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Chancellor MB, Lucioni A, Staskin D. Oxybutynin-associated Cognitive Impairment: Evidence and Implications for Overactive Bladder Treatment. Urology 2024; 186:123-129. [PMID: 38296001 DOI: 10.1016/j.urology.2023.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/20/2023] [Accepted: 11/28/2023] [Indexed: 03/21/2024]
Abstract
Anticholinergic medications have long been a mainstay of overactive bladder (OAB) treatment. Oxybutynin, a first-generation anticholinergic, still accounts for more than half of all OAB medication prescriptions, despite associations with impaired memory and cognition, as well as mounting evidence that it may increase the risk of incident dementia. This review details the current literature regarding oxybutynin and cognition, including evidence from preclinical, clinical, and real-world studies that show that oxybutynin binds nonspecifically to muscarinic receptors in the brain and is associated with adverse cognitive outcomes. We also discuss society recommendations to reduce use of oxybutynin and other anticholinergics to treat OAB.
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Affiliation(s)
- Michael B Chancellor
- Corewell Health Beaumont University Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI.
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Rajabali S, Asaana P, Nazari S, Wagg A. A Double-blind, Randomised Four-way Crossover Study to Compare the Effects of Fesoterodine 4 and 8 mg Once Daily and Qxybutynin 5 mg Twice Daily After Steady-state Dosing Versus Placebo on Cognitive Function in Overactive Bladder-wet Patients over the Age of 75 Years with Mild Cognitive Impairment. Eur Urol Focus 2024:S2405-4569(24)00022-1. [PMID: 38402104 DOI: 10.1016/j.euf.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/19/2023] [Accepted: 02/14/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND AND OBJECTIVE There is a reported association between overactive bladder (OAB) treated with antimuscarinic drugs and an increased risk of a dementia diagnosis, although short-term data suggest that newer OAB antimuscarinics are cognitively safe. This study examined the cognitive safety of fesoterodine in older adults with mild cognitive impairment (MCI) and OAB. METHODS This four-way randomised crossover study examined the cognitive effects of fesoterodine 4 and 8 mg and oxybutynin 5 mg b.i.d. compared with placebo. Older adult patients with OAB and MCI were included. Treatment and washout periods were of 1-week duration, to reach steady-state drug levels. The primary outcome was continuity of attention at 1 and 4 h after the dose. The secondary outcomes included other cognitive domains, change in Montreal Cognitive Assessment score, and alertness. KEY FINDINGS AND LIMITATIONS Twenty-three patients completed the study (16 females and seven males). For the primary outcome, at 1 h after the dose, a trend towards worsening of continuity of attention was observed for fesoterodine 4 mg (p = 0.09) compared with placebo. At 4 h after the dose, a nonstatistically significant trend towards improvement compared with placebo was observed in the fesoterodine 4 mg group (p = 0.0633) compared with placebo. No differences were observed in any other treatment group at either time point. Apart from quality of working memory, associated with a statistically significant improvement with fesoterodine 4 mg, there was no difference in any comparison for other secondary outcomes. CONCLUSIONS Exposure to steady-state dosing of fesoterodine 4 and 8 mg or oxybutynin 5 mg b.i.d. was not associated with any detectable effect on cognitive function using a sensitive battery of cognitive tests in a group of older adult patients with MCI and OAB. PATIENT SUMMARY In this report, we investigated whether the medication fesoterodine, a member of a family of drugs called anticholinergics, commonly used for the treatment of a condition called overactive bladder that leads to accidental leakage of urine, affected the memory function of older adults with mild memory impairment. These people might be more sensitive to memory side effects. We found that at the doses most used by doctors, the drug had no effect on any of the memory functions we tested.
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Affiliation(s)
- Saima Rajabali
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Prosper Asaana
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Sahar Nazari
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Adrian Wagg
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada.
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Franić D, Franić Ivanišević M, Verdenik I. Radiofrequency as the New Opportunity in Treating Overactive Bladder and Urge Urinary Incontinence-A Single-Arm Pilot Study. Medicina (Kaunas) 2024; 60:197. [PMID: 38399486 PMCID: PMC10890003 DOI: 10.3390/medicina60020197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/02/2024] [Accepted: 01/15/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: Until now, overactive bladder (OAB) with or without urge urinary incontinence (UUI) has been treated mainly in two ways: with behavioral methods and patient education, or using antimuscarinic drugs and/or beta-3 adrenergic receptor agonists. Unfortunately, these drugs may cause side effects in some women or are insufficiently effective, so patients abandon them. Therefore, in this pilot study, radiofrequency was evaluated as a new option in the treatment of OAB and UUI. Materials and Methods: Nineteen patients were enrolled in this pilot study using radiofrequency (RF), where the level of OAB and UUI was assessed using the validated ICIQ-OAB questionnaire. RF was applied four times for 20 min, once a week. Two weeks after treatment, the level of OAB and UUI was reassessed and processed statistically and the treatment effect evaluated. Results: Using the ICIQ-OAB, the severity of OAB and UUI was assessed: 0-3 mild symptoms; 4-7 moderate symptoms; 8-11 severe symptoms; 12-16 very severe symptoms. Before treatment, 10.5% of patients had mild symptoms, 21.1% moderate symptoms, 63.2% severe symptoms and 5.3% very severe symptoms. After treatment, 42.9% had mild symptoms, 50% moderate symptoms and 7% severe OAB and UUI symptoms. All four main symptoms-frequency, nocturia, urgency and incontinence-decreased statistically significantly, with the best results being found in urgency (p = 0.002). Conclusions: Based on this pilot study, RF seems a very promising method in the treatment of OAB and UUI. To extend our initial findings, it is necessary to perform a prospective, randomized and placebo-controlled study in order to obtain reliable results and to determine for how long one set of treatment maintains the results obtained immediately after the end of that treatment. In this way, we may determine how often the treatment needs to be repeated, if necessary, and when.
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Affiliation(s)
- Damir Franić
- Ginekologija Dr. Franić d.o.o., 3250 Rogaška Slatina, Slovenia
- Medical Faculty, University of Maribor, 2000 Maribor, Slovenia
| | - Maja Franić Ivanišević
- Obstetric and Gynecology Unit, Health Centre Slovenske Konjice, 3210 Slovenske Konjice, Slovenia;
| | - Ivan Verdenik
- Research Unit, University Gynecological Clinic Ljubljana, 1000 Ljubljana, Slovenia;
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Dmochowski RR, Newman DK, Rovner ES, Zillioux J, Malik RD, Ackerman AL. Patient and Clinician Challenges with Anticholinergic Step Therapy in the Treatment of Overactive Bladder: A Narrative Review. Adv Ther 2023; 40:4741-4757. [PMID: 37725308 PMCID: PMC10567877 DOI: 10.1007/s12325-023-02625-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/21/2023] [Indexed: 09/21/2023]
Abstract
Anticholinergics have been used in the treatment of overactive bladder (OAB), but their use is limited by poor tolerability and anticholinergic-related side effects. Increasingly, providers are discontinuing anticholinergic prescribing because of growing evidence of the association of anticholinergic use with increased risk of cognitive decline and other adverse effects. Newer medications for OAB, the β3-adrenergic receptor agonists mirabegron and vibegron, do not have anticholinergic properties and are typically well tolerated; however, many insurance plans have limited patient access to these newer OAB medications by requiring step therapy, meaning less expensive anticholinergic medications must be trialed and/or failed before a β3-agonist will be covered and dispensed. Thus, many patients are unable to easily access these medications. Step therapy and other drug utilization strategies (e.g., prior authorization) are often used to manage the growing costs of pharmaceuticals, but these policies do not always follow treatment guidelines and may harm patients as a result of treatment delays, discontinuations, or related increases in adverse events. Medical professionals have called for reform of drug utilization strategies through partnerships that include clinicians and policymakers. This narrative review discusses prescribing patterns for OAB treatment and the effect of switching between drugs, as well as the costs of step therapy and prior authorization on patients and prescribers.
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Affiliation(s)
- Roger R Dmochowski
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Diane K Newman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Eric S Rovner
- Department of Urology, Medical University of South Carolina, Charleston, SC, USA
| | - Jacqueline Zillioux
- Department of Urology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Rena D Malik
- Division of Urology, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - A Lenore Ackerman
- Departments of Urology and Obstetrics and Gynecology, Division of Pelvic Medicine and Reconstructive Surgery, David Geffen School of Medicine, University of California, Los Angeles, 10833 Le Conte Avenue, Box 951738, Los Angeles, CA, 90095-1738, USA.
