How do you manage noncompliant OAB patients?

June 13, 2018

“Unless there’s a contraindication, they have to try medications. ‘I don’t feel like taking it’ is not failing a medication,” says one urologist.

Urology Times reached out to three urologists (selected randomly) and asked them each the following question: How do you manage noncompliant OAB patients?

“First, it’s important to figure out why a patient is noncompliant. Is medication too expensive? Are there side effects? Patients are usually noncompliant, not because they choose not to take care of themselves, but because of side effects or cost.

If noncompliance is financial, that’s probably the harder issue. If people want to take medicine and can’t afford it, we have to go through insurance to find out what’s covered. In South Florida, a lot of HMOs don’t pay for a lot of medications, or older patients find themselves in the so-called doughnut hole where they reach a certain point of medication spending, insurance drops out and they can’t afford $70, $80, $90 a month.

Read: Nocturia Tx shows efficacy in elderly patients

If we’re lucky enough to have samples and it’s a doughnut-hole issue, we can maybe get them to the end of the year with samples.

If the problem is side effects, I try to move them quickly to third-line therapy if it’s appropriate.

If there are legitimate side effects after trying at least two of the OAB medicines, I go to third-line therapies. Unless there’s a contraindication, they have to try medications. ‘I don’t feel like taking it’ is not failing a medication. I explain we have to follow AUA guidelines. A lot of smart people decided this is the best way to manage patients. So they have to try it.

I’m not going to third-line therapy just because someone doesn’t feel like taking a pill.”

Yvonne Koch, MD

Miami Beach, FL

Next:"What I normally do is take it to the next step"“It depends how much patients want to be treated. Some patients get better and decide they don’t need to take medication anymore. Sometimes it’s because of side effects, sometimes cost, and sometimes people just have an aversion to taking medication.

Also see: Many OAB patients not receiving advanced therapy

What I normally do is take it to the next step. If they’re noncompliant with medications, I offer them PTNS. That basically takes side effects out of the equation, but does require patient time commitments-coming into the office once a week for 3 months, then monthly after that. Some patients find it refreshing; they don’t have side effects or the cost, and it’s similar to acupuncture so in a way, it's sort of natural.

Then there’s Botox and the patient doesn’t have to see you in the office or take a medication for several months. The downside is they need an injection every 4 to 6 months, but they avoid side effects.

Sometimes patients who like PTNS don’t like coming into the office, or can’t, because of transportation or other issues. I tell them to go on Amazon and buy a TENS unit. It works like PTNS, but patients can do it themselves. They put the stickers on their ankle and stimulate themselves while watching TV. People are more open to treating themselves at home and it helps with symptoms.

Read: Botulinum reinjection does not increase CIC risk

The downside is we’re not there to monitor to make sure they’re doing it correctly and getting the results they should be getting. But it sometimes works for patients whose insurance doesn’t cover PTNS.”

Shahrad Aynehchi, MD

Inglewood, CA

Next:"We’re still in the process of formalizing our navigator position, but we think patient satisfaction levels are much higher than before"“Fifteen years ago, we started UroPoint Bladder Control Centers, which include incontinence specialists-urologists, uro-gynecologists, and advanced practice providers who work as a team to deliver care for patients with OAB and other lower urinary tract voiding dysfunction problems. But we still had the same issues as other practices with patients not staying on medications or returning for follow-up. That’s why we met 3 years ago with UroGPO and a work group of 13 practices to develop a consensus on a clinical pathway for OAB.

The group recognized that there was really a need to have a navigator plugged in from the start, to make sure patients come back for their appointment, check on how they’re doing, the efficacy of their medication, side effects, and to encourage patients to stay with behavior modification therapies, even adjust medications if the patient is not doing well.

Also see:Beta-3 agonist significantly reduces urge incontinence

That immediate follow-up seems to make a difference. One thing that stimulated the UroGPO meeting was a study that showed only 40% of OAB patients complied with their treatment. That was pretty uniform across the country. We all found that shocking.

We’re still in the process of formalizing our navigator position, but we think patient satisfaction levels are much higher than before. We haven’t had time to measure the results of having a navigator, but a Nashville group showed improvement to a 60%-70% return rate. That’s a 40%-50% improvement.”

Peter Knapp, MD

Indianapolis

 

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