New drugs and the management of incontinence

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New drugs and the management of incontinence

• Stephen Mark

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Drug therapy for incontinence

• OAB Anti cholinergics different routes, Oxytrol
  and more selective M3, Tolteradine,
  Solifenacin, Darifenacin. Extended formulas,
  Ditropan XL . Botox
• SUI Duloxetine

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Normal bladder function Storage Bladder
Outlet Emptying Bladder Outlet
Abnormal bladder function Storage High P OAB
Treat Bladder retraining Drugs
Surgery
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Affects men with BPH
Combination medication alpha blocker and
anticholinergic being trialled
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Bladder retraining Effective Durable Minimum
duration 2 months Better results with Continence
therapist
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Drug treatment Aims Lower pressure of bladder
and increase storage volume Reduce sensitivity
bladder Minimal side effects Acceptable costs
Drug utilisation is increasing
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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

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New OAB Medication

• Effectiveness
• Side effects
• Cost
• Role

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Newer drugs for OAB
Solifenacin
Tolteradine
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Ditropan XL

• Longer acting Oxybutinin formula
• Rarely used in NZ
• Similar effectiveness but less side effects

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Oxytrol Oxybutinin patches

• Available in NZ
• Similar effectiveness but less side effects
• Dose 2 patches per week
• Cost 80 - 120 per month

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Comparison oral vs transdermal Oxybutinin
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Tolterodine Detrusitol

• M2 and M3 selective anticholinergic
• studied in adults and children
• similar effectiveness to Oxybutinin
• less side effects
• bid dose 2 to 4 mg
• Cost 80 - 120 per month

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Comparison Oxybutinin and Tolteradine
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Solifenacin Vesicare

• M3 selective anticholinergic
• studied in adults
• similar effectiveness to Oxybutinin
• less side effects
• once daily dose 5 or 10 mg
• Cost 80 - 120 per month

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Cost of medication

• 80 - 120 per month
• dependant on pharmacy and location
• occasional company discount

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Darifenacin Enablex

• M3 antagonist
• not available in NZ
• bid dose

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Comparison M3 receptor antagonists
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Role of anticholinergics in NZ
Oxybutinin fully funded All other drugs equal and
similar efficacy All 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 effects Patient will need to
pay
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Duloxotine for SUI

• Serotonin NE uptake inhibitor
• anti depressant
• 10 RCT showing 50 effective in reducing SUI..
  Not curative
• Improved Qol
• Significant side effects 20 withdrawl
• Summary No role in SUI treatment

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The End