Therapeutics III - Urinary Incontinence

  1. darifenacin
  2. festoterodine
  3. oxybutinin
    Ditropan, Ditropan XL, Oxytrol, Gelnique
  4. solifenacin
  5. tolterodine
    Detrol, Detrol LA
  6. trospium
    Sanctura, Sanctura XR
  7. mirabegron
  8. List antimuscarinic agents for the treatment of over active bladder.
    • 1. darifenacin (Enablex)
    • 2. festoterodine (Tovias)
    • 3. oxybutynin (Ditropan, Ditropan XL, Oxytrol, Gelnique
    • 4. solfenacin (Vesicare)
    • 5. tolterodine (Detrol, Detrol LA)
    • 5. trospium (Sanctura, Sanctura XR)
  9. List beta agonist(s) for overactive bladder.
    mirabegron (Myrbetriq)
  10. Which receptor is associated with stimulating bladder contraction?
    mu 3 receptor
  11. Which receptor is associated with stimulating bladder relaxation?
    beta 3 receptor
  12. Which receptor is associated with stimulating urethral smooth muscle contraction?
    alpha receptor
  13. Short bursts of urine leakage often associated with activity
    -insufficient support of pelveic floor musculature and vaginal connective tissue to urethra and bladder neck
    -loss of urethral tone
    Stress incontinence
  14. involuntary loss of urine associated with abrupt or strong desire to void
    -detrusor muscle over activity
    -increased sensation in the bladder
    urge incontinence
  15. urgency with or without incontinence
    over active bladder (OAB)
  16. urinary retention
    -urethral over activity or compression
    -decreased bladder contractility
    overflow incontinence
  17. List the common causes and risk factors of chronic incontinenece
    • 1. drugs
    • 2. aging
    • 3. obesity
    • 4. vaginal delivery and higher parity
    • 5. BPH
    • 6. vaginal atrophy
    • 7. neurologic disorders
    • 8. cognitive impairment
    • 9. cancer
  18. What are the therapeutic objectives of urinary incontinence (OAB)?
    • 1. improve (NOT ELIMINATE) patient-specific symptoms
    • 2. Minimize treatment adverse effects
    • 3. Per OAB guidelines: "choosing to forego treatment is a valid decision"
    • 5. Monitoring for efficacy: Subjective reports
  19. What are the potentially correctable causes of urinary incontinence?
    • 1. stress incontinence
    •    -alpha antagonists, ACE inhibiotrs
    •    -obesity
    •    -vaginal atrophy
    • 2. urge incontinence / OAB
    •    -diuretics, caffiene
    •    -alcohol
    •    -UTI
    • 3. overflow incontinence
    •    -alpha agonists
    •    -anticholinergics, TCAs
    •    -CCBs
    •    -Narcotics
  20. Considered "FIRST LINE" based on risks/burdens in terms of invasiveness of the treatment, the duration and severity of potential adverse events and the reversibility of potential adverse events.
    Non Pharmacologic Therapy for OAB
  21. What are examples of non-pharmacologic therapy for OAB that account for 50-80% of reduction in incontinence episodes?
    • 1. bladder training
    • 2. bladder control strategies
    • 3. pelvic floor muscle training
    • 4. fluid management
  22. What are considered "SECOND-LINE" treatments after non-pharmacologic?
    • 1. antimuscurinics
    • 2. beta agonists

    (note: no evidence to support one class over the other; lack of evidence with one antimuscarinic does NOT preclude the use of a second antimuscarininc)
  23. TRUE or FALSE. Literature supports the combination therapy within and between classes

