ACTIVITY DISCLAIMER. Urge Incontinence, Detrusor Instability, and Overactive Bladder: (OAB) DISCLOSURE. Learning Objectives

Urge Incontinence, Detrusor

Instability, and Overactive

Bladder: (OAB)

Benroe Blount

,

MD, MPH, FAAFP

ACTIVITY DISCLAIMER

The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations.

The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Every effort has been made to ensure the accuracy of the data presented here. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.

DISCLOSURE

It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose.

The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.

Benroe Blount

,

MD, MPH, FAAFP

Medical Director, JenCare, Atlanta, Georgia; Adjunct Professor, Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia.

Dr. Blount is a graduate of the University of Miami Miller School of Medicine, Florida. He completed a faculty development fellowship at Madigan Army Medical Center, Tacoma, Washington, and earned a Master of Public Health degree from the University of Washington School of Public Health, Seattle. He has published numerous articles covering many areas of family medicine. Prior to his tenure at JenCare and Emory University School of Medicine, he was professor and chair of family medicine at the University of Tennessee Graduate School of Medicine, Knoxville

Learning Objectives

1. Incorporate current guidelines for diagnosis in patients presenting with urinary problems.

2. Coordinate referral to an urologist or urogynecologist if initial diagnosis in unclear, or red flags such as hematuria, obstructive symptoms or recurrent urinary tract infections are present.

3. Counsel patients regarding first-line treatment options, including behavioral therapy and lifestyle modifications, emphasizing adherence and follow-up.

4. Prescribe second or third line treatment options if first-line therapies are unsuccessful, coordinating referral and follow-up care for surgical treatment as necessary.

Audience Engagement System

Presentation Topics

• The approach to the incontinent patient • The work-up of said patient

• The evidence-based, practical treatment of said patient

• The follow-up of such a patient

Defining

OAB

•The International Continence Society (2002) defines OAB as:

“Urgency, with or without urge incontinence, usually with frequency and nocturia”

•Characterizes OAB as a syndrome that requires presence of 2+ symptoms

This makes OAB a clinical Dx

Polling Question 1 Which of the following is the most

common symptom of OAB?

A. Frequency A.Urgency B.Nocturia

C.Urge Incontinence D.None of the above

OAB Symptoms

• Frequency—voiding too often during the day: Most Common Sx: 85% • Urgency—the complaint of a sudden,

compelling desire to pass urine that is hard to defer: 2nd_{most Common: 54%}

• Urge Incontinence: 36%

• Nocturia—voiding ‘too often’ during the night.

Types of Urinary Incontinence (UI)

Type Symptom Most Common Cause Urge (UUI) (OAB) Involuntary leakage with urgency, frequency, Nocturia Detrusor overactivity

Stress (SUI) Involuntary leakage with exertion (sneezing, coughing) Urethral hypermobility; intrinsic sphincter deficiency Mixed (MUI) Combination of stress

and urge symptoms Combination

Urge Incontinence

“

Incontinence Clinic:

Epidemiology of OAB

• Affects approximately 33 million US adults

(17% of women; 16% of men)1

• Second most common chronic condition (behind arthritis)

• Symptom prevalence increases with age and is higher in nursing-home and homebound populations

Managing OAB in the Primary

Care Setting:

Diagnosis

Urinary Incontinence:

A “Silent” Issue

• Majority of community-dwelling older adults fail to report UI to provider

• UI may not be perceived as important or may be seen as part of aging process

• Men may ascribe UI to enlarged prostate; women to menopause

• Patients may privately associate UI with gradual loss of bodily control

Shhhh! Shhhh!

_{Reasons For Not Seeking Help}

• Considered minor problem

• Accepted as normal part of aging or being female • Denial of problem

• Embarrassment

• Fear that doctor will think problem is trivial • Hope for improvement without intervention • Unaware of treatment availability • Low expectations from treatment • Too busy

• Cost

The First Step: Ask About It!

• Begin with open-ended query: – “Do you have any problems with urination?” • If “no,” become more specific:

– “How many times do you urinate during the day or night?” – What’s normal?

•5-6 X/day

– “Do you ever feel that you cannot empty your bladder?”

