NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update

Reviewing the need for urinary incontinence medications

Urinary incontinence is common; SIGN estimates that 5-9% of the Scottish population have significant problems with urinary continence. There should be a trial of lifestyle interventions and pelvic floor exercise training or bladder training as appropriate, before a medicine is started.

 

Pharmacotherapy is often initiated to alleviate symptoms and then prescribed continuously as repeat medication. If pharmacological therapy is initiated, the response to antimuscarinic treatment should be reviewed after 4-8 weeks and after appropriate titration. NICE advises that if the first treatment agent is not effective or well-tolerated, another drug with the lowest acquisition cost should be offered. If medicines are found to be ineffective at this stage, they should be discontinued.

 

For ongoing treatment, there should be a regular review of effectiveness, at least every 6-12 months. Patients can be advised to take a ‘drug holiday’ for 2-3 weeks and if successful discontinue treatment. Special consideration or advice may be needed for stopping therapy for patients with Parkinson’s disease, multiple sclerosis or spinal cord injury as these indications may be the underlying cause of the incontinence.  

 

Patient safety issues and polypharmacy

Antimuscarinics are one of the key drug groups that are poorly tolerated in frail adults. The elderly are more likely to experience adverse effects such as falls and impaired cognitive function. Consider other factors which may influence the patient’s condition and response to treatment, eg excessive intake of fluid. These drugs, especially oxybutynin, should be used with caution in older patients with evidence of potential cognitive impairment.

 

Formulary Preferred List choices

 

Drug Drug Tariff price per month (January 2015)
Oxybutynin (standard release tablets) £1.60 - £4.75
Tolterodine (standard release and modified release) £2.94 - £12.94
Solifenacin    £27.62 - £35.91
   

                                                                                           

Total Formulary choices

  • Fesoterodine fumarate
  • Oxybutynin modified release tablets, oxybutynin transdermal patch (Restricted to specialist initiation)
  • Duloxetine (Restricted to specialist initiation)
  • Mirabegron
  • Trospium (Moved from the Preferred List to the Total Formulary in April 2015)

 

Key Points

  • There are safety concerns when prescribing antimuscarinics for the frail elderly as they have a higher risk of falls and cognitive impairment
  • Standard release preparations are significantly less expensive than modified release preparations. Where standard release preparations have been tried and failed or are not tolerated, then tolterodine modified release should be considered as the next alternative.
  • Patients should take the lowest effective dose since the side effects are dose-related and higher doses may produce only a small increase in benefit
  • Assess response to therapy 4-8 weeks after initiation and titration.
  • Review patients regularly at 12 month intervals (6 months when aged over 75) to assess need for continued therapy. This is one of the issues that should be covered when completing a polypharmacy review.

 

 

With thanks to NHS Ayrshire and Arran for allowing use of material from Prescribing Plus October 2014.

 

A summary of some of the work carried out in NHS Ayrshire and Arran has been published in the International Journal of Pharmacy Practice (poster 91) which provides some evidence to support clinical disinvestment