Overactive Bladder - Medication Pathway for Treatment of

Publication: 05/12/2013  --
Last review: 15/03/2018  
Next review: 15/03/2021  
Clinical Guideline
CURRENT 
ID: 3590 
Supported by: LTHT D&T
Approved By: Leeds Area Prescribing Committee 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Leeds Overactive Bladder Medicine Treatment Pathway

 

Which patients should be initiated on the overactive bladder (OAB) medication pathway?

This pathway is for patients who have failed conservative management for their overactive bladder symptoms. This includes trials of both lifestyle interventions and physical therapies. Patients should have undergone at least 3 months of conservative management prior to the initiation of drug therapy

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General Principles when using OAB drugs

Before treatment starts discuss

  • The likelihood of success and common adverse effects including cognitive impairment
  • The frequency and route of administration
  • Adverse effects such as dry mouth and constipation may indicate that treatment is starting to have an effect.
  • That they may not see the full benefits until they have taken the treatment for at least 4 weeks
  • the long-term effects of anticholinergic medicines for overactive bladder on cognitive function are uncertain

Do not use Flavoxate, Propantheline or Imipramine for treatment of urinary incontinence or overactive bladder in women

Do not offer oxybutynin (immediate release) to older women who may be at higher risk of a sudden deterioration in their physical or mental health.

If the first medicine for overactive bladder or mixed urinary incontinence is not effective or well-tolerated, offer another medicine with a low acquisition cost.

Offer a transdermal overactive bladder treatment to women unable to tolerate oral medicines.

The use of Desmopressin may be considered specifically to reduce nocturia in women with urinary incontinence or overactive bladder who find it a troublesome symptom. Use particular caution in women with cystic fibrosis and avoid in those over 65 years with cardiovascular disease or hypertension.

 

Desmopressin Contra-indications:
Cardiac insufficiency; conditions treated with diuretics; history of hyponatraemia; polydipsia in alcohol dependence; psychogenic polydipsia; syndrome of inappropriate ADH secretion (in adults)
Desmopressin Cautions:
Asthma; avoid fluid overload; cardiovascular disease (not indicated for nocturnal enuresis or nocturia); conditions which might be aggravated by water retention; cystic fibrosis; elderly (avoid for primary nocturnal enuresis and nocturia associated with multiple sclerosis in those over 65 years) (in adults); epilepsy; heart failure; hypertension (not indicated for nocturnal enuresis or nocturia); migraine; nocturia—limit fluid intake to minimum from 1 hour before dose until 8 hours afterwards; nocturnal enuresis—limit fluid intake to minimum from 1 hour before dose until 8 hours afterwards
Should not be given intranasally for nocturnal enuresis due to an increased incidence of side-effects
Elderly:
Elderly patients are at increased risk of hyponatraemia and renal impairment—manufacturer advises measure baseline serum sodium concentration, then monitor regularly during treatment; discontinue treatment if levels fall below the normal range. Review treatment if no therapeutic benefit after 3 months

Do not offer systemic hormone replacement therapy to treat urinary incontinence.

Offer intravaginal oestrogens to treat overactive bladder symptoms in postmenopausal women with vaginal atrophy.

Use caution when prescribing antimantimuscarinics for patients with Alzheimer’s

Take into account coexisting conditions (such as poor bladder emptying, cognitive impairment or dementia), the use of other existing medication affecting the total anticholinergic load and the risk of adverse effects (For anticholinergic profile of commonly prescribed drugs see https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-015-0029-9)

Anticholinergic burden should be considered at every stage

Offer a face-to-face or telephone review 4 weeks after starting a new medicine for overactive bladder. Ask the woman if she is satisfied with the treatment and:

  • If improvement is optimal, continue treatment
  • If there is no or suboptimal improvement, or intolerable adverse effects, change the dose or try an alternative medicine for overactive bladder and review again 4 weeks later.

Offer a review before 4 weeks if the adverse events of a medicine for overactive bladder are intolerable.

Offer a further face-to-face or telephone review if a medicine for overactive bladder or urinary incontinence stops working after an initial successful 4-week review.

Offer a review in primary care to women who remain on long-term medicine for overactive bladder or urinary incontinence every 12 months, or every 6 months if they are aged over 75.

