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Drugs and Urinary Incontinence Cheryl Ritchie R.Ph., CGP Janzen’s Pharmacy Thunder Bay, ON Medications and Urinary incontinence Presentation Outline Bladder receptors – Drug activity sites Drugs contributing to urinary incontinence Drugs for treatment of urinary incontinence Alpha Adrenergic Receptors in Bladder – Stimulation Sphincter contraction – – Inhibit urine flow Block receptors Sphincter relaxation – Allow urine flow Beta adrenergic receptors in bladder Stimulation – Detrusor muscle relaxation Allows bladder filling Block receptors – Detrusor muscle contraction Facilitates bladder emptying Muscarinic (M2 & M3 - Cholinergic) Receptors Stimulation – Detrusor muscle contraction Facilitates bladder emptying Block receptors – Detrusor muscle relaxation Facilitates bladder filling Medications contributing to Incontinence Stress Incontinence – Alpha adrenergic blocking agents cause sphincter relaxation – Terazosin doxazosin ACE inhibitors may cause cough Enalapril Ramipril Lisinopril fosinopril Medications contributing to Urinary Incontinence Urge incontinence due to uncontrolled bladder contractions or increased urine output – – – Diuretics Caffeine Sedative Hypnotics Medications contributing to urinary incontinence Urinary retention due to decreased bladder contractions – – – – – – – – – Anticholinergics – oxybutynin, scopolamine Antidepressants – amitriptyline, doxepin Antipsychotics – chlorpromazine, prochlorperazine Sedative hypnotics – diazepam, flurazepam Antihistamines – diphenhydramine, hydroxyzine, chlorpheniramine Muscle relaxants – baclofen, cyclobenzaprine Calcium Channel Blockers – diltiazem,nifedipine, verapamil Antiarrhytmics - quinidine Antiparkisonian agents – trihexyphenidyl, benztropine Medications Contributing to Urinary Incontinence Urinary retention due to sphincter contraction – Alpha adrenergic agonists pseudoephedrine Urinary retention due to detrusor muscle relaxation – Beta adrenergic agonists Salbutamol terbutaline Medications contributing to urinary incontinence If medications are a contributing factor – consider an alternative medication If not able to discontinue offending medication, the lowest possible dose of the aggravating medication should be used. Medications to treat urinary incontinence - goals of treatment Decrease uninhibited bladder contractions Increase functional bladder capacity Decrease frequency and urgency Drugs in the management of urinary incontinence – Points to consider Will adding medication improve or complicate quality of life? Drug therapy alone rarely cures elderly urinary incontinence sufferers. Ensure accurate diagnosis prior to choosing drug therapy Drugs in treatment of urinary incontinence – stress incontinence Topical estrogens – Increase sphincter tone Duloxetine – unlabelled use – By blocking norepinehrine reuptake may increase sphincter control Drugs in the treatment of urinary incontinence – Urge incontinence Oxybutynin - Ditropan Tolterodine - Detrol Drugs in the treatment of urinary incontinence – Urge incontinence Adverse effects of oxybutynin & tolterodine – – – – – – Dry mouth Constipation Dry eyes or blurred vision Tachycardia Worsening GERD Worsening cognitive impairment (especially with cholinesterase inhibitors) Drugs in the treatment of urinary incontinence – Urge incontinence Contraindications – – Urinary and gastric retention Uncontrolled narrow angle glaucoma Drugs in the treatment of urinary incontinence – Urge incontinence Drug interactions – – Additive effects with other anticholinergic medications Tolterodine only (reduce dose) Azole antifungals Cyclosporine Macrolide antibiotics Fluoxetine – if possible choose alternative SSRI Drugs in the treatment of urinary incontinence – Urge incontinence Dosage form availability – – – Immediate release tablet Extended release tablet Transdermal patch (oxybutynin only) Dosage form notes – – Short acting may be good choice for occasional use for special occasions Long-acting formulation may cause less adverse effects Drugs in the treatment of urinary incontinence – overflow incontinence UI associated with benign prostatic hyperplasia – Alpha adrenergic antagonists Terazosin, doxazosin – – Non-selective – monitor for hypotension especially with first dose alfuzocin, tamsulosin 5-alpha reductase inhibitors Finasteride, dulasteride Drugs in the management of urinary incontinence – Points to consider Several weeks of drug therapy are usually required to achieve maximum effect If no subjective improvement in 4-6 weeks, consider – – – Increase dose Change medication Discontinue medication
