Overactive bladder (OAB) symptoms are among the most bothersome complaints of our elderly patients. They have substantial impact on all aspects of patients’ well–being and reduce their quality of life. This condition affects almost 12% of the adult population of Europe. The prevalence is constantly rising with age and reaches 36% in the group of patients above 75 years of age. The incidence of overactivity related incontinence reaches 28.7% and 50% respectively in men and women [1].
Muscarinic receptor antagonists still constitute the mainstay of the OAB pharmacotherapy. The efficacy of different antimuscarinics is comparable; they relieve symptoms partially and their efficacy is at best moderate. The adverse reaction profiles of muscarinic receptor antagonists used as first line treatment are comparable except for higher oral doses of oxybutynine and propiveryne [2].
The results of clinical trials show really high discontinuation rates – from 4% to 31% in 12 weeks observation. Furthermore, 43% to 81% of patients discontinue their treatment within 30 days, according to the medical claims studies [3].
Professor Kosilov and the co–authors, whose paper appeared in this edition of CEJU address the important clinical problem that is safe and effective treatment of the Overactive Bladder Syndrome (OAB) in the elderly [4].
The Vladivostok team describes the placebo controlled study that analyzes the effects of a novel scheme of treatment with anticholinergic agents (combined high dose pulse anticholinergic therapy) in elderly patients with detrusor overactivity related urinary incontinence. The authors used two compounds with antimuscarinic activity, which are currently not being studied as extensively, as those, having different mechanisms of action.
The authors observed a reduction of incontinence events (IE) and urgency episodes lasting until the end of the observation in the group assigned to the double pulse treatment arm in both incontinence severity subgroups. Similar reduction of IE and urgency episodes was observed in patients assigned to single pulse treatment arm, but only in the moderate incontinence severity subgroup. Particularly interesting is why the severtiy of symptoms remains reduced, even after treatment cessation.
When the subjects are at least in their sixties and the study drug has relatively narrow therapeutic window, the key question is the safety.
The study results revealed a low rate of adverse reactions (AR) – below 12% of patients experienced ARs. These ARs were classified as moderate. The authors provide only an overall percentage of episodes. Taking into account the high doses of study medications and the age of subjects, it is particularly important to show a detailed list of ARs, grouped by treatment arms. Due to intermittent modes of drug administration, it would also be interesting to know the ARs incidence according to the corresponding study phases. The authors claim they showed acceptable tolerance of higher doses of anticholinergics in a previous paper [5]. Unfortunately, the results of this study could be biassed by the patient selection criteria.
The next question is why the authors limited the study population to elderly patients with urge incontinence only? Wouldn't it have been safer to choose an idiopathic OAB population not narrowed to those with “wet” OAB in the elderly? The incidence of IE is not the only reliable outcome measure in OAB studies.
Invasive urodynamic studies (UDS) were performed at the beginning and the end of the evaluation. UDS results presented in the paper did not reveal much more than the clinical data and the patient reported outcomes. Please, accept this opinion from the point of view of an urodynamics enthusiast.
Overall, the authors did a real piece of work trying to look for the new possibilities in OAB treatment. They entered a good number of 313 patients into the prospective placebo controlled study. We are looking forward to see results longer than 6 months and we are also curious what there is behind the prolonged action of anticholinergics.
References
- 1.Irvin DE, Milsom I, Hunskaar S, Reilly K, Kopp Z, Herschorn S, et al. Population–based survey of urinary incontinence, overactive bladder and other lover urinary tract symptoms in five countries: results of the EPIC study. Eur Urol. 2006;50:1306–1314. doi: 10.1016/j.eururo.2006.09.019. [DOI] [PubMed] [Google Scholar]
- 2.Buser N, Ivic S, Kessler TM, Kessels AGH, Bachmann LM. Efficacy and adverse events of antimuscarnics for treating overactive bladder: network meta analises. Eur Urol. 2012;60:1040–1060. doi: 10.1016/j.eururo.2012.08.060. [DOI] [PubMed] [Google Scholar]
- 3.Sexton CC, Notte SM, Maroulis C, Dmochowski RR, Cardozo L, Subramanian D, Coyne KS. Persistence and adherence in the treatment of overactive bladder syndrome with anticholinergic therapy: a systematic review of the literature. Int J Clin Pract. 2011;65:567–585. doi: 10.1111/j.1742-1241.2010.02626.x. [DOI] [PubMed] [Google Scholar]
- 4.Kosilov KV, Lopaarev SV, Iwanowskaya MA, Kosilova LV. Effectiveness of Combined High–Dosed Trospium and Solifenacin depending on severity of OAB symptoms in elderly men and women under cyclic therapy. Cent European J Urol. 2014;67:43–48. doi: 10.5173/ceju.2014.01.art9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Kosilov KV, Lopaarev SV, Ivanovskaya MA, Kosilova LV. Management of Overactive Bladder (OAB) in Elderly Men and Women with Combined, High–Dosed Antimuscarinics without Increased Side Effects. UroToday Int J. 2013;6 art 47. [Google Scholar]