The Best Drug Therapies for Urgency Urinary Incontinence

Article

In a new systematic review, researchers studied the benefits and harms of pharmacological therapies for overactive bladder in women.

Appropriate treatment of urgency urinary incontinence (UI) is largely dependent on the severity of symptoms and how much they interfere with one’s quality of life. Medication, retraining, and surgery are the 3 main treatment approaches for urge incontinence. In a new systematic review, researchers studied the benefits and harms of pharmacological therapies for urge incontinence in women.1 The results are consistent with those of other similar studies, according to the authors.

Study findings showed that when compared with placebo, medications are strongly associated with an increase in the rates of continence and clinically important improvement in UI symptoms.1 However, the available medications provide only limited effectiveness and the overall benefits are small. For every 1000 women treated with medication, fewer than 200 achieve continence. Of significance is that discontinuation rates were higher for certain drugs, suggesting that medication choice should be based on an agent’s adverse effect profile since the benefits of all urgency UI medications are similar (Table).

Medication
Conclusions (Strength of Evidence)
Darifenacin
7.5-mg and 15-mg doses improved urgency UI and several domains of quality of life compared with placebo (High); 30-mg dose offered no additional benefits but increased rates of adverse effects (High); caused more adverse effects, including constipation, dry mouth, dyspepsia, and headache, than placebo (Moderate); discontinuation rates were similar for darifenacin and placebo (High).
Fesoterodine
Better response with 8-mg dose than with 4-mg dose, but adverse effects were more common with the higher dose (High); compared with placebo, fesoterodine had higher rates of adverse effects and treatment discontinuation because of adverse effects (High); improved quality of life (Low).
Oxybutynin
Increased continence rates and improved UI (High); increased treatment discontinuation due to adverse effects; dry mouth was most common (High); immediate-release formulation had greater rates of adverse effects compared with oral controlled-release or transdermal formulations (Low); higher vs lower doses had greater improvement in UI, the same rates of dry mouth, and greater rates of treatment withdrawal (Low).
Solifenacin
Increased continence rates and greater benefits with higher dose in women with urgency and mixed UI (High); increased risk for dry mouth, constipation, and blurred vision (High); 10-mg dose increased risk for severe dry mouth and constipation (High); resulted in treatment discontinuation due to adverse effects more often than did placebo (High).
Tolterodine
Increased continence rates and improved UI (High); improved quality of life (Low); adverse effects, including autonomic nervous system disorders, abdominal pain, dry mouth, dyspepsia, and fatigue, were significantly more common compared with placebo (High); discontinuation rates were similar to those for placebo (High).
Trospium
Increased continence rates (High); dry mouth, dry eye, dry skin, and constipation occurred more often than with placebo (Moderate); adverse effects resulted in treatment discontinuation more often than did placebo (High).
 
Adapted from Shamliyan T et al. Ann Intern Med. 2012.

Poor adherence to UI treatments is a significant problem. More than 50% of patients stop taking UI medications after 1 year.2 Most patients discontinue treatment because of adverse effects. Solifenacin, at a dose of 5 mg, is associated with the lowest rates of discontinuation.2 Solifenacin is also often beneficial to women whose previous treatments have failed, but dose increases provide no benefit.1 Oxybutynin, trospium, and darifenacin were better for improving UI symptoms in older women. Trospium was the best treatment option for women taking concomitant medications. Patients taking 7 or more concomitant medications were most likely to experience adverse effects. Future research should focus on which factors might improve adherence rates.

Pertinent Point:
- Treatment choice should be based more on the medication’s adverse effects profile, because the benefit profiles of all medications for urgency UI are similar.

 

References:

1. Shamliyan T, Wyman JF, Ramakrishnan R, et al. Benefits and harms of pharmacologic treatment for urinary incontinence in women. Ann Intern Med. 2012;156:861-874.
2. Cordozo L, Thorpe A, Warner J, Sidhu M. The cost-effectiveness of solifenacin vs fesoterodine, oxybutynin immediate-release, propiverine, tolterodine extended-release and tolterodine immediate-release in the treatment of patients with overactive bladder in the UK National Health Service. BJU Int. 2010;106:506-514.

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raanan meyer, md
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