1

1

The Second Step: Get Details

•Get the usual 7 characteristics of every symptom:

–

Location

–

Onset

–

Characrter

–

A lleviating factors

–

Timing

–

E xaccerbating factors

–

Severity

2

2

3rd Step: The Voiding Diary:

•Encourage patient to keep voiding diary by recording:

• Voiding patterns • Precursor symptoms

• Relationships between leaking and activity • Presence of urge

• Fluid and caffeine intake

..Education on Urinary Incontinence and Women’s Health, available at http://www.stressui.org/bladder_diary.pdf.

3

3

Polling Question 2

Which of the following is/are a reversible cause of Urinary Incontinence?

•A. Delerium

•B. Infection

•C. Stool Impaction

•D. Psychological Problems

•E. All of the above

4

th

_Step:

Exclude Reversible Causes

D

elirium

I

nfection

A trophic vaginitis

P

harmaceuticals

P

sychological problems

E

xcessive Urination

R

estricted mobility

S

tool impaction

D

elirium

I

nfection

A trophic vaginitis

P

harmaceuticals

P

sychological problems

E

xcessive Urination

R

estricted mobility

S

tool impaction

4

4

Medicines that May Influence

Bladder Function

• Diuretics • Antidepressants • Antihypertensives • Hypnotics • Analgesics • Narcotics • Sedatives

• Over-the-counter sleep aids and cold remedies

Complicating

Factors

(Need Referral)

• Prior incontinence surgery • Prior radical pelvic surgery • Prior pelvic radiation • Gross pelvic prolapse

• Recent onset overactive symptoms • Hematuria (w/o infection)

The 5th Step:

Establishing Diagnosis of OAB

Initial Workup

a. Physical Exam

b. Urinalysis

c. Post void Residual

5

5

Step 5a: The Physical Exam

• Focused Neurological

• Mental Status • Weight

• Abdominal (looking for masses)

• Genitalia & pelvic (Check pelvic floor, for cystocele, S.U.I., & masses)

• Rectal

Overactive Bladder Evaluation

_{Step 5b: Urinalysis}

Dipstick for:

• Proteinuria • Glycosuria • Hematuria • Bacteruria • Pyuria

Step 5c: Exclude Overflow

Measure Post-Void Residual Urine

•Patient empties bladder

•Catheter or sono to measure PVR

–0-50 cc NORMAL

–50-200 cc EQUIVOCAL

–>200 cc HIGH

Patients w/overflow need urodynamic testing and catheter drainage; i.e.

referral

Referral/Consultation Criteria

• Uncertain diagnosis; pelvic organ prolapse • Uncertain treatment plan; prior pelvic surgery • Failure to respond to therapy

• Consultation regarding surgery • Hematuria; recurrent U.T.I. • Recurrent urinary tract infections • Abnormal PVR (postvoid residual) • Neurogenic bladder

Mid-Summary

Diagnostic Plan for UI/OAB

• Diagnose with history, physical, U/A • Exclude reversible causes and

complicating factors • Exclude overflow

• Use history to decide on urge vs. stress Treat: 6th_Step

??QUESTIONS??

6

th

_Step:

Managing OAB

in the Primary Care Setting:

6

6

General Considerations for OAB

Management

• Focus on meeting reasonable expectations (e.g., < 100% dryness)

- Decrease incontinent episodes; frequency of bathroom; & improve control

• Discuss options with the patient • Tailor therapy to the patient’s needs • Use behavioral and pharmacologic

interventions in combination

• Recognize that regimens may need to be altered over time

Behavioral Interventions

Bladder Retraining Pelvic Floor Muscle Rehabilitation Lifestyle Interventions

Behavioral Intervention

Polling Question 3

Which of the following has ‘A’ level evidence as effective in decreasing OAB?

A.Weight reduction B.Smoking cessation C.Caffeine reduction D.All of the above E.Only B & C

Lifestyle Interventions

•Conservative management strategies that apply or remove a particular behavior

• Weight reduction : ‘A’ Rec • Smoking cessation : ‘C’ or ‘B’ • Constipation prevention ‘C’ • Dietary modifications: ‘C’ • Caffeine reduction : ‘C’ (<400mg/d)

Lifestyle Interventions:

Weight Reduction

• Obesity is an independent risk factor for UI •Each unit increase in BMI increases risk of UI by

5 percent

•Weight reduction associated with improved UI in moderately obese women

Polling Question 4

Patients with urinary incontinence should be advised to decrease their fluid intake.

