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Update On oab joon Chul Kim
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tarix | 14.09.2018 | ölçüsü | 1,03 Mb. | | #68215 |
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Update On OAB The Catholic University of Korea
Overactive Bladder Syndrome : ICS Definition Urgency, with or without urge incontinence, usually with frequency and nocturia - Absence of pathologic or metabolic conditions that might explain these symptoms
Urgency - Sudden, compelling desire to pass urine that is difficult to defer
OAB Initiating Treatment If there is no significant abnormality of physical exam, urine analysis and PVR, treatment for OAB can be initiated without further workup In some cases where abnormalities are found, treatment can be initiated, but abnormality must be worked up (e.g. hematuria)
Antimuscarinics 2008 in Korea Oxybutynin IR BID-TID Oxybutynin ER QD Tolterodine IR/ER BID / QD Trospium BID / QD* Solifenacin QD
What’s The Difference?? Efficacy Tolerability Safety Clinical Effectiveness – different for different patients depending on expectations
Differences Among Anticholinergics Metabolism Pharmacokinetics - Delivery system
- Bioavailability
Receptor selectivity Chemical structure - 50-60% of patients will choose higher dose
Why is Efficacy So Hard to Measure in the OAB Population Different patients have different: Different studies have different populations
Side Effects: Dry Mouth Incidence Drug Placebo Oxybutynin ER 10mg 28.1-29.7% n.a. Tolterodine ER 4mg 23% 8% Oxybutynin TDS 9.6% 8.3% Solifenicin 5 mg 14% 4.9% Solifenicin 10 mg 21.3% 4.9% Darifenicin 7.5 mg 18.8% 13.2% Darifenicin 15 mg 31.3% 13.2%
Side Effects: Constipation Incidence Drug Placebo Oxybutynin ER 10mg 6.4-7.0% n.a. Tolterodine ER 4mg 6% 4% Oxybutynin TDS <2% <2% Solifenicin 5mg 7.2% 1.9% Solifenicin 10 mg 7.8% 1.9% Darifenicin 7.5mg 14.8% 6.7% Darifenicin 15mg 21.3% 6.7%
Urgency: Defining Symptom of OAB How is it measured? - Yes/no
- Degree
- Warning time
- OAB voids
Recent studies have shown positive effects on antimuscarinics on urgency - Darifenicin and solifenicin using yes/no scales
- Tolterodine and trospium using fixed scales
- Darifenicin using a VAS
Reduction in Urgency Episodes/24 hrs
Improvement in Urgency Perception Score: Baseline to End of Study
Tolterodine LA Nighttime Dosing Reduced 24-Hour Frequency
Individual Agents Advantages and Drawbacks
Oxybutynin - ER Advantages - Widest range of dose titration
- Only compound approved for “high dose” administration
Drawbacks - Effects on cognitive function
Tolterodine Advantages - Long safety record
- Number 1 prescribed drug
- New CNS data favorable
- Data on male OAB
Drawbacks: - Lack of titration
- Mild increase in QT interval at super therapeutic doses
Trospium Advantages - No hepatic metabolism
- Less drug-drug interactions
- Less crossing of blood-brain barrier
- ? Clinical correlation at this time
- Higher urine concentration
Solifenicin Advantages - Dose titration
- Relatively low dry mouth incidence
Drawbacks - Mild increase in QT interval at super therapeutic doses
Antimuscarinics Summary Efficacy among antimuscarinic agents is similar There are several different advantages (some theoretical) which may influence drug choice in a particular patient Expect in cases of high dose antimuscarinics, decisions are more likely to revolve around tolerability and safety (or perceived safety)
Male LUTS Can Be Associated With the Bladder, the Prostate, or Both
Timing of combination treatment Primary vs. Add-on from alpha blocker only : Initially treated with an alpha blocker : Anticholinergics is added in patients who report partial response to the alpha blocker but still have persistent OAB symptoms
In Men With OAB, Treatment With Tolterodine Was Not Associated With Increased Incidence of AUR
TIMES Study : Urinary Retention Summary
Several recent clinical trials have refuted But, given the exclusion criteria should be considered Exclusion criteria for PVR in clinical trials - greater than 30-40% of maximum capacity - or 50-200ml
Post-void residual volume should be measured to exclude baseline urinary retention Post-void residual volume should be measured to exclude baseline urinary retention The safety in patients with baseline urinary retention is not known
Summary: OAB in Men Available data suggests that antimuscarinics are safe in men with OAB + BOO, but PVR should be considered Optimal way to use + alpha blockers needs to be sorted out It should be evaluated which patient benefit from adding of antimuscarinics initially in real life practice
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