Anticholinergic/Antimuscarinic Drug Prescribing for OAB: Caution is Needed
There have been several recent articles about the use of anticholinergic (AC) medications prescribed in patients with overactive bladder (OAB). The study by Risacher and colleagues (2016) investigated the association between AC medication use and neuroimaging biomarkers of brain metabolism and atrophy to understand the underlying clinical effects of these medications. The population studied was cognitively normal older adults (n=402), from the Alzheimer’s disease neuroimaging initiative (ADNI) and the Indiana Memory Aging Study (IMAS), who were on ACs. The results are disturbing as use of medications with medium or high AC effects in the ADNI cohort was associated with poorer cognition (particularly in immediate memory recall and executive function). The authors felt that the effect may be additive because an increased burden of AC medications was associated with poorer executive function and increased brain atrophy. The authors suggest that medication with AC properties may be detrimental to brain structure and function as well as, cognition compared with those who were not on AC medications. This research further supports the need to consider cognitive adverse effects of AC medications before prescribing them in older adults in any care setting and in any who may be at risk for cognitive decline.
A study by Gray and colleagues (2015) looked at the cumulative use of ACs in a population of persons with dementia in a perspective population-based cohort study. The authors wanted to examine whether cumulative AC use is associated with a high risk for incident dementia. Data was obtained from the Adult Changes in Thought study in Group Health, an integrated health care delivery system in Seattle, Washington. Over 343 participants. 65 years and older, with no dementia. were enrolled in the study. Initial recruitment began in 1994 through 1996 and from 2000 to 2003. AC exposure was defined as a total standardized day doses dispensed in the past 10 years. Main outcome and measures were incident dementia and Alzheimer’s disease using standard diagnostic criteria. The results are very disturbing. The most common AC class drugs were triglyceride antidepressants, first generation antihistamines and bladder antimuscarinics. During a mean follow up of 7.3 years of 797 participants, 23.2% developed dementia, and 79.9% developed Alzheimer’s disease. The authors concluded that an increased risk for dementia was seen in people with higher use of ACs which means that a person taking AC oxybutynin chloride, 5 mg/day for more than 3 years would have a greater risk for dementia. This is an important study for clinicians who prescribe ACs to older adult patients with OAB.
A third study by Suchs and colleagues (2016) was a retrospective database analysis (Medicare Advantage Prescription Drug Plan for ages 65 and older between 2008 to 2012) of potentially inappropriate medication (PIM) use in older adults who were prescribed an antimuscarinic medication for OAB. OAB treatment were identified and assigned to PIM and non-PIM comparison groups based on 2012 American Geriatrics Society Beers Criteria and/or the presence of an anticholinergic medication interaction at the time of initiation of treatment (N = 66,275). Majority of members were female and Caucasian. Of members initiated on an antimuscarinic OAB medication, 31.1% (n = 20,629) had a drug–drug or drug–disease or syndrome interaction. Most common disease or syndrome interaction was dementia (11.3%, n = 7,455), followed by constipation (8.6%, n = 5,713) and delirium (2.9%). Most common medications that were interacting included Paroxetine (2.6%), amitriptyline (2.2%), cyclobenzaprine (1.7%), and meclizine (1.6%). Oxybutynin (46.3%) was the most frequently observed index OAB medication in both groups, followed by tolterodine (25.5%) and solifenacin (22.8%). Subjects in the PIM group had greater healthcare costs over 12 months of follow-up ($12,001) than those in the non-PIM group ($9,373) after controlling for baseline characteristics (P < .001). The authors recommended that PIM use should be minimized and medical history and concurrent medication use must be considered before initiating OAB medication treatment. These authors are also recommended standardized cognitive assessment before initiating antimuscarinic treatment for OAB in older adults.
Written by: Diane K. Newman, DNP, Adjunct Professor of Urology in Surgery, Research Investigator Senior and Co-Director, Penn Center for Continence and Pelvic Health
University of Pennsylvania, Division of Urology, 3400 Spruce Street, 3rd Floor Perelman Bldg, Philadelphia, PA. 19104
Gray SL, Anderson ML, Dublin S, Hanlon JT, Hubbard R, Walker R, Yu O, Crane PK, Larson EB. Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study. JAMA Intern Med. 2015 Mar;175(3):401-7. doi: 10.1001/jamainternmed.2014.7663.
Risacher SL, McDonald BC, Tallman EF, West JD, Farlow MR, Unverzagt FW, Gao S, Boustani M, Crane PK, Petersen RC, Jack CR Jr, Jagust WJ, Aisen PS, Weiner MW, Saykin AJ; Alzheimer’s Disease neuroimaging initiative. Association between anticholinergic medication use and cognition, brain metabolism, and brain atrophy in cognitively normal older adults. JAMA Neurol. 2016 Jun 1;73(6):721-32. doi: 10.1001/jamaneurol.2016.0580
Suehs BT, Davis C, Franks B, Yuran TE, Ng D, Bradt J, Knispel J, Vassilakis M, Berner T. Effect of Potentially Inappropriate Use of Antimuscarinic Medications on Healthcare Use and Cost in Individuals with Overactive Bladder. J Am Geriatr Soc. 2016 Apr;64(4):779-87. doi: 10.1111/jgs.14030
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