    There is no literature to support combination therapy between classes but the guidelines DO allow for trial therapy of combination drug + behavioral therapy.
  24. What is the STOPP criteria for OAB therapy?
    • -avoid antimuscarinics in dementia or chronic cognitive impairment
    • -do not use antimuscarinics and anticholinergics concurrently (supported by OAB guidelines)
  25. What is the BEERS List criteria for OAB therapy?
    • all muscarinic agents are considered "STRONG anticholinergics"
    •    -avoid in delirium and dementia
    •    -do not combine with other anticholinergics in patients with BPH
  26. What is the OAB guideline for therapy?
    • -avoid antimuscarinics in open-angle glaucoma
    • -caution against antimuscarinics in impaired gastric emptying or history of urinary retention
  27. Which OAB medication dose NOT require renal or hepatic dosing, or consideration for CYP inhibitors?
    Oxybutynin (Ditropan, Ditropan XL, Oxytrol, Gelnique)
  28. Which medications do not require renal dosing for OAB?
    • 1. darifenacin (Enablex)
    • 2. oxybutynin (Ditropan)
  29. Which medications do not require hepatic dosing for OAB?
    • 1. fesoterodine (Tovias)
    • 2. trospium (Sanctura)
    • 3. oxybutynin (Ditropan)
  30. Which medications for do not need dosing adjustments for CYP enzyme inhibition?
    • 1. trospium (Sanctura)
    • 2. oxybutynin (Ditropan)
    • 3. mirabegron (Myrbetriq)
  31. Which OAB medication should NOT be titrated until after 8 weeks of use?
    mirabegron (Mybetriq)
  32. Where is oxybutynin gel applied?
    to the abdomen, upperarms/shoulders, or thighs
  33. Where are oxybutynin patches applied?
    to the abdomen, hip or buttock
  34. List the expected adverse drug reactions with OAB medications.
    • 1. dry mouth
    • 2. constipation
    • 3. dry itchy eyes
    • 4. dyspepsia
    • 5. UTO
    • 6. urinary
    • retention
    • 7. impaired cognitive function
    • 8. application site reaction
    • (topical oxybutynin)
  35. Which OAB medication has the HIGHEST incidence of constipation?
    darifenacin (Enablex)
  36. Which medication(s) have the highest incidence of dry mouth?
    • first: oxybutynin IR (Ditropan)
    • second: tolterodine IR (Detrol)
  37. Which OAB medication has the least incidence of dry mouth and constipation of all OAB meds?
    mirabegron (Myrbetriq)
  38. What are side effect treatment options for those on OAB meds for constipation?
    • 1. dietary fiber and fluid
    • 2. psyllium-based fiber supplements
    • 3. regular exercise
  39. What are side effect treatment options for those on OAB meds for dry mouth?
    • 1. oral lubricants
    • 2. avoid mouthwashes with alcohol
    • 3. sip on water frequently
    • 4. sugar free hard candy or chewing gum
  40. How is toxicity monitored in patients receiving OAB therapy?
    No laboratory testing or physical exam; patient report of incidence/tolerability only
  41. An 82-year old woman has moderate dementia and is cared for full-time by her daughter. Per the daughter, mom has been experiencing “accidents” approximately 3 times weekly due to not being able to tell the daughter that she needs to use the bathroom. The patient has many chronic health conditions and takes almost 20 prescription medications, many of which have anticholinergic properties. Based on this information, what is the best recommendation for treating this patient’s overactive bladder?

    a. Do not treat at this time
    b. Implement bladder training
    c. Start oxybutynin patch
    d. Start solifenacin tablet
  42. A 72-year old man has been using oxybutynin 5 mg po TID for the past month. He reports excellent relief of his overactive bladder symptoms, but complains of intolerable dry mouth despite constant use of sugar-free chewing gum. Which of the following represents the best recommendation?

    a. Switch from sugar-free gum to sugar-free hard candy
    b. D/C oxybutynin and start tolterodine 2 mg po BID
    c. D/C oxybutynin and start oxybutynin patch twice weekly
    d. D/C oxybutynin and start fesoterodine 4 mg po daily
    c. D/C oxybutynin and start oxybutynin patch twice weekly
  43. A patient with severe overactive bladder symptoms has tried several medications, including Myrbetriq, Vesicare, and Toviaz, without sympomatic relief. Most recently, the patient was switched to Enablex. This drug is finally helping the OAB symptoms, but has also caused mild constipation and dry, itchy eyes. Based on the information provided, what is the best recommendation for this patient?

    a. Switch from Enablex to Ditropan XL
    b. Switch from Enablex to Gelnique
    c. Switch from Enablex to Detrol
    d. Continue Enablex and add psyllium-based fiber supplements
    • a. Switch from Enablex to Ditropan XL
    • b. Switch from Enablex to Gelnique
    • c. Switch from Enablex to Detrol
    • d. Continue Enablex and add psyllium-based fiber supplements
Card Set
Therapeutics III - Urinary Incontinence
Therapeutics III Urinary Incontinence