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Davis B, Chen K, Markert O, Zillioux J. Anticholinergic Use for OAB in the Older Woman: An Update. Curr Geri Rep 2023. [DOI: 10.1007/s13670-023-00380-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
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Nicholls C, Chyou TY, Nishtala PS. Analysis of the nervous system and gastrointestinal adverse events associated with solifenacin in older adults using the US FDA adverse event reporting system. Int J Risk Saf Med 2023; 34:63-73. [PMID: 35491805 DOI: 10.3233/jrs-210054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Antimuscarinics are the backbone of the pharmacological management of overactive bladder. Still, concerns have been raised over the nervous system (NS) adverse drug events (AEs) due to their dissimilarities to muscarinic receptor-subtype affinities. OBJECTIVE This study aimed to identify the nervous system and gastrointestinal adverse drug events (ADEs) associated with solifenacin use in older adults (≥65 years). METHODS A case/non-case analysis was performed on the reports submitted to the FDA Adverse Event Reporting System (FAERS) between 01/01/2004 and 30/06/2020. Cases were reports for solifenacin with ≥1 ADEs as preferred terms included in the Medical Dictionary of Regulatory Activities (MedDRA) system organ classes 'nervous system' or 'gastrointestinal' disorders. Non-cases were all other remaining reports for solifenacin. The case/non-cases was compared between solifenacin and other bladder antimuscarinics. Frequentist approaches, including the proportional reporting ratio (PRR) and reporting odds ratio (ROR), were used to measure disproportionality. The empirical Bayesian Geometric Mean (EBGM) score and information component (IC) value were calculated using a Bayesian approach. A signal was defined as the lower limit of 95% confidence intervals of ROR ≥ 2, PRR ≥ 2, IC > 0, EBGM > 1, for ADEs with ≥4 reports. RESULTS 107 MedDRA preferred terms (PTs) comprising 970 ADE reports were retrieved for nervous system disorders associated with solifenacin. For gastrointestinal disorders, 129 MedDRA PTs comprising 1817 ADE reports were retrieved. Statistically significant results were found for 'altered state of consciousness': ROR = 9.71 (2.13-44.35), PRR = 9.69 (2.12-44.2) and IC = 1.29 (0.93-1.66). CONCLUSIONS The disproportionality reporting of 'altered state of consciousness', a previously unidentified ADE, was unexpected. Further monitoring of this ADE is needed to ensure patient safety, as this could be linked to poor balance and falls in older adults.
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Affiliation(s)
- Connie Nicholls
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Te-Yuan Chyou
- Department of Biochemistry, University of Otago, Dunedin, Otago, New Zealand
| | - Prasad S Nishtala
- Pharmacy and Pharmacology, Centre for Therapeutic Innovation, University of Bath, Bath, UK
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Dengler KL, High RA, Moga DC, Zillioux J, Wagg A, DuBeau CE, Ackenbom MF, Alperin M, Dumoulin C, Birder LA, Mazloomdoost D, Lai HH, Sung VW, Gray SL, Sanses TVD. Overactive Bladder and Cognitive Impairment: The American Urogynecologic Society and Pelvic Floor Disorders Research Foundation State-of-the-Science Conference Summary Report. Urogynecology (Hagerstown) 2023; 29:S1-S19. [PMID: 36548636 DOI: 10.1097/SPV.0000000000001272] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE Overactive bladder (OAB) is prevalent in older adults in whom management is complicated by comorbidities and greater vulnerability to the cognitive effects of antimuscarinic medications. OBJECTIVES The aim of this study is to provide a comprehensive evidence-based summary of the 2021 State-of-the-Science (SOS) conference and a multidisciplinary expert literature review on OAB and cognitive impairment. STUDY DESIGN The American Urogynecologic Society and the Pelvic Floor Disorders Research Foundation convened a 3-day collaborative conference. Experts from multidisciplinary fields examined cognitive function, higher neural control of the OAB patient, risk factors for cognitive impairment in older patients, cognitive effects of antimuscarinic medications for OAB treatment, OAB phenotyping, conservative and advanced OAB therapies, and the need for a multidisciplinary approach to person-centered treatment. Translational topics included the blood-brain barrier, purine metabolome, mechanotransduction, and gene therapy for OAB targets. RESULTS Research surrounding OAB treatment efficacy in cognitively impaired individuals is limited. Short- and long-term outcomes regarding antimuscarinic effects on cognition are mixed; however, greater anticholinergic burden and duration of use influence risk. Oxybutynin is most consistently associated with negative cognitive effects in short-term, prospective studies. Although data are limited, beta-adrenergic agonists do not appear to confer the same cognitive risk. CONCLUSIONS The 2021 SOS summary report provides a comprehensive review of the fundamental, translational, and clinical research on OAB with emphasis on cognitive impairment risks to antimuscarinic medications. Duration of use and antimuscarinic type, specifically oxybutynin when examining OAB treatments, appears to have the most cognitive impact; however, conclusions are limited by the primarily cognitively intact population studied. Given current evidence, it appears prudent to minimize anticholinergic burden by emphasizing nonantimuscarinic therapeutic regimens in the older population and/or those with cognitive impairment.
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Zillioux J, Welk B, Suskind AM, Gormley EA, Goldman HB. SUFU white paper on overactive bladder anticholinergic medications and dementia risk. Neurourol Urodyn 2022; 41:1928-1933. [PMID: 36066046 DOI: 10.1002/nau.25037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 08/20/2022] [Indexed: 11/09/2022]
Abstract
AIMS Anticholinergic medications are widely used in the treatment of overactive bladder (OAB), as well as for short-term treatment of bladder symptoms following a variety of urologic surgeries. Mounting evidence points to an association between anticholinergic medications and the increased risk of incident dementia. The Society for Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU) thus convened a committee of subject experts to contextualize the current understanding of the cognitive risks of anticholinergic medications in the urologic patient population and to provide practical clinical guidance on this subject. METHODS Statements are based on an expert literature review and the committee's opinion. The document has been reviewed and approved by the SUFU board. RESULTS Chronic use (>3 months) of OAB anticholinergic medications is likely associated with an increased risk of new-onset dementia. Short-term (<4 weeks) use of most OAB anticholinergic medications is likely safe in most individuals. Clinicians should consider potential cognitive risks in all patient populations when prescribing OAB anticholinergics for chronic use. Consideration should be given to progressing to advanced therapy (botulinum toxin or neuromodulation) earlier in the OAB treatment paradigm CONCLUSIONS: The current body of literature supports a likely small but significant increased risk of dementia with chronic exposure to OAB anticholinergic medications. Potential harms should be balanced against potential quality of life improvement with treatment.
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Affiliation(s)
- Jacqueline Zillioux
- Department of Urology, University of Virginia School of Medicine, Charlottesville, Virginia, USA.,Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Blayne Welk
- Division of Urology, Department of Surgery, Western University, London, Ontario, Canada
| | - Anne M Suskind
- Department of Urology, University of California, San Francisco, California, USA
| | - E Ann Gormley
- Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Howard B Goldman
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Sripad A, Raker C, Shireman T, Sung V. Overactive bladder medication prescription trends from 2014 to 2018. Neurourol Urodyn 2022; 41:806-812. [PMID: 35132687 DOI: 10.1002/nau.24880] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 12/30/2021] [Accepted: 01/03/2022] [Indexed: 12/11/2022]
Abstract
PURPOSE A growing literature points to an association between overactive bladder (OAB) medications and dementia. Given differences in side effects for extended-release (ER) and immediate-release (IR) anticholinergic formulations and beta-3 agonists, we examined prescription utilization patterns in a national dataset of older adults from 2014 to 2018. METHODS We performed a retrospective study using the Medicare Part D Drug Spending Dashboard, a publicly available database that includes data from outpatient pharmacy claims from 2014 to 2018 in the United States. We identified total claims and total spending on common OAB medications, and further assessed trends by anticholinergic burden by medication, and immediate and ER formulations. RESULTS There were 54.1 million claims for OAB medications, accounting for $10.1 billion (2018 United States dollars) in spending from 2014 to 2018. When considering beta-agonist, mirabegron accounted for 13.1% of total claims and 29.0% of total spending. Mirabegron accounted for a greater proportion of OAB medication claims and spending during the 5 years from 5.7% to 20.1% and 11.3% to 44%, respectively. IR anticholinergics accounted for fewer total claims over this period, from 58.5% to 42.6%. ER formulations increased in proportion of all OAB medication total claims from 35.8% to 37.5% from 2014 to 2016, and decreased to 37.3% by 2018. CONCLUSION OAB medications and expenditures increased from 2014 to 2018. Mirabegron accounted for higher proportions and IR-formulations for decreased proportions of each from 2014 to 2018. The impact on clinical outcomes is a key area for future investigation considering our findings.
