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® Best Care for Everyone OXYBUTYNIN – SAFE PRESCRIBING – A LITTLE BIT DRY 4ENSURE THE INDICATION IS APPROPRIATE 4CHECK FOR GLAUCOMA BEFORE PRESCRIBING 4START LOW AND GO SLOW – ELDERLY PATIENTS REQUIRE LOWER DOSES 4ASK ABOUT ADVERSE EFFECTS AND ACTIVELY MANAGE THESE Oxybutynin decreases muscle spasms of the bladder and increases bladder capacity. It is indicated for symptoms of urinary frequency and urgency1 that result in incontinence. Oxybutynin can cause classic anticholinergic adverse effects such as dry mouth, blurred vision, urinary retention, constipation and confusion. These adverse effects may limit titration up to effective doses and adherence to therapy. Make sure patients are aware of these adverse effects and to report them so they can be effectively managed. If the patient is non-responsive to oxybutynin or has a documented intolerance to it, solifenacin and tolterodine could be considered as alternative options2 however patients can still experience anticholinergic side effects with these. Solifenacin and tolterodine are available on Special Authority.3,4 ENSURE THE INDICATION IS APPROPRIATE Before prescribing, investigate the cause of incontinence, and make sure oxybutynin is appropriate. Take care with older patients who may be more likely to experience adverse effects with anticholinergic medicines and have an increased risk of interactions due to multiple medicines prescribed.6 Oxybutynin increases bladder capacity and delays the desire to void, so it is useful for urgency and frequency incontinence.1 Oxybutynin is not indicated for stress or urge urinary incontinence; initial treatment should include lifestyle interventions such as weight reduction and dietaryfluid modification. These lifestyle interventions will also be useful for patients who are prescribed medicines such as oxybutynin for overactive bladder with urgency and frequency incontinence.2 CHECK FOR GLAUCOMA BEFORE PRESCRIBING Anticholinergic medicines can aggravate glaucoma, and for this reason oxybutynin is contraindicated if the patient has uncontrolled angle-closure glaucoma.1 Oxybutynin should be used with caution in patients who are susceptible to angleclosure glaucoma.2 Dry eyes Anticholinergic medicines frequently cause dry eyes; consult with an ophthalmologist before prescribing oxybutynin to patients who already suffer from dry eyes.7 For all patients prescribed anticholinergic medicines, actively enquire about dry eyes during treatment; offer lubricating eye drops or alternative medicines if it is particularly troublesome. Tolterodine can also cause dry eyes. In a study of 52 patients randomly assigned to tolterodine or oxybutynin, a burning sensation in the eyes was observed in 43% of those assigned tolterodine (2mg twice daily) and 58% of those assigned to oxybutynin (5 mg three times daily).7 Note: Anticholinergic medicines can also impair distant vision and dilate the pupils leading to increased light sensitivity. Driving and potentially dangerous activities that rely on clear vision should be avoided if affected. START LOW AND GO SLOW – ELDERLY PATIENTS REQUIRE LOWER DOSES Oral oxybutynin undergoes gastrointestinal and hepatic first-pass metabolism producing high plasma levels of an active metabolite. This metabolite is associated with dry mouth, constipation and dizziness, which can be especially problematic for elderly patients. Elderly patients may only require half the usual dose of oxybutynin. Start with oxybutynin, 2.5mg twice daily, and increase only if necessary. Carefully monitor for and ask about adverse effects, especially if renal or hepatic impairment are present.1 All anticholinergic medicines should be used cautiously if patients are cognitively impaired or have Parkinson’s disease because they can precipitate acute confusional states. Oxybutynin can also exacerbate symptoms of hyperthyroidism, coronary heart disease, congestive heart failure, arrhythmia, tachycardia, hypertension and prostatic hypertrophy.8 ➥ continued 1 Best Care for Everyone 2 OXYBUTYNIN The topical patch formulation of oxybutynin may reduce the occurrence of adverse effects compared to oral oxybutynin because of reduced first-pass metabolism, and lower plasma levels of the active metabolite.9 The patch may increase the tolerability of higher doses and can be a useful option for patients who are likely to experience troublesome adverse effects with the oral formulation.9 However, application site reactions and relative cost10 may limit their use. ASK ABOUT ADVERSE EFFECTS AND ACTIVELY MANAGE THESE Many of the adverse effects of anticholinergic medicines are dose-related; consider reducing the dose before switching to an alternative medicine or formulation. Some adverse effects can be effectively managed; inform patients about these so they know to ask for advice, if needed. Dry mouth Dry mouth is the most common and troublesome adverse effect of all anticholinergic medicines, affecting one in three patients,11 and is the main reason for discontinuing oxybutynin.12 Persistent dry mouth can cause ulceration of the gums, tooth decay, and lead to fungal infections. Advise patients to maintain good oral hygiene and to use saliva substitutes, if necessary. Note: Solifenacin and tolterodine can also cause dry mouth, but possibly to a lesser extent than oxybutynin.7,12 Gastrointestinal effects Oxybutynin, like other