Are we shortchanging frail older people when it comes to the pharmacological treatment of urgency urinary incontinence?

Overactive bladder and urgency incontinence are common and distressing conditions in older people, for which the first‐line pharmacological treatment is a bladder antimuscarinic agent. Of these, oxybutynin is often recommended in guidelines, but is associated with a higher incidence of adverse drug effects, and in particular has been suggested to have deleterious cognitive effects. Despite this, guidelines often suggest oxybutynin as first‐line treatment, and insurance based healthcare systems often require oxybutynin to be used as a first‐line therapy and fail before reimbursement for the cost of newer anticholinergics is authorised. We reviewed the literature of bladder antimuscarinics in older adults, using the headings overactive bladder, urinary frequency, urgency, urge, oxybutynin, antimuscarinic, older, older people, and frail. In general, oxybutynin had a similar efficacy to other anticholinergic drugs, but a higher incidence of adverse drug events, in particular significant yet unnoticed cognitive impairment. We conclude that oxybutynin should not be used in frail older people.     

The periodontal status of subjects receiving non-steroidal anti-inflammatory drugs

A test group of 22 subjects who had been taking non-steroidal anti-inflammatory drugs for periods in excess of one year were matched with a control group of 22 office workers with reference to age and Plaque Index. It was found that the test group had significantly lower values of Gingival Index and shallower depths of pockets than the control group of subjects. There was a trend also for there to be less loss of attachment in the test group. These results were interpreted as indicating that anti-inflammatory drugs may influence the response of the periodontal tissues to plaque by reducing the prostaglandin concentration in the tissues. The slight decrease in loss of attachment in the test group may also be explained by the reduction in prostaglandin synthesis in the subjects taking anti-inflammatory drugs.     

The extent and severity of urinary incontinence amongst women in UK GP waiting rooms

INTRODUCTION: Few women seek help for urinary incontinence. Subsequently, there may be many women accessing primary care services who would benefit from treatment or advice. If high levels of unexpressed need are present in this population, a more proactive approach to continence management may be appropriate, but the feasibility of this depends on an accurate assessment of the level of unmet need in this population. AIM: To assess the prevalence of urinary incontinence in a female population attending primary care and the extent of treatment seeking in relation to level of need. METHODS: A cross-sectional survey of urinary incontinence of adult women attending primary care practices in West Yorkshire, London, Glasgow and Leicestershire during a 10- or 15-day period. RESULTS: Three thousand two hundred and seventy-three (54%) women responded. Twenty-one per cent reported stress urinary incontinence only, 3.5% reported urge incontinence only and 21% reported mixed stress and urge incontinence during the preceding month (9% had moderate or severe symptoms). Fifty-three per cent of these had not consulted a health care professional, which is equivalent to 1 in 20 of women in GP waiting rooms, most of whom have stress and urge incontinence (75%) or stress incontinence only (21%). CONCLUSIONS: Nearly half of female primary care attendees had experienced incontinence during the preceding month, but only a minority had sought help. Even amongst the nearly 1 in 10 women with moderate or severe incontinence only about half had sought help. There remains considerable health decrement due to urinary incontinence in those not receiving help in a population readily accessible to primary care services.     

Oral pharmacotherapy for overactive bladder in older patients: mirabegron as a potential alternative to antimuscarinics

Objective Overactive bladder (OAB) is a particular challenge to treat in older adults with co-morbid conditions taking multiple medications. Antimuscarinics (e.g., solifenacin, fesoterodine) and β₃-adrenergic receptor agonists (mirabegron) are similarly efficacious; however, antimuscarinics may be associated with side effects that result in poor persistence and contribute to anticholinergic burden, particularly in those taking other medications with anticholinergic properties. With a mechanism of action distinct from antimuscarinics, mirabegron has a different tolerability profile and does not contribute to anticholinergic burden. The objective of this review was to compare and contrast the tolerability profiles of antimuscarinics and mirabegron in older patients to inform practice.

Methods Prospective trials or retrospective subgroup analyses of antimuscarinics for the treatment of OAB in older patients were identified through a search of PubMed. Tolerability data and results of subgroup analyses of mirabegron in patients aged ≥65 and ≥75 years from a pooled analysis of three trials each of 12 weeks and a 1 year trial are described.

Results Anticholinergic adverse events (AEs) including dry mouth and constipation were more frequent with antimuscarinics versus mirabegron. In patients aged ≥65 years, dry mouth occurred with a six-fold higher incidence with tolterodine extended-release (ER) 4?mg than with mirabegron 25?mg or 50?mg over 12 weeks, and a three-fold higher incidence with tolterodine ER than mirabegron 50?mg over 1 year. Mirabegron had a low incidence of central nervous system effects. A systematic review of the cardiovascular safety profile of mirabegron has not identified any clinically significant effects on blood pressure or pulse rate at therapeutic doses amongst patients aged ≥65 years.

Conclusions Mirabegron has a more favorable tolerability profile than antimuscarinics amongst older patients and may provide an improved benefit-to-risk ratio and therefore be considered as an alternative to antimuscarinics for older patients.