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Affiliation(s)
- Abhishek Sripad
- Division of Urogynecology, Department of Obstetrics & Gynecology, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Christina Raker
- Division of Research, Women & Infants Hospital of Rhode Island, Providence, Rhode Island, USA
| | - Theresa Shireman
- Department of Health Services Policy & Practice, Center for Gerontology & Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Vivian Sung
- Division of Urogynecology, Department of Obstetrics & Gynecology, Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Dantas L, Forte A, Lima B, Sousa C, Vasconcelos E, Lessa P, Vieira R, Patrocínio M, Vasconcelos S. Treatment of bladder dysfunction with solifenacin: is there a risk of dementia or cognitive impairment? Braz J Med Biol Res 2022; 55:e11721. [PMID: 35320336 PMCID: PMC8851948 DOI: 10.1590/1414-431x2021e11721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 11/16/2021] [Indexed: 11/22/2022] Open
Affiliation(s)
- L.P. Dantas
- Universidade Federal do Ceará, Brasil; Hospital Geral de Fortaleza, Brasil
| | | | - B.C. Lima
- Universidade Federal do Ceará, Brasil
| | | | | | | | | | - M.C.A. Patrocínio
- Centro Universitário Christus, Brasil; Instituto Dr. Jose Frota, Brasil
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Abstract
Solifenacin is a muscarinic receptor antagonist that has been used to treat overactive bladder since 2004. It has a great affinity for the detrusor M3 receptor, which must be stimulated for bladder muscle contraction, and demonstrates the most selective profile to the bladder of the muscarinic receptor subtypes. It is thought that urinary antimuscarinic agents, due to their passage to the central nervous system and lipophilic properties, may cause central nervous system symptoms in some rare cases. A case report of a 42-year-old male patient who had an acute psychotic attack as a result of solifenacin treatment for overactive bladder is presented in this article.
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Affiliation(s)
- Betul Kirsavoglu
- Psychiatry, Istanbul Erenkoy Mental and Nervous Diseases Training and Research Hospital, Istanbul, Turkey
| | - Ozan Odabasi
- Psychiatry, Istanbul Erenkoy Mental and Nervous Diseases Training and Research Hospital, Istanbul, Turkey
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Abstract
Overactive bladder (OAB) is often treated with medications that block the cholinergic receptors in the bladder (known as anticholinergics). The effect of this medication class on cognition and risk of dementia has been increasingly studied over the past 40 years after initial studies suggested that the anticholinergic medication class could affect memory. Short-term randomized clinical trials demonstrated that the administration of the anticholinergic oxybutynin leads to impaired memory and attention, and large, population-based studies showed associations between several different anticholinergic medications and dementia. However, trials involving anticholinergics other than oxybutynin have not shown such substantial effects on short-term cognitive function. This discordance in results between short-term cognitive safety of OAB anticholinergics and the long-term increased dementia risk could be explained by the high proportion of patients using oxybutynin in the OAB subgroups of the dementia studies, or a study duration that was too short in the prospective clinical trials on cognition with other OAB anticholinergics. Notably, all studies must be interpreted in the context of potential confounding factors, such as when prodromal urinary symptoms associated with the early stages of dementia lead to an increase in OAB medication use, rather than the use of OAB medication causing dementia. In patients with potential risk factors for cognitive impairment, the cautious use of selected OAB anticholinergic agents with favourable physicochemical and pharmacokinetic properties and clinical trial evidence of cognitive safety might be appropriate.
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Affiliation(s)
- Blayne Welk
- Department of Surgery and Epidemiology & Biostatistics, Western University, London, Ontario, Canada.
| | | | - Jalesh N Panicker
- Department of Uro-Neurology, The National Hospital for Neurology and Neurosurgery, and UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
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Kim YJ, Tae BS, Bae JH. Cognitive Function and Urologic Medications for Lower Urinary Tract Symptoms. Int Neurourol J 2020; 24:231-40. [PMID: 33017894 DOI: 10.5213/inj.2040082.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 04/08/2020] [Indexed: 02/06/2023] Open
Abstract
Special considerations should be made when selecting medications for the treatment of lower urinary tract symptoms (LUTS) in older patients especially those over 65 years old. This review summarizes the relationship between current treatments for LUTS and cognitive impairment. Although the recently reported association between dementia and tamsulosin is debatable, the effects of α-blockers and pharmacokinetics are not reported in this context. Five-alpha reductase inhibitors appear to affect mood. However, the association between the development of dementia and cognitive impairment is unlikely. Anticholinergic agents, other than trospium, fesoterodine, and imdafenacin have a relatively high distribution in the central nervous system. In particular, oxybutynin is reported to cause cognitive impairment. Several animal studies on the blood-brain barrier permeability of oxybutynin support this. Therefore, care must be taken when they are used in older patients (65 years and older). Beta-3 agonists are an alternative to, or may be used in combination with, anticholinergic drugs for patients with an overactive bladder (OAB). Several phase 2 and 3 clinical studies report high tolerability and efficacy, making them relatively safe for OAB treatment. However, there is a possibility that cognitive function may be affected; thus, long-term study data are required. We have reviewed studies investigating the correlation of urologic medications with cognitive dysfunction and have provided an overview of drug selection, as well as other considerations in older patients (65 years and older) with LUTS. This narrative review has focused primarily on articles indexed in PubMed, Google Scholar, Scopus, and Embase databases. No formal search strategy was used, and no meta-analysis of data was performed.
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Araklitis G, Robinson D. The cognitive safety of antimuscarinics in the treatment of overactive bladder. Expert Opin Drug Saf 2020; 19:1303-1313. [PMID: 32857638 DOI: 10.1080/14740338.2020.1817377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Overactive bladder is a common problem women suffer from, with its incidence increasing with age. The mainstay of treatment is antimuscarinic medication. There is growing evidence that antimuscarinics may increase the risk of cognitive impairment, dementia, and even death. AREAS COVERED This review explores the evidence that antimuscarinics increase the risk of cognitive impairment, dementia, and death. It evaluates how best to treat overactive bladder the older woman. EXPERT OPINION The evidence suggests that antimuscarinics increase the risk of cognitive impairment and dementia in the older adult. Care should be taken to use an antimuscarinic that is less likely to cross the blood-brain barrier and thus reduce the risk of these significant adverse events. A patient's anticholinergic load also needs to be considered when treating this group. Other treatment options such as fluid management, bladder retraining, vaginal estrogens, mirabegron, Onabotulinum toxin A and neuromodulation can be used instead.
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Affiliation(s)
| | - Dudley Robinson
- Urogynaecology Department, King's College Hospital , London, UK
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15
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Araklitis G, Robinson D, Cardozo L. Cognitive Effects of Anticholinergic Load in Women with Overactive Bladder. Clin Interv Aging 2020; 15:1493-1503. [PMID: 32921995 PMCID: PMC7457731 DOI: 10.2147/cia.s252852] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/11/2020] [Indexed: 01/09/2023] Open
Abstract
Overactive bladder syndrome (OAB) is defined as urinary urgency, usually accompanied by frequency and nocturia, with or without urgency incontinence, in the absence of urinary tract infection or other obvious pathology. The mainstay of treatment of OAB is anticholinergic/antimuscarinic medication. These drugs block muscarinic receptors throughout the body, not only the bladder, including in the brain, which may lead to cognitive side effects. Anticholinergic load or burden is the cumulative effect of taking drugs that are capable of producing anticholinergic adverse effects. The elderly are more susceptible to these effects, especially as there is increased permeability of the blood brain barrier. The anticholinergic drugs for OAB are able to enter the central nervous system and lead to central side effects. There is increasing evidence that a high anticholinergic load is linked to the development of cognitive impairment and even dementia. Some studies have found an increased risk of mortality. In view of this, care is needed when treating OAB in the elderly. Trospium chloride is a quaternary amine anticholinergic, which has a molecular structure, which theoretically means it is less likely to cross the blood brain barrier and exert central side effects. Alternatively, mirabegron can be used, which is a beta-3 adrenoceptor agonist, which does not add to the anticholinergic load or exert central nervous system side effects. Conservative therapy can be used as an alternative to pharmacological treatment in the form of behavioral modification, fluid management and bladder retraining. Neuromodulation or the use of botox can also be alternatives, but success may be less in the older adult and will require increased hospital attendances.