True

False

What About Fluid Intake?

• Fluid reduction is not recommendedas a treatment strategy for incontinence • Role of fluid intake on UI is unclear • Fluid reduction may promote dehydration,

constipation, and urinary tract infections • To help alleviate nocturia, fluid intake may be

rescheduled to reduce intake 3-4 hours preceding bedtime

Bladder Retraining:Overview

• The Main behavioral intervention • Management strategy that combines

– Education – Scheduled voiding – Urge suppression behaviors – Reinforcement

• May be used alone or in conjunction with lifestyle interventions or pharmacotherapy

• Regimen design should consider patient’s physical capabilities and motivational level

Bladder Retraining: Efficacy

• In older women with UI (n=123), bladder retraining

reduced incontinence episodes by 57 percent vs control (P< 0.0001)1

• Bladder training plus caffeine reduction (in patients with intake > 100 g/day) significantly decreased the number of voids/24 hours and urgency episodes when compared to bladder training alone2

• After 24 weeks of treatment, bladder training plus

tolterodinesignificantly decreased voiding frequency and voided volume vs tolterodinealone (P< 0.001)3

•

More effective than

anticholinergics

Bladder Retraining Strategies:

Scheduled Voiding

• Establishes a fixed voiding schedule that may vary from 1.5-3 hours, depending on results from the patient’s voiding diary

•Is an essential adjunct to pharmacotherapy

• Can be used to retrain the habits of patients with mild-to-moderate mobility or cognitive defects

Bladder Retraining Strategies:

Suppressing the Urge

• Recognize that the best time to void is when calm • Squeeze pelvic floor muscles (2-4 seconds then

relax 2-4 seconds; repeat 3-5 times) • Breathe slowly and deeply

• Use simple distraction (counting backwards from 10, or success reinforcement methods (repeating “I am in control”))

• Wait until the urge subsides

• Walkto the bathroom at a normal pace

Behavioral Intervention

Practice Recommendation

Bladder education (normalizing the micturition interval) should be recommended to patients with mild urge urinary incontinence.

This statement is supported by evidence of Grade B(Moderate research-based evidence), indicating at least one relevant, high-quality study or multiple adequate studies.

EBM Source:National Guideline Clearinghouse. Finnish Medical Society Duodecim.

Urinary incontinence in women. In: EBM Guidelines. Evidence-Based Medicine. Helsinki, Finland: Duodecim Medical Publications Ltd.; 2005 Aug 31. www.guideline.gov/summary/summary.aspx?doc_id=8146&nbr=004539&string=overa ctive+AND+bladder#s24

Pelvic Floor Muscle Rehabilitation

Element Purpose

Muscle Training (12-16 weeks)

Improve function, tone, strength, endurance

Biofeedback Teach muscle isolation and identification

Neuromuscular Education

Promote continence, urge relief, and complete bladder evacuation during micturition

Pelvic Floor Muscle Training:

‘Kegel’ Exercises

•Strong, fast, and well-timed pelvic muscle contractions can prevent leakage resulting from a sudden increase in intra-abdominal pressure (e.g., coughing) by:

• Closing the urethra • Increasing urethral pressure

• Pressing the urethra against the pubic symphysis • Preventing urethral descent

Pelvic Floor Muscle (Kegel)

Exercises

Locate pelvic muscles

Repeat in sets of up to 10 each 3 times/day

Relax completely after

each contraction

Two types of contractions:

•Quick (2 sec)

•Long (up to 10 sec)

Practice Recommendation

Pelvic-floor muscle training should be included in the first-line management

of women with stress, urge, or mixed urinary incontinence.

The evidence supporting this recommendation is based on the meta-analysis of 6 randomized/quasi-randomized clinical trials (n=403) in women with stress, urge, or mixed urinary incontinence in which pelvic floor muscle training was compared with no treatment, placebo, sham, or another inactive control treatment. Grade B

EBM Source:Hay-Smith EJC, Dumoulin C. “Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women.”

Cochrane Database Syst Rev2006, Issue 1. Art. No.: CD005654.

http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005654/frame.ht ml.

