Drs MacDiarmid and Rogers discuss treatment for OAB and the use of care pathways to treat patients.
Alexandra Rogers, MD: Scott, how often are your fellow urologists following the AUA [American Urological Association] or ICS [International Continence Society] guidelines for the treatment of overactive bladder [OAB]?
Scott MacDiarmid, MD, FRCPSC: It’s interesting, I don’t know the exact number. The guidelines are important. We have very good guidelines, to the best that we can. Overactive bladder has reasonable data, but as you know, every patient with incontinence is different. It’s not PSA [prostate-specific antigen] and objective findings. The science is a little soft to make firm statements like, “Yes, do this.” There tends to be a lot of words like optional. If you want to do something, you can. But [the guidelines] are an excellent template that all my colleagues are familiar with, especially because you have to study them to pass your boards and recertify. They’re well aware of them, but we have to recognize the word optional. We have to recognize that urologists and urogynecologists practice differently. Some like urodynamics, while some don’t. They’re using the guidelines as their basis and using them how they like to.
Let’s keep moving on with treatment. Why don’t you touch on behavioral therapy?
Alexandra Rogers, MD: I’d argue that by the time a patient sees an OAB specialist like us, first-line offerings will have usually been attempted, or won’t be effective enough. I pass over that one pretty quickly. It’s certainly part of treating a patient to remind them, “I’m not giving you a bladder transplant. This doesn’t mean you can go have 10 cups of coffee. That’s not what we did for you. We’re trying to make your bladder more forgiving.” It’s important to incorporate the behavioral modifications, but it’s not effective enough, and there’s certainly a lack of evidence demonstrating that lifestyle changes help treat a patient with OAB. Then only 23% of patients adhere to pelvic floor muscle training long term, and access to a trained formal physical therapist can be very challenging in many settings.
Scott, talk us through the medication landscape and where they fit in with the patients you’re taking care of.
Scott MacDiarmid, MD, FRCPSC: I’m promedication. Obviously, they’ve been around a long time. As you know, we have the antimuscarinic [medications]. Other than fesoterodine, they’re all generic now. There are 7, 8, or 9 of them. Our audience probably knows to make them work well, it’s very hit and miss. If one doesn’t work, you try another. If one gave you adverse effects, you try another, because there’s a very heterogeneous response in an individual patient. We certainly don’t need to be cycling through multiple. When I’m trying them, I usually try 2.
Of course, they cause dry mouth and constipation. There are tolerability issues. With cognitive impairment, there are a lot more data supporting that with antimuscarinics perhaps with a higher dose or with long-term use, perhaps in older people. They’re linking it more to memory and cognitive impairment. As you know, AUGS [American Urogynecologic Society], our urogynecologists across the aisle, had a consensus statement saying this is something your patients need to be aware of. They discourage their use in women over 70, and they try to gear you toward third-line therapies and beta-3 [agents] to avoid antimuscarinics and the possibility of that adverse effect.
I’m so happy we have a second beta-3; Myrbetriq, or mirabegron, has been a wonderful drug. It helps us drive excellence and help our patients. It’s so well tolerated; it really helps. And now that we have a second one, I’ve noticed from my experience with the new medication that there’s also a heterogeneous response where if one doesn’t work, they can hit a home run with the second one. Not every time, but that’s going to make us better doctors if we have more than 1 beta-3, if they have a differential function in some individuals. We’re certainly glad to have that. Of course, we’re going to go through co-pay issues for a while, but in North Carolina, we’ve managed that pretty well.
Alexandra Rogers, MD: Yes, I couldn’t agree more. The newest beta-3 agonist, Gemtesa, has been a fabulous addition, given the reduction in noise about possible adverse effects.
I’ve been using care pathways pretty aggressively since Melissa Kaufman, [MD, PhD, FACS,] pointed out the need for them at a meeting over 5 years ago at SUFU [Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction meeting]. I try to make it just a 1-page summary, and I give it to each patient in person so they can best prepare for their next visit, which they schedule upon leaving.
My goals are to reduce patient attrition, end pill purgatory, and increase third-line penetration so we take care of these patients and get the best adherence if you do hit a third line. Because we know when we look at the data, even among formerly FPMRS [Female Pelvic Medicine and Reconstructive Surgery]-trained surgeons, the attrition rate is 84% by the fourth visit. Certainly, these folks know how to speak about these therapies and explain them and the pros and cons, but we’re losing patients from that first to fourth visit.
A care pathway sets the stage in a patient negotiation where it’s, “You have a chronic condition, we have this menu. You’re going to walk out of here with a 2-week sample of the newest, safest medication.” That’s what I do. Everyone does it differently, if they sample, etc. I’m circling on the menu where I think they’re headed, with shared decision-making, so that if anything, these patients have a bit of hope. Because with a lot of them, I get the reaction, “What do you mean chronic medications? I’m already on 12 to 14 medications. What are the adverse effects?” There’s sometimes a lot of hesitation with medications being the option, so patients are highly encouraged when you say there are a lot of other options beyond medications. “But stick with me, come back, put this care pathway or menu on your refrigerator,” and I like that they’re circling back in even less time, at 2 weeks. Hopefully they come back and tell me what they want to do, and they’ve been much more educated than when they initially walked in, when they don’t know why they leak and think they need to be on incontinence products.
I’ve tracked my numbers over time, and I’ve found that this care pathway has held me accountable to what I’m delivering to patients and how I’m adapting when we have things like COVID-19, both acute and chronic, and then into the vaccinated phase to make sure these patients are getting treated.
Transcript edited for clarity.