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Affiliation(s)
| | - Dudley Robinson
- Urogynaecology Department, King’s College Hospital, London, UK
| | - Linda Cardozo
- Urogynaecology Department, King’s College Hospital, London, UK
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Franco I, Hoebeke P, Baka-Ostrowska M, Bolong D, Davies LN, Dahler E, Snijder R, Stroosma O, Verheggen F, Newgreen D, Bosman B, Vande Walle J. Long-term efficacy and safety of solifenacin in pediatric patients aged 6 months to 18 years with neurogenic detrusor overactivity: results from two phase 3 prospective open-label studies. J Pediatr Urol 2020; 16:180.e1-180.e8. [PMID: 32007426 DOI: 10.1016/j.jpurol.2019.12.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 12/18/2019] [Indexed: 01/13/2023]
Abstract
INTRODUCTION The standard recommended treatment for neurogenic detrusor overactivity (NDO) is clean intermittent catheterization combined with an antimuscarinic agent. However, the adverse systemic side-effects of oxybutynin, the most widely used agent, are of concern. OBJECTIVE To evaluate the efficacy and safety of solifenacin in pediatric patients with NDO, aged 6 months-<5 years and 5-<18 years. STUDY DESIGN Two open-label, baseline-controlled, phase 3 studies were conducted in pediatric patients with NDO. Patients were treated with sequential doses of solifenacin oral suspension (pediatric equivalent doses 2.5-10 mg) for 12 weeks to determine each patient's optimal dose, followed by a fixed dose ≥40-week treatment period. Primary efficacy endpoint was change from baseline in maximum cystometric capacity (MCC) after 24 weeks. Secondary endpoints included bladder compliance, bladder volume until first detrusor contraction (>15 cmH2O), number of overactive detrusor contractions (>15 cmH2O), maximum catheterized volume (MCV)/24 h, and incontinence episodes/24 h. Safety parameters were treatment-emergent adverse events (TEAEs), serious adverse events, laboratory variables, vital signs, electrocardiograms, and ocular accommodation and cognitive function assessments. RESULTS After 24 weeks, MCC had significantly increased compared with baseline in patients aged 6 months -<5 years and 5-<18 years (37.0 ml and 57.2 ml, respectively; P < 0.001; Fig.). Improvement was also observed after 52 weeks' treatment. Significant changes were observed from baseline to week 24 in all secondary endpoints in both age groups: increase in bladder compliance, increase in bladder volume to first detrusor contraction as a percentage of expected bladder capacity, reduction in the number of overactive detrusor contractions, increase in MCV, and decreased incontinence episodes. TEAEs were mostly mild or moderate, and there were no new drug-related TEAEs compared with adult studies. Age-related improvements were noted in ocular accommodation and cognitive function. DISCUSSION These long-term multicenter investigations demonstrated the efficacy and safety of solifenacin in pediatric patients with NDO. The observed increases in MCC were clinically relevant and demonstrated that an increase in fluid volume can be accommodated in the bladder prior to reaching intravesical pressures that endanger kidney function and/or are associated with leakage or discomfort. Solifenacin was well tolerated with low incidences of constipation and dry mouth (typically associated with antimuscarinics), central nervous system-related side-effects, and facial flushing. CONCLUSION Solifenacin was effective and well tolerated in pediatric patients with NDO, aged 6 months-<18 years, suggesting that it is a viable alternative to oxybutynin, the current standard of care. STUDIES ARE REGISTERED AT CLINICALTRIALS.GOV: NCT01981954 and NCT01565694.
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Affiliation(s)
- Israel Franco
- Yale/New Haven Hospital Section of Pediatric Urology, New Haven, CT, USA.
| | - Piet Hoebeke
- Department of Pediatric Urology, Ghent University Hospital, Ghent, Belgium
| | | | - David Bolong
- Section of Pediatric Nephrology, Philippine Children's Medical Centre, Manila, Philippines
| | - Leon N Davies
- Aston Optometry School, Aston University, Birmingham, UK
| | - Ellen Dahler
- Astellas Pharma Europe B.V., Leiden, the Netherlands
| | | | - Otto Stroosma
- Astellas Pharma Europe B.V., Leiden, the Netherlands
| | | | | | | | - Johan Vande Walle
- Department of Pediatric Nephrology, Ghent University Hospital, Ghent, Belgium
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Griebling TL, Campbell NL, Mangel J, Staskin D, Herschorn S, Elsouda D, Schermer CR. Effect of mirabegron on cognitive function in elderly patients with overactive bladder: MoCA results from a phase 4 randomized, placebo-controlled study (PILLAR). BMC Geriatr 2020; 20:109. [PMID: 32183741 PMCID: PMC7079371 DOI: 10.1186/s12877-020-1474-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 02/14/2020] [Indexed: 12/02/2022] Open
Abstract
Background Antimuscarinics are often used for treatment of overactive bladder (OAB), but exposure to medications such as antimuscarinics that have anticholinergic properties has been linked to adverse cognitive effects. A phase 4 placebo-controlled study (PILLAR; NCT02216214) described the efficacy and safety of mirabegron, a β3-adrenoreceptor agonist, for treatment of wet OAB in patients aged ≥65 years. This pre-planned analysis aimed to measure differences in cognitive function between mirabegron and placebo, using a rapid screening instrument for mild cognitive impairment: the Montreal Cognitive Assessment (MoCA). Methods Outpatients aged ≥65 years with wet OAB were randomized 1:1 to mirabegron or placebo, stratified by age (<75/≥75 years). There were no exclusion criteria regarding cognitive status. Patients randomized to mirabegron initially received 25 mg/day with an optional increase to 50 mg/day after week 4/8 based on patient/investigator discretion. The MoCA was administered at baseline and end of treatment (EoT, week 12). The study protocol was Independent Ethics Committee/Institutional Review Board-approved. Results Of the 887 randomized patients who received ≥1 dose of study drug, 72.3% were female, 79.5% were white, and 28.1% were aged ≥75 years. All patients had ≥1 comorbidity and 94.3% were receiving ≥1 concomitant medication. One third of patients had a history of psychiatric disorders, the most common being depression (17.2%), insomnia (15.7%), and anxiety (11.4%). Baseline mean (standard error, SE) MoCA total scores were 26.9 (0.1) and 26.8 (0.1) in the mirabegron and placebo groups, respectively. Among patients with MoCA data available at baseline/EoT, 27.1% (115/425) and 25.8% (106/411) of mirabegron and placebo group patients, respectively, had impaired cognitive function at baseline (MoCA total score <26). There was no statistically significant change in adjusted mean (SE) MoCA total score from baseline to EoT in the mirabegron group (−0.2 [0.1]) or the placebo group (−0.1 [0.1]). Conclusions Treatment with mirabegron for 12 weeks did not contribute to drug-related cognitive side effects in patients aged ≥65 years, as measured by the MoCA. Furthermore, the pattern of change in cognition over time in an older OAB trial population does not appear to differ from that of subjects receiving placebo. Trial registration NCT02216214 (prospectively registered August 13, 2014).
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Affiliation(s)
- Tomas L Griebling
- Department of Urology and The Landon Center on Aging, University of Kansas School of Medicine, Kansas City, KS, USA.
| | - Noll L Campbell
- College of Pharmacy, Purdue University, Lafayette, IN, USA.,Center for Aging Research, Indiana University, Indianapolis, IN, USA
| | - Jeffrey Mangel
- Division of Urogynecology and Pelvic Reconstructive Surgery, MetroHealth Medical Center, Cleveland, OH, USA
| | - David Staskin
- Division of Urology, St Elizabeth's Medical Center, Boston, MA, USA
| | - Sender Herschorn
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Dina Elsouda
- Medical Affairs, Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Carol R Schermer
- Medical Affairs, Astellas Pharma Global Development, Inc., Northbrook, IL, USA
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Abstract
Introduction: Muscarinic receptor antagonists, 5α-reductase inhibitors and α1-adrenoceptor antagonists are frequently used drug classes for the treatment of lower urinary tract symptoms including those of overactive bladder syndrome and benign prostatic enlargement/benign prostatic obstruction. Areas covered: The authors review the evidence for adverse effects of these drug classes on cognitive function, mood and other functions of the central nervous system and discuss such effects against the evidence for mechanistic plausibility. Expert opinion: Muscarinic antagonists carry a risk for impaired cognition and other brain functions that differs quantitatively between compounds, being highest with oral formulations of oxybutynin. 5□-Reductase inhibitors can cause depressive symptoms even at low doses and starting several months after discontinuation of treatment. The evidence for α1-adrenoceptor antagonists and specifically tamsulosin to cause dementia is controversial and lacks mechanistic plausibility. We recommend that physicians treating patients with lower urinary tract symptoms carefully monitor mental status prior to prescribing and periodically thereafter.
