- Urge Incontinence
- Urinary Catheter leakage
- Anticholinergic Medications
- Inhibit involuntary detrusor contractions
- First-line management for Urge Incontinence are non-pharmacologic measures
- Decrease Caffeine intake
- Schedule voiding times
- Bladder TrainingExercises
- All Bladder Relaxants are only modestly effective
- Reduce Urinary Frequency and Incontinence by approximately 1 episode daily
- Expect 1 in 7 patients to benefit
- Expect 1 in 5 patients to have significant side effects (typically Anticholinergic)
- References
-
Anticholinergic side effects (antimuscarinic agents, no beta-3 Agonists)
- Anticholinergic symptom examples: Dry Mouth, confusion, Tachycardia, Blurred Vision
- See Medication Use in the Elderly (Beers List, STOPP)
- Seen less with Tolterodine then with Oxybutynin
- Seen less with long acting agents and transdermal agents
- Non-selective Agents (M1/M2/M3 antimuscarinics)
- Long-acting Oral agents: (preferred of the non-selective agents)
- Detrol LA (Tolterodine LA) 2 to 4 mg daily
- Similar efficacy compared to Oxybutinin XR
- Tolterodine causes less Dry Mouth
- Diokno (2003) Mayo Clin Proc 78:687-95 [PubMed]
- Ditropan XL or Oxytrol XR (Oxybutynin XR) 5 to 10 to 30 mg daily
- Ditropan XL is now generic
- Reduces Urge Incontinence 28%
- Dry Mouth is more common
- Least likely to cause Constipation
- CNS effects such as Dizziness and sedation are more common
- Sanctura XR (trospium XR)
- No Drug Interactions with CYP3A4 metabolized agents
- Renal Clearance
- Less CNS effects (does not cross BBB)
- Dry Mouth is less common
- Toviaz XR (Fesoterodine XR)
- Risk of high drug levels in decreased metabolism of Cytochrome P450 2D6
- Detrol LA (Tolterodine LA) 2 to 4 mg daily
- Transdermal agents
- Tolterodine transdermal patch
- Oxybutynin transdermal patch (Oxytrol) apply 2x/week
- As effective as oral agent
- Less Anticholinergic side effects
- Frequently causes skin reaction
- Dmochowski (2003) Urology 62:237-42 [PubMed]
- Oxytrol for Women (OTC, Oxybutynin patch)
- Indicated for women over age 18 years with at least 3 months of urinary urgency with frequency or Urinary Incontinence
- Cost is $30 per month (OTC out-of-pocket cost) versus $270 for prescription
- Contraindicated in men (due to Overflow Incontinence risk due to BPH related urinary obstruction)
- (2013) Presc Lett 20(9):51
- Short acting oral agents (avoid now that Ditropan XL is now generic)
- Increased Anticholinergic side effects (Dry Mouth, Constipation)
- Tolterodine (Detrol) 1 to 2 mg PO bid
- Oxybutynin (Ditropan) 2.5 to 5 mg PO qid
- M3 Selective Antimuscarinics
- Indications
- Urge Incontinence (preferred agents due to less cognitive effects)
- Mechanism
- Selective for M3 Muscarinic Receptor blockade
- Less drowsiness and Dizziness than agents above
- Higher rate of Constipation, Dry Mouth, Vision change
- Agents
- Solifenacin (Vesicare) 5 to 10 mg PO daily
- Darifenacin (Enablex) 7.5 to 15 mg PO daily
- Beta-3 Adrenergic Agonist
- Agents
- Mirabegron (Myrbetriq)
- Vibegron (Gemtessa)
- Does not appear to have Blood Pressure, Heart Rate effects or CYP450 2D6 interactions
- Contrast with Mirabegron
- Does not appear to have Blood Pressure, Heart Rate effects or CYP450 2D6 interactions
- Indications
- Consider in patients intolerant to the Anticholinergic effects of the anti-muscarinic agents
- Examples: Cognitive Impairment, Glaucoma
- Mechanism: Beta-3 Agonist
- Relaxes Smooth Muscle including the Bladder
- Secondary increase in Bladder storage capacity
- Efficacy
- Similar to effectiveness to antimuscarinics (e.g. Oxybutynin)
- However, substantially more expensive than antimuscarinics (>$400 per month)
- Adverse effects (Mirabegron)
- No Anticholinergic side effects
- Hypertension
- Tachycardia
- Headache
- Dizziness
- Gastrointestinal Upset
-
Drug Interactions (Mirabegron)
- Inhibits CYP450 2D6
- Raises levels of Metoprolol, Desipramine, Digoxin
- Older agents now replaced by those above
- Flavoxate (Urispas) 100 to 200 mg PO qid
- Hyoscyamine (Cystospaz) 0.125 to 0.5 mg PO qid
- Dicyclomine (Bentyl) 10 to 20 mg PO qid
- (2021) Presc Lett 28(3): 17
- (2012) Presc Lett 19(10): 57-8
- Appell (2001) Mayo Clin Proc 76:358-63 [PubMed]