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Contraindications to Antimuscarinic

Angle closure glaucoma
Myasthenia gravis
Severe ulcerative colitis
Intestinal obstruction
Toxic megacolon

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Contraindication to Mirabegron

Uncontrolled hypertension systolic BP≥180mmHg and /diastolic ≥110mmHg

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Additional drug info can be located at

http://www.leedsformulary.nhs.uk/
http://www.medicines.org.uk/emc/
http://www.nice.org.uk/cg97
http://guidance.nice.org.uk/CG171
https://www.gov.uk/drug-safety-update/mirabegron-betmiga-risk-of-severe-hypertension-and-associated-cerebrovascular-and-cardiac-events

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First line Antimuscarinic drug treatment (Box A treatment pathway)

Offer one of the following choices first for OAB or mixed urinary incontinence - (do not offer oxybutynin immediate release to frail elderly patients)

  • Oxybutynin (immediate release) or
  • Tolterodine (immediate release) or

If the first line treatment for OAB or mixed urinary incontinence is not effective or well tolerated, offer another drug with a lower or similar acquisition cost while taking into account anticholinergic burden and poly pharmacy.

To help inform prescribing decisions all antimuscarinics are price linked to the Leeds net formulary

http://www.leedsformulary.nhs.uk/docs/7.4.2urinaryincontinencecosts(NICE).pdf?UNLID=734700187201746133212.

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Second line Antimuscarinic drug treatment (Box B treatment pathway)

Patients considered not be candidate for NICE recommended first line treatment can be initiated on an antimuscarinic from Box B of the drug pathway. The second line agents of choice are;

  • Solifenacin
  • Trospium

Patients should be trialled on two antimuscarinics before moving to mirabegron Treatment failure with one or even several drugs in the same class does not imply that the entire class will be ineffective for a particular patient

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What constitutes treatment failure? – Always consider referral to secondary care after treatment failure

  • Unsatisfactory reduction in number or 24 hour voids
  • Unsatisfactory reduction in number of episodes of frequency, urgency, and urge incontinence
  • Intolerable side effects
  • Unsatisfactory improvement in patient’s quality of life

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What is Mirabegron?

Mirabegron is a B3 adrenoceptor agonist, which activates B3 adrenoceptors causing the bladder to relax which helps it to fill and store urine.

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Which patients should be commenced on Mirabegron?

Mirabegron is recommended as an option for treating the symptoms of overactive bladder for people in whom antimuscarinic drugs are contraindicated or clinically ineffective, or have unacceptable side effects.

Mirabegron is also recommended when the risk of anticholinergic burden (ACB) outweighs the expected benefit of starting OAB anticholinergic therapy Offer referral to secondary care if the patient does not want to try another drug but would like to consider further treatment

Mirabegron dose needs to be adjusted in patients with renal or hepatic impairment (Check BNF for the appropriate dose before prescribing)  

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Patients not suitable for mirabegron - consider for referral to Urology/Urogynecology

  • Patients with severe renal impairment (eGFR 15 to 29 mL/min/1.73 m2) concomitantly receiving strong CYP3A inhibitors
  • patients with severe hepatic impairment (Child-Pugh Class C) or patients with moderate hepatic impairment (Child-Pugh B) concomitantly receiving strong CYP3A inhibitors
  • Patients with severe uncontrolled hypertension (SBP ≥ 180 mm Hg and/or DBP ≥ 110 mm Hg). Data is limited in patients with stage 2 Hypertension (SBP ≥ 160mmHg or DBP ≥ 100mmHg). Mirabegron can increase blood pressure therefore blood pressure should be monitored at baseline and periodically
  • Caution use in patients with a known history of QT prolongation or in patients who are taking medications which are known to prolong the QT interval.

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Summary of Side effects profile for overactive bladder medications

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Antimuscarinics

  • Dry mouth/eyes
  • Blurred vision
  • Urinary retention
  • Constipation

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Beta 3-adrenoceptor agonist (Mirabegron)

  • Urinary tract infection
  • Tachycardia

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Provenance

Record: 3590
Objective:
Clinical condition:

Overactive bladder

Target patient group:
Target professional group(s): Pharmacists
Secondary Care Doctors
Primary Care Doctors
Midwives
Adapted from:

Evidence base

Not supplied

Approved By

Leeds Area Prescribing Committee

Document history

LHP version 1.1

Related information

Not supplied

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