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Affiliation(s)
- A Elif Muderrisoglu
- Dept. of Pharmacology, School of Pharmacy, Ankara University , Ankara , Turkey
| | - Klaus F Becher
- Dept. of Geriatrics and Early Rehabilitation, Helios Hanseklinikum Stralsund GmbH , Stralsund , Germany
| | - Stephan Madersbacher
- Dept. of Urology, Kaiser Franz Josef Spital, Sigmund Freud Private University , Vienna , Austria
| | - Martin C Michel
- Dept. of Pharmacology, Johannes Gutenberg University , Mainz , Germany
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Sacomani CAR, Almeida FGD, Silvinato A, Bernardo WM. Overactive bladder - pharmacological treatment. Rev Assoc Med Bras (1992) 2019; 65:487-492. [DOI: 10.1590/1806-9282.65.4.487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2018] [Indexed: 11/22/2022] Open
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Abstract
Urinary incontinence (UI) is a common and disabling problem among older people. Anticholinergic drugs (ADs) are a pharmacological option recommended for overactive bladder or mixed UI when non-pharmacological approaches have failed. However, UI is a more prevalent and complex condition in frail older people and to simply assume that AD actions are the same across all age groups would be wrong. This article reviews evidence for the efficacy and safety of these drugs, especially when prescribed for frail older people. Although ADs have a small but statistically significant benefit for UI in non-frail people, the vast majority choose to discontinue treatment because they feel that the beneficial effects do not outweigh the burden of taking the medication. Not only are the most frail older people more likely to experience adverse effects but there is also no evidence that these drugs are effective for UI. In addition, there is a mounting body of evidence that they impair cognitive function. The continued use of ADs in frail older people simply does not hold water.
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Golding JF, Wesnes KA, Leaker BR. The effects of the selective muscarinic M3 receptor antagonist darifenacin, and of hyoscine (scopolamine), on motion sickness, skin conductance & cognitive function. Br J Clin Pharmacol 2018. [PMID: 29522648 DOI: 10.1111/bcp.13579] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
AIMS The aim of this study was to compare the effects of the selective M3 muscarinic acetylcholine receptor antagonist darifenacin, oral hyoscine hydrobromide and placebo on motion sickness induced by cross-coupled stimulation. METHODS The effects of darifenacin 10 mg or 20 mg, hyoscine hydrobromide 0.6 mg and placebo were assessed in a randomized, double-blind, four-way cross over trial of 16 healthy subjects. Motion sickness, skin conductance (a measure of sweating) and psychomotor cognitive function tests were investigated. RESULTS Hyoscine hydrobromide produced significantly increased tolerance to motion versus placebo (P < 0.05 to P < 0.01). The motion protection effect of darifenacin (10 or 20 mg) was approximately one third that of hyoscine hydrobromide but was not significant versus placebo. Darifenacin and hyoscine hydrobromide both significantly reduced skin conductance versus placebo. Darifenacin produced either no effect or an enhanced effect on cognitive function in contrast to hyoscine hydrobromide, where there was significant impairment of psychomotor performance. CONCLUSION The results suggest that selective antagonism of the M3 receptor may not be important in the prevention of motion sickness. However, selective M3 antagonism does not impair cognitive function. These observations may be important given that long-term treatment with non-selective anti-muscarinic agents such as oxybutynin may lead to an increased incidence of dementia.
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Affiliation(s)
- John F Golding
- Department of Psychology, Faculty of Science & Technology, University of Westminster, London, UK
| | - Keith A Wesnes
- Medical School, University of Exeter, Exeter, UK.,Wesnes Cognition Ltd, Streatley-on-Thames, UK
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Geoffrion R. N o 283-Traitements visant la vessie hyperactive : Accent sur la pharmacothérapie. Journal of Obstetrics and Gynaecology Canada 2018; 40:e33-e44. [DOI: 10.1016/j.jogc.2017.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
OBJECTIVE To provide guidelines for pharmacotherapy to treat overactive bladder syndrome (OAB). OPTIONS Pharmacotherapy for OAB includes anticholinergic (antimuscarinic) drugs and vaginal estrogen. Both oral and transdermal anticholinergic preparations are available. OUTCOMES To provide understanding of current available evidence concerning safety and clinical efficacy of pharmacotherapy for OAB; to guide selection of anticholinergic therapy based on individual patient characteristics. EVIDENCE The Cochrane Library and Medline were searched for articles published from 1950 to the present related to individual anticholinergic drugs. Review articles on management of refractory OAB were also examined. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to 2010. VALUES The quality of evidence is rated and recommendations are made using the criteria described by the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS Anticholinergics are the mainstay of pharmacotherapy for OAB. Evidence for their efficacy is mostly derived from short-term phase III randomized drug trials. Placebo response is strong, and long-term follow-up and patient subjective outcome data are lacking. Care providers need to be well acquainted with the side effects of anticholinergics and select therapy based on individual patient parameters. RECOMMENDATIONS
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Krebs J, Scheel-Sailer A, Oertli R, Pannek J. The effects of antimuscarinic treatment on the cognition of spinal cord injured individuals with neurogenic lower urinary tract dysfunction: a prospective controlled before-and-after study. Spinal Cord 2017; 56:22-27. [PMID: 28786411 DOI: 10.1038/sc.2017.94] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 07/07/2017] [Accepted: 07/11/2017] [Indexed: 12/14/2022]
Abstract
STUDY DESIGN Prospective controlled before-and-after study. OBJECTIVES To investigate the effects of antimuscarinic treatment of neurogenic lower urinary tract dysfunction on the cognition of individuals with spinal cord injury (SCI) during the early post-acute phase. SETTING Single SCI rehabilitation center. METHODS Patients with acute traumatic SCI admitted for primary rehabilitation from 2011 to 2015 were screened for study enrollment. Study participants underwent baseline neuropsychological assessments prior to their first urodynamic evaluation (6-8 weeks after SCI). Individuals suffering from neurogenic detrusor overactivity received antimuscarinic treatment, and those not requiring antimuscarinic treatment constituted the control group. The neuropsychological follow-up assessment was carried out 3 months after the baseline assessment. The effects of group and time on the neuropsychological parameters were investigated. RESULTS The data of 29 individuals were evaluated (control group 19, antimuscarinic group 10). The group had a significant (P≤0.033) effect on immediate recall, attention ability and perseveration. In the control group, individuals performed significantly (P≤0.05) better in immediate recall both at baseline (percentile rank 40, 95% CI 21-86 versus 17, 95% CI 4-74) and follow-up (percentile rank 40, 95% CI 27-74 versus 16, 95% CI 2-74). The time had a significant (P≤0.04) effect on attention ability, processing speed, word fluency and visuospatial performance. The individuals in both groups performed better at the follow-up compared to the baseline assessment. CONCLUSION Even though, we did not observe cognitive deterioration in the investigated, cognitively intact SCI individuals during the first 3 treatment months, the concerns regarding deleterious effects of antimuscarinics on cognition remain.
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Affiliation(s)
- J Krebs
- Clinical Trial Unit, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - A Scheel-Sailer
- Rehabilitation and Quality Management, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - R Oertli
- Neurology, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - J Pannek
- Neurourology, Swiss Paraplegic Centre, Nottwil, Switzerland
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Affiliation(s)
- José Carlos Truzzi
- Sociedade Brasileira de Urologia. Universidade Federal de São Paulo. Hospital Alemão Oswaldo Cruz, São Paulo, SP, Brazil
| | - Antonio Silvinato
- Sociedade Brasileira de Urologia. Universidade Federal de São Paulo. Hospital Alemão Oswaldo Cruz, São Paulo, SP, Brazil
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Geoffrion R. Traitements visant la vessie hyperactive : Accent sur la pharmacothérapie. Journal of Obstetrics and Gynaecology Canada 2016; 38:S158-S170. [DOI: 10.1016/j.jogc.2016.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Wagg A, Nitti VW, Kelleher C, Castro-Diaz D, Siddiqui E, Berner T. Oral pharmacotherapy for overactive bladder in older patients: mirabegron as a potential alternative to antimuscarinics. Curr Med Res Opin 2016; 32:621-38. [PMID: 26828974 DOI: 10.1185/03007995.2016.1149806] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Overactive bladder (OAB) is a particular challenge to treat in older adults with co-morbid conditions taking multiple medications. Antimuscarinics (e.g., solifenacin, fesoterodine) and β3-adrenergic receptor agonists (mirabegron) are similarly efficacious; however, antimuscarinics may be associated with side effects that result in poor persistence and contribute to anticholinergic burden, particularly in those taking other medications with anticholinergic properties. With a mechanism of action distinct from antimuscarinics, mirabegron has a different tolerability profile and does not contribute to anticholinergic burden. The objective of this review was to compare and contrast the tolerability profiles of antimuscarinics and mirabegron in older patients to inform practice. METHODS Prospective trials or retrospective subgroup analyses of antimuscarinics for the treatment of OAB in older patients were identified through a search of PubMed. Tolerability data and results of subgroup analyses of mirabegron in patients aged ≥65 and ≥75 years from a pooled analysis of three trials each of 12 weeks and a 1 year trial are described. RESULTS Anticholinergic adverse events (AEs) including dry mouth and constipation were more frequent with antimuscarinics versus mirabegron. In patients aged ≥65 years, dry mouth occurred with a six-fold higher incidence with tolterodine extended-release (ER) 4 mg than with mirabegron 25 mg or 50 mg over 12 weeks, and a three-fold higher incidence with tolterodine ER than mirabegron 50 mg over 1 year. Mirabegron had a low incidence of central nervous system effects. A systematic review of the cardiovascular safety profile of mirabegron has not identified any clinically significant effects on blood pressure or pulse rate at therapeutic doses amongst patients aged ≥65 years. CONCLUSIONS Mirabegron has a more favorable tolerability profile than antimuscarinics amongst older patients and may provide an improved benefit-to-risk ratio and therefore be considered as an alternative to antimuscarinics for older patients.
