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OU Geriatrics Spring 2018 > Pharmacotherapy of Urinary Incontinence in the Elderly > Flashcards

Pharmacotherapy of Urinary Incontinence in the Elderly Flashcards

1
Q

Causes of urge incontinence

A
  • infection
  • neurologic disorder
  • diabetes
  • acetylcholinesterase inhibitors
  • diuretics
  • lithium
  • caffeine
  • alcohol
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2
Q

Causes of functional incontinence

A

neurological injury

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3
Q

Causes of urinary retention

A
  • Alpha 1 receptor agonist especially in men (i.e. phenylephrine, phenylpropanolamine, clonidine, guanfacine)
  • Drugs with anticholinergic side effects (i.e. antihistamines, antiparkinsonian agents, antidepressants, antipsychotics)
  • Beta-agonist, narcotics
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4
Q

Causes of urethral underactivity

A
  • Alpha 1 receptor antagonists (in women – carvedolol, labetolol , mirtazepine, tarazosin, doxazosin)
  • ACE inhibitors which induce cough
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5
Q

T/F; For both urge incontinence and stress incontinence, bladder training and pelvic floor muscle training are important components of therapy

A

True

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6
Q

General Principles to Guide Pharmacotherapy of Urge Incontinence (UI)

A
  • start medications on lowest possible dose to minimize common side effects
  • allow sufficient time to adequately assess efficacy
  • concomitant behavioral therapy may enhance drug response
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7
Q

What are the anticholinergics used in UI?

A
  • Oxybutynin
  • Tolterodine
  • Trospium chloride
  • Solifenacin succinate (VESIcare*)
  • Darifenacin hydrobromide (Enablex*)
  • Fesoterodine (Toviaz*)
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8
Q

Oxybutynin

A
  • Immediate Release (Ditropan* and generics) – Geriatric Patients: 2.5 to 5 mg up to three times daily. Change dose no more frequently than once per month
  • Extended Release (Ditropan XL* and generics) – 5 mg once per day. Change doses no more frequently than once per month
  • Transdermal patch– twice weekly (Alleged decreased anticholinergic effects)
  • Gel (Gelnique*) – daily application (Alleged decreased anticholinergic effects)
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9
Q

Tolterodine

A
  • Immediate Release (Detrol* and generics) – Geriatric Patients: 1 to 2 mg twice daily. Change dose no more frequently that once per month
  • Extended Release (Detrol LA* and generics) – Geriatric Patients: 2 to 4 mg daily. Change dose no more frequently than once per month
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10
Q

Trospium chloride

A
  • 20 mg BID
  • Dose should probably be 20 mg q d in patient over 75 years of age as renal function may be decreased
  • ER -> 60 mg
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11
Q

Solifenacin succinate (VESIcare*)

A
  • 5mg once per day

- Drug interaction with potent 3A4 inhibitors (clarithromycin, ketoconazole, ritinovir)

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12
Q

Darifenacin hydrobromide (Enablex*)

A
  • 7.5 to 15 mg once per day

- Drug interactions with potent 3A4 inhibitors

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13
Q

MOA of anticholinergics

A

Muscarinic receptor antagonists acting on the smooth muscle of the bladder to decrease bladder contractility and increase bladder capacity

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14
Q

Toxicity of Anticholinergics in Urge Incontinence

A
  • Drop out rate for oxybutynin IR = 20% due most often to severe dry mouth (xerostomia) leading to taste disturbance, anorexia, difficulty chewing, esophogeal dysmotility, etc.
  • Drop out rates for oxybutynin XL and the tolterodine compounds are less than 10% with dry mouth remaining the most common complaint
  • Other side effects expected from anticholinergics include dry eyes, blurred vision, constipation, reflux, confusion and SVT
  • Oxybutynin likely has the greatest amount anticholinergic effects
  • Tolterodine probably produces troublesome CNS effects less frequently than does oxybutynin due to the fact that it is less likely to cross the blood-brain barrier
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15
Q

Drug interactions with the UI medicationsn

A
  • potent CYP 3A4 inhibitors such as macrolide antibiotics (clarithromycin), imidazole antifungal agents, ritinovir –> decrease dose of tolterodine, solifenacin, darifenacin and fesoterodine by 50%
  • antacids and PPIs interact with tolterodine LA
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16
Q

UI drug uses in other disease states

A
  • Contraindicated in narrow angle glaucoma

- With Alzheimer’s disease -> enhanced sensitivity to CNS side effects; use of ACh-inhibitors lead to OAB

17
Q

Role of Estrogens in Urge Incontinence

A
  • Indicated for treatment of OAB associated with atrophic vaginitis or urethritis
  • Oral therapy with estrogen and progestin – ineffective and may worsen OAB (Womens Health Initiative)
  • Topical therapy with intravaginal estrogen tablets (63% improvement vs. 32% placebo)
  • Recurrent vaginitis – estrogen cream one to two times per week
18
Q

Other Agents Used in Urge Incontinence

A
  • Tricyclic antidepressants

* Mirabegron (Myrbetriq*)

19
Q

Tricyclic antidepressants

A
  • No more effective than oxybutynin, more risk, use only as last resort
  • Notripytyline (Aventyl*)
  • Desipramine (Norpramin*)
20
Q

What is considered ineffective for the treatment of UI?

