug treatment continues to have an important role in the management of women with OAB. Other treatment options include conservative management with lifestyle interventions, modification of fluid intake, and physiotherapy including bladder retraining. Surgery remains the last resort in the treatment and is usually reserved for intractable detrusor overactivity, as it is associated with significant morbidity. This article reviews the management of the overactive bladder with specific focus on newer developments in the medical treatment of OAB in women.

Long-Term Efficacy of Tolterodine and Patient Compliance in Pediatric Patients with Neurogenic Detrusor Overactivity

INTRODUCTION

We investigated the effects of standard oral anticholinergic treatment with tolterodine in children with neurogenic bladder over a 5-year follow-up period and focused on treatment satisfaction, patient compliance and urodynamic parameters.

MATERIAL AND METHODS

The follow-up consisted of regular visits and urodynamic evaluation at least once a year. The patients or their parents were interviewed to evaluate voiding behavior, as well as factors leading to lower patient compliance and deterioration in urodynamic parameters.

RESULTS

Of the 43 patients evaluated, 30 (70%) took their anticholinergic medication consistently and 13 (30%) sporadically. The mean bladder capacity was 354.7 ml in the first group but only 214.7 ml in the noncompliant group (p < 0.001). The mean maximal detrusor pressure decreased from 42.2 to 33.6 cm H(2)O in the compliant group (p < 0.001) and from 49.7 to 46.4 cm H(2)O in the noncompliant group (p = 0.21). The mean detrusor compliance increased from 18.9 to 19.3 ml/cm H(2)O in the compliant group (p = 0.63) and from 11.8 to 12.3 ml/cm H(2)O in the noncompliant group (p = 0.87). Side effects such as dry mouth (11/13) and dizziness (7/13) were common in the noncompliant group, whereas only 5/30 reported dry mouth in the compliant group.

CONCLUSIONS

These data demonstrate the efficacy and tolerability of tolterodine over a long follow-up period. The results are promising in view of the fact that the patients will probably require life-long medication. Nevertheless, anticholinergic side effects still cause some patients to refuse regular medication, which results in a poorer urodynamic outcome.

Pharmacological treatment for overactive bladder in women

Urinary incontinence is a common and distressing condition that is known to adversely affect quality of life. Overactive bladder is the term used to describe the symptom complex of urinary frequency and urgency, with or without urge incontinence. Drug therapy, in addition to behavioral modification, remains integral in the management of women with overactive bladder, and the development of new drugs, treatment regimens and methods of delivery should improve patient compliance and acceptability. This article critically reviews the current pharmacological treatment of overactive bladder in addition to providing a rationale for treatment.

Tolterodine-associated acute mixed liver injury

OBJECTIVE

To report a patient with an acute mixed liver injury associated with tolterodine therapy.

CASE SUMMARY

An 81-year-old white woman with urge incontinence experienced malaise, fever, and gastrointestinal disturbances 18 days after starting tolterodine 2 mg twice daily. The patient's concurrent medications included flunitrazepam, diclofenac, and dorzolamide/timolol eye drops. Laboratory examination was consistent with the presentation of an acute mixed liver injury with increased transaminase enzymes, alkaline phosphatase, gamma-glutamyltransferase, and bilirubin. Additionally, she had mild leukocytosis with eosinophilia. After tolterodine was discontinued, the abnormal liver and hematologic parameters returned to normal within 4 weeks.

DISCUSSION

Tolterodine, a muscarinic receptor antagonist, has predominantly anticholinergic effects. To our knowledge, this is the first case published describing tolterodine-associated acute mixed liver injury. However, some of the patient's additional symptoms can also be considered part of a drug-induced hypersensitivity syndrome. This is usually defined by the triad of fever, cutaneous reaction, and involvement of internal organs, mainly affecting the liver. The close temporal relationship between the start of tolterodine therapy and the first symptoms and the reversibility after dechallenge led us to conclude that the adverse reaction was possibly related to tolterodine exposure.

CONCLUSIONS

Our case illustrates that tolterodine may rarely be associated with liver injury. This may have been an organ manifestation of tolterodine-induced hypersensitivity syndrome.