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Affiliation(s)
| | | | - Con Kelleher
- c Guy's and St Thomas' NHS Foundation Trust , UK
| | | | - Emad Siddiqui
- e Astellas Pharma Europe Ltd , Chertsey , Surrey , UK
| | - Todd Berner
- f Formerly of Astellas Scientific and Medical Affairs , Northbrook , IL , USA
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Thiagamoorthy G, Cardozo L, Srikrishna S. Drug therapy for an overactive bladder. Womens Health (Lond) 2015; 11:445-8. [PMID: 26238677 DOI: 10.2217/whe.15.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Ganesh Thiagamoorthy
- Department of Urogynaecology, 3rd Floor, Golden Jubilee Wing, King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Linda Cardozo
- Department of Urogynaecology, 3rd Floor, Golden Jubilee Wing, King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Sushma Srikrishna
- Department of Urogynaecology, 3rd Floor, Golden Jubilee Wing, King's College Hospital, Denmark Hill, London SE5 9RS, UK
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Abstract
Multiple sclerosis (MS) is a chronic, progressive central neurological disease characterized by inflammation and demyelination. In patients with MS, dysregulation of the autonomic nervous system may present with various clinical symptoms including sweating abnormalities, urinary dysfunction, orthostatic dysregulation, gastrointestinal symptoms, and sexual dysfunction. These autonomic disturbances reduce the quality of life of affected patients and constitute a clinical challenge to the physician due to variability of clinical presentation and inconsistent data on diagnosis and treatment. Early diagnosis and initiation of individualized interdisciplinary and multimodal strategies is beneficial in the management of autonomic dysfunction in MS. This review summarizes the current literature on the most prevalent aspects of autonomic dysfunction in MS and provides reference to underlying pathophysiological mechanisms as well as means of diagnosis and treatment.
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Affiliation(s)
- Alexandra Pintér
- Institute of Human Physiology and Clinical Experimental Research, Faculty of Medicine, Semmelweis University, Budapest 1085, Hungary.
- Center for Clinical Research and Management Education, Division of Health Care Sciences, Dresden International University, Dresden 01067, Germany.
| | - Domonkos Cseh
- Institute of Human Physiology and Clinical Experimental Research, Faculty of Medicine, Semmelweis University, Budapest 1085, Hungary.
| | - Adrienn Sárközi
- Institute of Human Physiology and Clinical Experimental Research, Faculty of Medicine, Semmelweis University, Budapest 1085, Hungary.
| | - Ben M Illigens
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
| | - Timo Siepmann
- Center for Clinical Research and Management Education, Division of Health Care Sciences, Dresden International University, Dresden 01067, Germany.
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden 01307, Germany.
- Department of Psychotherapy and Psychosomatic Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden 01307, Germany.
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Orme S, Morris V, Gibson W, Wagg A. Managing Urinary Incontinence in Patients with Dementia: Pharmacological Treatment Options and Considerations. Drugs Aging 2015; 32:559-67. [DOI: 10.1007/s40266-015-0281-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Capo' JP, Lucente V, Forero-Schwanhaeuser S, He W. Efficacy and Tolerability of Solifenacin in Patients Aged ⩾ 65 Years with Overactive Bladder: Post-Hoc Analysis of 2 Open-Label Studies. Postgrad Med 2015; 123:94-104. [DOI: 10.3810/pgm.2011.01.2250] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
OBJECTIVE To provide guidelines for pharmacotherapy to treat overactive bladder syndrome (OAB). OPTIONS Pharmacotherapy for OAB includes anticholinergic (antimuscarinic) drugs and vaginal estrogen. Both oral and transdermal anticholinergic preparations are available. OUTCOMES To provide understanding of current available evidence concerning safety and clinical efficacy of pharmacotherapy for OAB; to guide selection of anticholinergic therapy based on individual patient characteristics. EVIDENCE The Cochrane Library and Medline were searched for articles published from 1950 to the present related to individual anticholinergic drugs. Review articles on management of refractory OAB were also examined. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to 2010. VALUES The quality of evidence is rated and recommendations are made using the criteria described by the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS Anticholinergics are the mainstay of pharmacotherapy for OAB. EVIDENCE for their efficacy is mostly derived from short-term phase III randomized drug trials. Placebo response is strong, and long-term follow-up and patient subjective outcome data are lacking. Care providers need to be well acquainted with the side effects of anticholinergics and select therapy based on individual patient parameters. Recommendations 1. Behavioural management protocols and functional electrical stimulation should be offered in the spectrum of effective primary treatments for overactive bladder syndrome. (I-A) 2. Oral oxybutynin, immediate and extended release, as well as transdermal oxybutynin, may be offered as treatment for overactive bladder syndrome, as they are associated with significant objective clinical improvement at 12 weeks. (I-A) Oxybutynin immediate release has superior cost-effectiveness but more side effects than other anticholinergics. (I-A) Adverse events associated with transdermal oxybutynin are fewer than with oral oxybutynin. (I-A) 3. Tolterodine, immediate and extended release, may be offered as treatment for overactive bladder syndrome, as it is associated with significant objective clinical improvement at 12 weeks. (I-A) 4. Trospium, immediate and extended release, may be offered as treatment for overactive bladder syndrome as it is associated with significant clinical improvement at 12 weeks. (I-A) Trospium is an adequate anticholinergic choice for overactive bladder syndrome patients with pre-existing cognitive impairment (II-B) and for overactive bladder syndrome patients taking concurrent CYP450 inhibitors. (III-B) 5. Solifenacin may be offered as treatment for overactive bladder syndrome, as it is associated with significant objective clinical improvement at 12 weeks. (I-A) Solifenacin may be an adequate anticholinergic choice for elderly overactive bladder syndrome patients or patients with pre-existing cognitive dysfunction. (I-B) 6. Darifenacin may be offered as treatment for overactive bladder syndrome, as it is associated with significant objective clinical improvement at 12 weeks. (I-A) Darifenacin is an adequate anticholinergic choice for overactive bladder syndrome patients with pre-existing cardiac concerns or cognitive dysfunction. (I-B) 7. Overactive bladder syndrome patients should be offered a choice between bladder training, functional electric stimulation, and anticholinergic therapy, as there is no difference in cure rates. Combination therapy does not have a clear advantage over one therapy alone. (I-A) 8. The choice of anticholinergic therapy should be guided by individual patient comorbidities, as objective efficacy of anticholinergic drugs is similar. (I-A) Dose escalation does not improve objective parameters and causes more anticholinergic adverse effects. It is, however, associated with improved subjective outcomes. (I-A) To decrease side effects, switching to a lower dose or using an extended release formulation or a transdermal delivery mechanism should be considered. (I-A) 9. Education on treatment efficacy, realistic expectations, and length of treatment should be offered to patients upon initiation of anticholinergic therapy, as continuation rates for anticholinergic therapy are low. (III-B) 10. Oral or transdermal estrogen supplementation should not be recommended for treatment of overactive bladder syndrome as its effects are comparable to placebo. (I-E) Vaginal estrogen can be suggested for subjective improvements in overactive bladder syndrome symptoms. (III-B) 11. Intravesical botulinum toxin injection and sacral nerve and posterior tibial nerve stimulation are clinically effective options for patients with overactive bladder syndrome unresponsive to conservative options, anticholinergics, or vaginal estrogen. (I-A).
