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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
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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 • Effectiveness • Side effects • Cost • Role
Newer drugs for OAB Solifenacin Tolteradine
Ditropan XL • Longer acting Oxybutinin formula • Rarely used in NZ • Similar effectiveness but less side effects
Oxytrol: Oxybutinin patches • Available in NZ • Similar effectiveness but less side effects • Dose 2 patches per week • Cost: $ 80 - $120 per month
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
Comparison Oxybutinin and Tolteradine
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
Cost of medication • $ 80 - $120 per month • dependant on pharmacy and location • occasional company discount
Darifenacin [Enablex] • M3 antagonist • not available in NZ • bid dose
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
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