New drugs and the management of incontinence

Stephen Mark

Drug therapy for incontinence

OAB: Anti cholinergics: different routes, Oxytrol and more selective [ M3], Tolteradine, Solifenacin, Darifenacin. Extended formula’s, Ditropan XL . Botox

SUI: Duloxetine

Normal bladder function

Storage: Bladder

Outlet

Emptying: Bladder

Outlet

Abnormal bladder function

Storage: High P [ OAB ]

Treat: Bladder retraining

Drugs

Surgery

Affects men with BPH

Combination medication alpha blocker and anticholinergic being trialled

Bladder retraining

Effective

Durable

Minimum duration 2 months

Better results with Continence therapist

Drug treatment: Aims

Lower pressure of bladder and increase storage volume

Reduce sensitivity bladder

Minimal side effects

Acceptable costs

Drug utilisation is increasing

Drug treatment in OAB

Oxybutinin: [ Ditropan ]: Anticholinergic. Direct smooth muscle relaxant [ M1,2,3] and local anaesthetic. Non-selective agent. 70% effective but over 50% stop due to intolerable side effects [ dry mouth, blurred vision, GI symptoms…]. Government funded .

Most commonly used agent

New OAB Medication

EffectivenessSide effectsCostRole

Newer drugs for OAB

Solifenacin

Tolteradine

Ditropan XL

Longer acting Oxybutinin formulaRarely used in NZSimilar effectiveness but less side

effects

Oxytrol: Oxybutinin patches

Available in NZSimilar effectiveness but less side

effectsDose 2 patches per weekCost: $ 80 - $120 per month

Comparison oral vs transdermal Oxybutinin

Tolterodine [ Detrusitol]

M2 and M3 selective anticholinergicstudied in adults and childrensimilar effectiveness to Oxybutininless side effectsbid dose 2 to 4 mgCost: $ 80 - $ 120 per month

ComparisonOxybutinin andTolteradine

Solifenacin [ Vesicare]

M3 selective anticholinergicstudied in adultssimilar effectiveness to Oxybutininless side effectsonce daily dose 5 or 10 mgCost: $ 80 - $120 per month

Cost of medication

$ 80 - $120 per monthdependant on pharmacy and locationoccasional company discount

Darifenacin [Enablex]

M3 antagonistnot available in NZbid dose

Comparison M3 receptor antagonists

Role of anticholinergics in NZ

Oxybutinin fully fundedAll other drugs equal and similar efficacyAll other drugs less side effects

Pharmac unlikely to change

Dose escalation Oxybutinin to reduce side effects [ except children]Offer alternative if effective and significant side effectsPatient will need to pay

Duloxotine for SUI

Serotonin NE uptake inhibitoranti depressant10 RCT showing 50% effective in

reducing SUI….. Not curativeImproved QolSignificant side effects [ 20%

withdrawl]Summary: No role in SUI treatment

The End