A

– Flavoxate (Urispas*)

– Propantheline (Pro-Banthine*)

21
Q

What has insufficient information on efficacy in UI?

A

– Hyoscyamine (Anaspaz*)

– Dicyclomine (Bentyl*)

22
Q

Mirabegron (Myrbetriq*)

A

– Beta 3 receptor agonist: Relaxes detrusor muscle thereby increasing bladder capacity
– Thought to be similar in efficacy to tolterodine – No anticholinergic side effects, thus may be better tolerated
– Side effects: HTN (8%), headache (3%) – Dose: 25 mg per day, may increase to 50 mg per day after 8 week
– Inhibitor of CYP2D6 – metoprolol, flecainide

23
Q

Pharmacotherapy of Stress Incontinence

A

• No more effective than bladder training
therapy, pelvic floor muscle training (Kegel exercises) and pessaries
• Alpha-1 receptor agonists
• Estrogen Therapy
• Combined estrogen therapy with alphaagonists better than either alone
• Last resort – tricyclic antidepressants

24
Q

Pharmacotherapy of Stress Incontinence: Alpha-1 receptor agonists

A

– Ephedrine 25 mg bid
– Pseudoephedrine 15 to 45 mg tid
– Toxicity: CNS stimulation
– Relatively contraindicated in elderly with HTN, angina, or MI
– Contraindicated in narrow angle glaucoma

25
Q

Estrogen Therapy

A

– No proven role for oral therapy

– Topical therapy seems logical but insufficient evidence to determine its role

26
Q

Pharmacotherapy of Urinary Incontinence due to BPH

A
  • Lifestyle modification, reduced fluid intake and identify and treat reversible causes.
  • avoid exacerbating medications, alcohol and caffeine
  • Alpha -1 receptor antagonists
  • Antiandrogens (5- ARI)
  • Saw palmetto
  • Other: Tadalafil (Cialis*) – 5 mg/day
  • Combination of alpha-1 receptor antagonist and antiandrogen – Improve symptoms of BPH more effectively than either agent alone, preliminary impression
27
Q

Lower Urinary Tract Symptoms (LUTS)

A
  • Mild LUTS (AUA-SI < 8) or moderate or severe LUTS (AUA-SI score ≥8) without symptoms: Watchful waiting (active surveillance) should be implemented; follow up in 1 year or as clinically indicated
  • Bothersome LUTS (AUA-SI ≥ 8): Initiate basic treatment with lifestyle modifications, reduce fluid intake, and examine reversible causes (i.e., medication)
  • Bothersome LUTS (AUA-SI ≥ 8) despite basic treatment: Initiate detailed drug treatment based on symptoms
  • LUTS without BOO (urgency)
28
Q

treatment of bothersome LUTS

A

– Bladder outlet obstruction (BOO) and OAB (urge incontinence): Initiate alpha-1 blocker ± anti-muscarinic agent
– BOO with small prostate size/low PSA (≤ 1.4 ng/mL): Initiate alpha-1 blocker
– BOO with large prostate size/high PSA (> 1.5 ng/ mL): Initiate alpha-1 blocker, 5-ARI, or combination

29
Q

Pharmacotherapy of Urinary Incontinence due to BPH: Alpha-1 Receptor Antagonists

A
  • MOA: Relax smooth muscle tone in bladder neck, proximal urethra and prostate
  • Terazosin (Hytrin*) – 1 to 5 mg q.h.s.
  • Doxazosin (Cardura) – 1 to 5 mg q.h.s. • Tamsulosin (Flomax) – 0.4 to 0.8 mg q.d. (30 minutes after the same meal each day)
  • Alfuzosin (Uroxatral*) – 10 mg q.d.
  • Silodosin (Rapaflo*) – 8 mg q.d. with a meal
  • Response to a particular dose is typically seen within two to three weeks
  • Although there are slight differences in the adverse events profiles of these agents, all four (not including silodosin) appear to have equal clinical effectiveness.
  • Postural hypotension – dose related and less likely with tamsulosin and alfuzosin due to preferential binding in prostatic sites
30
Q

Pharmacotherapy of Urinary Incontinence due to BPH: Alpha-1 Receptor Antagonists and Antiandrogen (5-ARI)

A

Dutasteride and Tamsulosin (Jalyn*)

31
Q

Pharmacotherapy of Urinary Incontinence due to BPH: Antiandrogen

A

• Fenasteride – MOA: a 5 alpha-reductase inhibitor which inhibits the conversion of testosterone to dihydrotestosterone upon which the prostate depends for growth
– Dose: 5 mg per day – Decreases prostate volume by 24 to 27% with the greatest effect seen in patients with prostate enlargement
– Symptom improvement: 30% – Maximum benefit: 6 to 12 months – Decrease PSA by 50% (Multiply X 2), Sexual dysfunction
• Dutasteride (Avodart*)
– Dose – 0.5 mg per day

32
Q

Pharmacotherapy of Urinary Incontinence due to BPH: Saw Palmetto

A 
– MOA: Similar to fenasteride 
– Dose: 320 mg per day 
– Efficacy: Similar to fenasteride 
– Well tolerated > fenasteride 
– Non-legend drug therefore purity and potency may vary between brands

OU Geriatrics Spring 2018 (9 decks)

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