anticholinergic medicines can decrease gastrointestinal motility and is contraindicated in patients with severe ulcerative colitis. Reduced gastric motility also causes constipation. Ask about constipation at each visit and manage proactively with dietary advice and laxatives, where required. Note: Diarrhoea may be a symptom of incomplete intestinal obstruction; if diarrhoea occurs, withdraw oxybutynin.1 Decreased sweating Anticholinergic medicines decrease sweating and can increase photosensitivity,13 both of which may be problematic in hot environments. Patients should be informed about the risk of overheating during exercise or in hot weather because these can lead to heatstroke and fever.13 Hot baths and saunas should also be avoided because dizziness or fainting may result. Drowsiness and confusion Older adults have an increased risk of drowsiness, confusion and memory loss when using anticholinergic medicines. This risk is further increased if more than one anticholinergic medicine is prescribed. These central effects can lead to an increased risk of falls; make sure patients and their caregivers are aware of this.1 Note: Alcohol may further increase the sedative effect of oxybutynin; all patients should be advised to limit their alcohol intake. Anticholinergic Side Effects14 Peripheral Effects Potential Medical Complications Decreased salivation Dental caries, gum ulceration Decreased sweating Hyperthermia Increased pupil size Photophobia, precipitation of acute angle-closure glaucoma Inhibition of accommodation Blurred vision Difficulty urinating Urinary retention Decreased gastrointestinal motility Constipation Central Effects Drowsiness and confusion ➥ continued Falls Best Care for Everyone 3 OXYBUTYNIN REFERENCES ACKNOWLEDGEMENTS 1. Apotex New Zealand Limited. Apo-Oxybutynin chloride 5mg tablets and 5mg/5mL syrup, New Zealand datasheet http://www.medsafe.govt.nz/ profs/datasheet/a/apooxybutynintabsyrup.pdf (Accessed 22-04-13) We wish to thank John Scott, Geriatrician and Clinical Director of Health of Older Adults Services, Waitemata DHB, for his valuable contribution to this bulletin. 2. New Zealand Formulary. Urinary incontinence in women http://www.nzf. org.nz/nzf_4287.html?searchterm=solifenacin (Accessed 29-04-13) 3. Pharmaceutical Management Agency (PHARMAC). Special authority form Solifenacin (SA0998) http://www.pharmac.govt.nz/2013/08/01/SA0998.pdf (Accessed 03-07-13) 4. Pharmaceutical Management Agency (PHARMAC). Special authority form Tolterodine (SA1272) http://www.pharmac.govt.nz/2013/08/01/SA1272.pdf (Accessed 03-07-13) 5. Hanger C. Managing medicines in older people. Best Practice Journal 2012;47:6-14 http://www.bpac.org.nz/BPJ/2012/October/elderlyMedicines. aspx (Accessed 08-05-13) 6. Best Practice Advisory Centre. A practical guide to stopping medicines in older people. Best Practice Journal 2010;27:10-23 http://www.bpac.org.nz/ magazine/2010/april/stopGuide.asp (Accessed 22-04-13) 7. Altan-Yaycioglu R, Yaycioglu O, Akova A et al. Ocular side-effects of tolterodine and oxybutynin, a single-blind prospective randomized trial. British Journal of Clinical Pharmacology 2005;59(5):588–92. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1884849/ (Accessed 01-05-13) 8. Arrow Pharmaceuticals (NZ) Limited. Oxytrol Transdermal Drug Delivery System. New Zealand datasheet 13-12-12. http://www.medsafe.govt.nz/ profs/datasheet/o/oxytroltransdermal.pdf (Accessed 22-04-13) 9. Saltzstein L. Management of overactive bladder in a difficult-to-treat patient with a transdermal formulation of oxybutynin. Medscape article 511631. http://www.medscape.com/viewarticle/511631_2 (Accessed 22-04-13) 10.Pharmaceutical Management Agency (PHARMAC). Pharmacology and Therapeutics and Advisory Committee (PTAC) minutes 2007-2008 http:// www.pharmac.govt.nz/2008/10/08/2008-07%20PTAC%20Minutes.pdf (Accessed 22-04-13) 11.Nabi G, Cody JD, EllisG, Hay-Smith J, Herbison GP. Anticholinergic drugs versus placebo for overactive bladder syndrome in adults. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD003781. DOI: 10.1002/14651858.CD003781.pub2. http://onlinelibrary.wiley.com/ doi/10.1002/14651858.CD003781.pub2/abstract (Accessed 03-05-14) 12.Madhuvrata P, Cody JD, Ellis G et al. Which anticholinergic drug for overactive bladder symptoms in adults. Cochrane Database of Systematic Reviews 2012, Issue 1. Art. No:CD005429. DOUI:10.1002/14651858. CD005429.pub2 http://onlinelibrary.wiley.com/doi/10.1002/14651858. CD005429.pub2/pdf/abstract (Accessed 3-05-13) 13.New Zealand Formulary. Oxybutynin http://www.nzf.org.nz/nzf_4303. html?searchterm=oxybutynin (Accessed 22-04-13) 14.Lieberman JA. Managing anticholinergic side effects. Primary Care Companion Journal of Clinical Psychiatry 2004;6(2):20-3 http://www. ncbi.nlm.nih.gov/pmc/articles/PMC487008/pdf/i1523-5998-6-s2-20.pdf (Accessed 11-05-13) For further information on other high-risk medicines visit our website at: www.saferx.co.nz No: 0182-01-112, Issued: July 2013, Review: July 2015 DISCLAIMER: This information is provided to assist primary care health professionals with the use of prescribed medicines. Users of this information must always consider current best practice and use their clinical judgement with each patient. This information is not a substitute for individual clinical decision making. Issued by the Quality Use of Medicines Team at Waitemata District Health Board, email: [email protected]