"Interestingly, I think physicians are aware of the potential cognitive issues associated with long-term use of anticholinergics, so when they are being used, those aspects, the potential risks and potential benefits, are considered and balanced.
Part of the problem is insurance coverage. Anticholinergics are often Tier 1 drugs, so step therapy is a problem. You have to try certain formulations or medications and fail to be eligible to use other OAB medications that may minimize or have less potential side effects or have a safer side effect profile.
There are good data on the association of anticholinergic medications and potential cognitive effects, including the 2015 JAMA paper that showed an increased risk of dementia over 7-10 years in an elderly population. Based on this, you can prescribe anticholinergics and counsel patients on potential risks or you can skip them. However, you often have to trial them in order to be eligible for other options.
There are options, and patients should be presented with all options: maximizing conservative treatments, all the medical options—anticholinergics, beta-3 receptor adrenergic receptor agonists, possibly off-label medications—and then also be educated on third-line therapies.
On the overuse of medication, the number of prescriptions probably doesn’t reflect reality. Some studies have shown about a 20%-30% compliance rate with anticholinergics in 1 or 2 years; patients don’t necessarily stay on the medication. Prescriptions may be not filled, or not tolerated after a few weeks.
Some older data show that medication is most effective if done in combination with things like urge supression, moderating fluids, and strengthening muscles. It takes time, however, for medical providers to teach patients these things and also commitment from the patient to make these changes. But it can be effective.
There’s also sacral neuromodulation (Interstim), peripheral tibial nerve stimulation (Urgent PC), and onabotulinumtoxinA (Botox). Some patients manage their symptoms conservatively, some patients will take medication and be successful, and a certain percentage will be treated with more invasive therapies and be happy.”
Una Lee, MD
“By no means. Most people who are referred to me for urinary tract infections don’t have them. They have overactive bladder that’s been undetected. Primary care doctors diagnose UTI and give them antibiotics, so those may be overused. When they don’t work, they send the patients to me.
Some medicines we use are really good—solifenacin (VESIcare), fesoterodine (Toviaz). But insurance companies don’t want us to prescribe them. We have to give the old ones first. I use a lot of oxybutynin. If that doesn’t work, I have to try tolterodine before they’ll pay for VESIcare and Toviaz.
You only have to use those until they work. A lot of patients will respond to oxybutynin; they may get dry mouth and/or constipation but they’ll get through. It would be nice, however, if you could use the better medicines with the lower side-effect profile.
In reality, I see very little cognitive damage with the anticholinergics. You read about it and the reps tell you these drugs increase or accelerate the dementia rate, but I’ve only seen a few cases. That’s why people like mirabegron (Myrbetriq); it doesn’t have that side effect. My problem is that Myrbetriq doesn’t work that well for me. VESIcare and Toviaz work better. I always go with those first if I can.
I save mirabegron until last if patients haven’t responded to anything, even urethral dilatation, which by the way is also underutilized. Somehow stretching the urethra relaxes the trigonal, and if I use it in conjunction with a month of VESIcare, I find it accelerates the resolution of symptomatology.
People in my field say you can’t prove that, and you have to use evidence-based medicine. And I say, ‘OK, I know what works on my patients.’
I also use neuromodulation with medication. Again, improvements are dramatic, and you don’t have to use the medication long term.”
Thomas Cerasaro, MD
“Personally, I don’t feel they’re being overused, at least not in our community. The problem is, we’re not the only ones prescribing them. The medications are being marketed to primary care docs, internists, OB/GYNs, so if there’s overuse, it’s probably not coming from the urologic sector. We’re going to be a little bit more deliberate or scientific about it.
I have not seen a lot of cognitive issues arising from the anticholinergics. A little bit of constipation or bowel dysfunction is the more common side effect rather than a cognitive change. I don’t have a controlled study, however.
It could also be that problems are not being conveyed to me. Quite honestly, if patients are much older, unless they’re really having complications, they are often managed either with a catheter or pads. I may not treat them because in the later stages of declining overall function, I try not to add anticholinergics to the overall potpourri of other medicines.
Also see: Do you prescribe MET for stone patients?
I have seen cognitive issues a couple times; the internist says to me, so-and-so is acting more confused. I’ll ask, ‘Is it just a deterioration of their status? Do they have Alzheimer’s? Do they have cerebrovascular dementia?’ We’ll usually say, ‘Yes, they don’t really need it. Take them off.’ So, we don’t know if it’s actually cause and effect.
More often than not, anticholinergics do work, but it’s dose related. If it’s not working, you might suggest increasing the dose, and then you’re going to get dry mouth and constipation. As medication becomes more effective, the side effects increase.”
Thomas Shook, MD
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