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Fox C, Smith T, Maidment I, Chan WY, Bua N, Myint PK, Boustani M, Kwok CS, Glover M, Koopmans I, Campbell N. Effect of medications with anti-cholinergic properties on cognitive function, delirium, physical function and mortality: a systematic review. Age Ageing 2014; 43:604-15. [PMID: 25038833 DOI: 10.1093/ageing/afu096] [Citation(s) in RCA: 221] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES to determine the effect of drugs with anti-cholinergic properties on relevant health outcomes. DESIGN electronic published and unpublished literature/trial registries were systematically reviewed. Studies evaluating medications with anti-cholinergic activity on cognitive function, delirium, physical function or mortality were eligible. RESULTS forty-six studies including 60,944 participants were included. Seventy-seven percent of included studies evaluating cognitive function (n = 33) reported a significant decline in cognitive ability with increasing anti-cholinergic load (P < 0.05). Four of five included studies reported no association with delirium and increasing anti-cholinergic drug load (P > 0.05). Five of the eight included studies reported a decline in physical function in users of anti-cholinergics (P < 0.05). Three of nine studies evaluating mortality reported that the use of drugs with anti-cholinergic properties was associated with a trend towards increased mortality, but this was not statistically significant. The methodological quality of the evidence-base ranged from poor to very good. CONCLUSION medicines with anti-cholinergic properties have a significant adverse effect on cognitive and physical function, but limited evidence exists for delirium or mortality outcomes.
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Affiliation(s)
- Chris Fox
- School of Medicine, University of East Anglia, Norwich, Norfolk NR47TJ, UK
| | - Toby Smith
- School of Rehabilitation Sciences, University of East Anglia, Norwich, Norfolk, NR4 7TJ, UK
| | - Ian Maidment
- Pharmacy, School of Life and Health Sciences, Medicines and Devices in Ageing, Aston Research Centre for Healthy Ageing, (ARCHA), Aston University, Birmingham, UK
| | - Wei-Yee Chan
- School of Medicine, University of East Anglia, Norwich, Norfolk NR47TJ, UK
| | - Nelson Bua
- School of Medicine, University of East Anglia, Norwich, Norfolk NR47TJ, UK
| | - Phyo Kyaw Myint
- School of Medicine & Dentistry, University of Aberdeen, Aberdeen, Scotland AB25 2ZD, UK
| | - Malaz Boustani
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chun Shing Kwok
- Norfolk and Norwich University Hospital, Norwich, Norfolk NR4 7UY, UK
| | - Michelle Glover
- School of Medicine, University of East Anglia, Norwich, Norfolk NR47TJ, UK
| | - Imogen Koopmans
- School of Medicine, University of East Anglia, Norwich, Norfolk NR47TJ, UK
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Wagg A, Cardozo L, Nitti VW, Castro-Diaz D, Auerbach S, Blauwet MB, Siddiqui E. The efficacy and tolerability of the β3-adrenoceptor agonist mirabegron for the treatment of symptoms of overactive bladder in older patients. Age Ageing 2014; 43:666-75. [PMID: 24610862 DOI: 10.1093/ageing/afu017] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION mirabegron is a β3-adrenoceptor agonist developed for the treatment of symptoms of overactive bladder (OAB). As the prevalence of OAB increases with age, a prospective subanalysis of individual and pooled efficacy and tolerability data from three 12-week, randomised, Phase III trials, and of tolerability data from a 1-year safety trial were conducted in order to evaluate the efficacy and tolerability of mirabegron in subgroups of patients aged ≥65 and ≥75 years. METHODS primary efficacy outcomes were change from baseline to final visit in the mean number of incontinence episodes/24 h and the mean number of micturitions/24 h. Tolerability was assessed by the incidence of treatment-emergent adverse events (TEAEs). RESULTS over 12 weeks mirabegron 25 mg and 50 mg once-daily reduced the mean numbers of incontinence episodes and micturitions/24 h from baseline to final visit in patients aged ≥65 and ≥75 years. Mirabegron was well tolerated: in both age groups, hypertension and urinary tract infection were among the most common TEAEs over 12 weeks and 1 year. The incidence of dry mouth, a typical anticholinergic TEAE, was up to sixfold higher among the older patients randomised to tolterodine than any dose of mirabegron. CONCLUSIONS these analyses have demonstrated the efficacy of mirabegron over 12 weeks and the tolerability of mirabegron over 12 weeks and 1 year in OAB patients aged ≥65 and ≥75 years, supporting mirabegron as a therapeutic option in older patients with OAB.
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Affiliation(s)
- Adrian Wagg
- Department of Geriatric Medicine, University of Alberta, Alberta, Canada
| | - Linda Cardozo
- Department of Urogynaecology, Kings College London, London, UK
| | - Victor W Nitti
- Department of Urology, NYU Langone Medical Center, New York City, NY, USA
| | - David Castro-Diaz
- Department of Urology, University Hospital of the Canary Islands, Santa Cruz de Tenerife, Tenerife, Spain
| | - Stephen Auerbach
- Department of Urology, Hoag Memorial Presbyterian Hospital, Newport Beach, Long Beach, CA, USA
| | - Mary Beth Blauwet
- Department of Biostatistics, Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Emad Siddiqui
- Astellas Pharma Europe Ltd, Chertsey, Surrey, UK and Department of Urology, Ealing Hospital, London, UK
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Srikrishna S, Robinson D, Cardozo L. Important drug–drug interactions for treatments that target overactive bladder syndrome. Int Urogynecol J 2013; 25:715-20. [PMID: 24232071 DOI: 10.1007/s00192-013-2259-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 10/12/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Overactive bladder (OAB) is the term used to describe the symptom complex of urinary urgency,usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or other obvious pathology. It is a common distressing condition that significantly impairs quality of life(QoL). After lifestyle advice and bladder retraining,antimuscarinic drugs are most commonly used to treat OAB. METHODS The antimuscarinics in common use are all metabolised through differing mechanisms. Therefore, the risk of an enhanced drug effect is increased when the potentially interacting substrates compete for the same metabolic pathways. The aim of this review is to provide an overview on potential drug–drug interactions with special emphasis on high-risk groups and clinically important consequences of these interactions RESULTS AND CONCLUSION Knowledge of current important drug interactions is vital whilst prescribing antimuscarinics, particularly in high-risk groups. Novel therapies, such as beta 3 agonists or alternative drug delivery systems, such as the oxybutynin vaginal ring, might provide alternative options where these interactions are unavoidable.
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Abstract
Solifenacin-induced cognitive adverse effects have not been reported frequently, but solifenacin-induced delirium and hallucinations with successful switching to darifenacin, without additional drug, have not been reported in the literature. In this case report, we present an 80-year-old Caucasian male with insomnia and anxiety symptoms and overactive bladder who developed delirium and hallucinations when treated with solifenacin and trazodone. After solifenacin discontinuation and switching to darifenacin, symptoms significantly improved immediately. Such a case has not yet been described in literature; however, an adverse effect associated with solifenacin can occur, as this report clearly demonstrates.
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Affiliation(s)
- Matej Štuhec
- Ormoz Psychiatric Hospital, Department for Clinical Pharmacy, Slovenia, Ptujska Cesta 33, Ormoz, Slovenia.
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De Ridder D, Van Der Aa F, Debruyne J, D’hooghe MB, Dubois B, Guillaume D, Heerings M, Ilsbroukx S, Medaer R, Nagels G, Seeldrayers P, Van Landegem W, Willekens B, Zicot AF. Consensus guidelines on the neurologist's role in the management of neurogenic lower urinary tract dysfunction in multiple sclerosis. Clin Neurol Neurosurg 2013; 115:2033-40. [DOI: 10.1016/j.clineuro.2013.06.018] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Revised: 06/11/2013] [Accepted: 06/24/2013] [Indexed: 11/25/2022]
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Abstract
INTRODUCTION Overactive bladder (OAB) is a common condition which affects both men and women across many age groups with significant impact on quality of life. There is currently an armamentarium of treatment options available ranging from conservative, medical therapy to radical surgeries. Increasing understanding of OAB is resulting in the rapid development of new therapies today. AREAS COVERED The purpose of this article was to summarise the latest developments in non-neurogenic OAB treatment, discuss the evidence and results of current and new treatment modalities available through review of published data and results presented at recent international meetings. EXPERT OPINION The ultimate goal in OAB therapy is to provide good clinical efficacy, safe, non-invasive and easy to administer. There is definitely room for development of new therapies in OAB and current progress is encouraging.
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Wagg A, Dale M, Tretter R, Stow B, Compion G. Reply from Authors re: Jean-Nicolas Cornu. Overactive Bladder Medical Management in the Elderly: It Is Time to Go Beyond the Tip of the Iceberg. Eur Urol 2013;64:82–3. Eur Urol 2013; 64:83-4. [DOI: 10.1016/j.eururo.2013.02.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Accepted: 02/15/2013] [Indexed: 11/16/2022]
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Wagg A, Dale M, Tretter R, Stow B, Compion G. Randomised, Multicentre, Placebo-controlled, Double-blind Crossover Study Investigating the Effect of Solifenacin and Oxybutynin in Elderly People with Mild Cognitive Impairment: The SENIOR Study. Eur Urol 2013; 64:74-81. [DOI: 10.1016/j.eururo.2013.01.002] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 01/06/2013] [Indexed: 11/28/2022]
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Tannenbaum C, Paquette A, Hilmer S, Holroyd-Leduc J, Carnahan R. A systematic review of amnestic and non-amnestic mild cognitive impairment induced by anticholinergic, antihistamine, GABAergic and opioid drugs. Drugs Aging 2013; 29:639-58. [PMID: 22812538 DOI: 10.1007/bf03262280] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Mild cognitive deficits are experienced by 18% of community-dwelling older adults, many of whom do not progress to dementia. The effect of commonly used medication on subtle impairments in cognitive function may be under-recognized. OBJECTIVE The aim of the review was to examine the evidence attributing amnestic or non-amnestic cognitive impairment to the use of medication with anticholinergic, antihistamine, GABAergic or opioid effects. METHODS MEDLINE and EMBASE were searched for randomized, double-blind, placebo-controlled trials of adults without underlying central nervous system disorders who underwent detailed neuropsychological testing prior to and after oral administration of drugs affecting cholinergic, histaminergic, GABAergic or opioid receptor pathways. Seventy-eight studies were identified, reporting 162 trials testing medication from the four targeted drug classes. Two investigators independently appraised study quality and extracted relevant data on the occurrence of amnestic, non-amnestic or combined cognitive deficits induced by each drug class. Only trials using validated neuropsychological tests were included. Quality of the evidence for each drug class was assessed based on consistency of results across trials and the presence of a dose-response gradient. RESULTS In studies of short-, intermediate- and long-acting benzodiazepine drugs (n = 68 trials), these drugs consistently induced both amnestic and non-amnestic cognitive impairments, with evidence of a dose-response relationship. H(1)-antihistamine agents (n = 12) and tricyclic antidepressants (n = 15) induced non-amnestic deficits in attention and information processing. Non-benzodiazepine derivatives (n = 29) also produced combined deficits, but less consistently than benzodiazepine drugs. The evidence was inconclusive for the type of cognitive impairment induced by different bladder relaxant antimuscarinics (n = 9) as well as for narcotic agents (n = 5) and antipsychotics (n = 5). Among healthy volunteers >60 years of age, low doses of commonly used medications such as lorazepam 0.5 mg, oxybutynin immediate release 5 mg and oxycodone 10 mg produced combined deficits. CONCLUSION Non-amnestic mild cognitive deficits are consistently induced by first-generation antihistamines and tricyclic antidepressants, while benzodiazepines provoke combined amnestic and non-amnestic impairments. Risk-benefit considerations should be discussed with patients in order to enable an informed choice about drug discontinuation or substitution to potentially reverse cognitive adverse effects.
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Affiliation(s)
- Cara Tannenbaum
- Faculties of Pharmacy and Medicine, Universit de Montral, Montreal, QC, Canada.
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Abstract
Overactive bladder is a common condition that increases in prevalence in association with age. Antimuscarinic therapy remains the mainstay of pharmacological treatment for the condition, and there is an increasing body of evidence that supports the use of these drugs. Despite this, and because of concerns about associated adverse effects, older people are less likely to receive active treatment for their condition. This review considers some of the factors that need to be taken into account when using these medications.
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Affiliation(s)
- Adrian S Wagg
- Division of Geriatric Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
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Miller KL, Baraldi CA. Geriatric gynecology: promoting health and avoiding harm. Am J Obstet Gynecol 2012; 207:355-67. [PMID: 22607665 DOI: 10.1016/j.ajog.2012.04.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2011] [Revised: 04/03/2012] [Accepted: 04/10/2012] [Indexed: 10/28/2022]
Abstract
Age increases vulnerability, commonly accompanied by greater reliance on others and susceptibility to maltreatment. Physiologic processes become less resilient; the potential for harm from medical care increases. Awareness of frailty, functional, social, and potential maltreatment issues enables early referrals to help the patient maintain her independence. Health issues that may impede both gynecologic care and self-sufficiency include sensory deficits, physical disability, and cognitive impairment. Speaking slowly and providing contextual information enhance patient comprehension. Cancer screening depends on life expectancy. Osteoporosis treatment requires managing fall risk. Gynecologic symptoms more likely have multiple contributing factors than one etiology. Incontinence is a particularly complex issue, but invariably includes bladder diary assessment and pelvic floor muscle training. Function and frailty measures best predict perioperative morbidity. Communication with the patient, her family, other providers, and health care organizations is an important frontier in avoiding errors and adverse outcomes.
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Kay GG, Maruff P, Scholfield D, Malhotra B, Whelan L, Darekar A, Martire DL. Evaluation of cognitive function in healthy older subjects treated with fesoterodine. Postgrad Med 2012; 124:7-15. [PMID: 22691894 DOI: 10.3810/pgm.2012.05.2543] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To evaluate the cognitive effects of fesoterodine 4 and 8 mg versus placebo in healthy older adults. METHODS This was an active- and placebo-controlled, double-blind, double-dummy crossover study conducted using healthy volunteers (aged 65-85 years) with baseline Mini-Mental State Examination score ≥ 26. The study comprised 4 treatment periods: fesoterodine 4 mg for 6 days; fesoterodine 4 mg for 3 days followed by fesoterodine 8 mg for 3 days; placebo for 6 days; and placebo for 6 days with alprazolam 1 mg on day 6. The treatment sequence was randomized, with a 3- to 6-day washout between periods. Subjects completed computer-based cognitive assessments and the Rey Auditory Verbal Learning Test on day 1 (before dosing) and day 6 (after dosing) of each period. The primary endpoint was the Detection task; secondary endpoints were the Identification task, 1-card learning task, Continuous Paired Associate Learning task, Groton Maze Learning Task, and the Rey Auditory Verbal Learning Test. RESULTS Among 18 subjects in the per protocol set, changes from baseline to day 6 with fesoterodine 4 and 8 mg were not significantly different from placebo for any endpoint (P > 0.05); alprazolam produced significant impairment in all endpoints versus placebo (P < 0.05). No serious adverse events were reported; the most common adverse events were dry mouth for fesoterodine and sedation for alprazolam. No sedation was reported with fesoterodine. CONCLUSION In healthy older adults, fesoterodine 4 and 8 mg once daily had no statistically significant effects versus placebo on any cognitive function assessed, including memory; alprazolam 1 mg produced statistically significant deterioration.
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Affiliation(s)
- Gary G Kay
- Cognitive Research Corporation, Saint Petersburg, FL 33701 , USA.
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Tannenbaum C, Paquette A, Hilmer S, Holroyd-Leduc J, Carnahan R. A Systematic Review of Amnestic and Non-Amnestic Mild Cognitive Impairment Induced by Anticholinergic, Antihistamine, GABAergic and Opioid Drugs. Drugs Aging 2012. [DOI: 10.2165/11633250-000000000-00000] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Abstract
Overactive bladder is a common condition that increases in prevalence in association with age. Antimuscarinic therapy remains the mainstay of pharmacological treatment for the condition, and there is an increasing body of evidence that supports the use of these drugs. Despite this, and because of concerns about associated adverse effects, older people are less likely to receive active treatment for their condition. This review considers some of the factors that need to be taken into account when using these medications.
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Affiliation(s)
- Adrian S Wagg
- Division of Geriatric Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
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Chancellor MB, Staskin DR, Kay GG, Sandage BW, Oefelein MG, Tsao JW. Blood–Brain Barrier Permeation and Efflux Exclusion of Anticholinergics Used in the Treatment of Overactive Bladder. Drugs Aging 2012; 29:259-73. [DOI: 10.2165/11597530-000000000-00000] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Abstract
BACKGROUND/AIMS Prior research about cognitive problems associated with the use of urinary urgency medication (UUM) has reported mixed results that suggest procedures and/or assessments may need to be refined. METHODS Ten elderly subjects who were actively taking a UUM were assessed with neuropsychological testing before and after a 4-week UUM washout period. Results were evaluated by examining discrete subtest results, full-scale scores, and the reliable change index methodology. RESULTS Four controls and 5 subjects with mild cognitive impairment showed significant improvement in at least one subtest score on well-characterized instruments. CONCLUSION In this case study of 10 subjects, withdrawal of oxybutynin and tolterodine resulted in significant changes in subtest scores with different patterns for each subject that were not necessarily reflected in their total scores. Thus, future clinical studies should always include analysis of subtest results as these changes may be the only indication that cognition has been improved or has declined significantly.
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Affiliation(s)
- Marilee Monnot
- Department of Neurology, University of Oklahoma Health Sciences Center and Veterans Affairs Medical Center, Oklahoma City, Okla., USA
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