Getting “The Knack”:

An Acute Method of Control

• A fast and strong pelvic muscle contraction used before and during an activity that causes leakage • Temporarily closes the urethra and increases

urethral pressure

• Useful once a patient has learned to identify and quickly contract pelvic floor muscles

• Unlike pelvic floor muscle exercise, the “Knack” provides an acute method to control leakage • Does not improve muscle tone over the long term

Using Behavioral Approaches

in Practice

• Biofeedback-assisted behavioral treatment reduces OAB episodes in women

• Combining behavioral and

pharmacotherapies in a stepped program increases reduction in incontinence compared to either single modality alone • Behavioral training can be efficacious when

self-administered

• In women with UUI or MUI (n=222), no statistically significant difference in incontinence episodes (P=0.23) between behavioral training regimens that employed biofeedback, verbal feedback, or a self-help booklet

Using Devices in OAB

• Most devices are for S.U.I.; BUT

• Pessariescan decrease incontinence is some women with strict OAB and in many women with mixed OAB

• Caveats to pessary use:

− Estrogen enough to have moist vagina

− No active pelvic infection

− No allergy to latex or silicone

Managing OAB in the Primary

Care Setting:

Pharmacotherapy

Antimuscarinic Agents

• Anticholinergic agents that operate on muscarinic acetylcholine receptors

• Well-established as a class

•Should be used only in context of coordinated treatment plan that includes behavioral interventions

• Common side-effects include constipation, dry eyes, and dry mouth

Antimuscarinic Agents

Agent Trade Name

Oxybutynin Ditropan® Oxybutynin ER Ditropan XL® Oxybutynin TDS Oxytrol® Tolterodine Detrol® Tolterodine ER Detrol LA® Darifenacin Enablex® Flavoxate Urispas® Hyoscyamine sulfate Levsin® Trospium Sanctura® Darifenacin Enablex® Solifenacin Fesoterodine VESIcare® Toviaz Polling Question 5

Which of the following is/are correct about using antimuscarinic agents for OAB? A. They are all clinically equally effective B. They all have equal side effects C. Use an antimuscarinic agent for at

least 2 weeks before assessing efficacy

D. All of the above E. Only A & C

Agent Selection Considerations

• Clinical efficacy • Safety

• Possible CNS side effects (cognitive impairment, sleep disturbance, photophobia)

• Drug-drug interactions • Cost

• Convenience • All are effective

Treatment Effect Rates

Drug # women/1000 resolved

–Fesoterodine 130

–Oxybutynin 114

–Trospium 114

–Solifenacin 107

Agent Selection Considerations

•ER formulations associated with less dry mouth than corresponding IR

formulations

• With the exception of trospium, most agents

easily pass the blood-brain barrier • Differences in tolerability & safety profiles

Clinical Considerations for

Antimuscarinic Agents

•Use agent at least 1 month before assessing efficacy

•Titrate to achieve balance between benefits and side effects

• Switch agent if it becomes less effective after long-term use; or if A.E.s are intolerable

• Use with caution in elderly because of possible CNS side effects and CV risk associated with anticholinergic agents

• Head-to-head trials have not shown clinically significant differences in effectiveness

Clinical Considerations for Antimuscarinic Agents

• More women stop Rx with fesoterodine & oxybutynin •5 mg solifenacin has lowest discontinuation rate.

• Adverse effects more common in pts already taking > 7 other meds

•Because of least CNS action, trospium MAY cause the least somnolence, dizziness, cognitive impairment, & insomnia

•Most are metabolized by the CYP450 system, except

Trospium

•No Effect on the QT interval: Darifenacin, fesoterodine, &

trospium

Considerations for Adverse Effects

•Dry mouth is most common A.E.

Discontinuation Rates/1000 women (in studies)

Drug # Discontinued Rx

•Oxybutynin 63

•Fesoterodine 31

•Trospium 18

•Solifenacin 13

Real world Discontinuation can be 70-90%. Avg. length of adherence = 3 months

Anticholinergics:

A Delicate Balance

• Efficacy • Less frequency • Less UUI • Increased voided volume

Counsel Pt.s they will have 1-4 wks’ delay for max Sx relief, but can see a response in 1 wk. Adverse effects • Dry mouth • Constipation • CNS

Practice Recommendation

Clinicians should consider an anticholinergic agent for adults

with OAB, as use of these agents results in statistically significant improvement

in symptoms compared to placebo.

The evidence supporting this recommendation is based on the meta-analysis of 61 randomized/quasi-randomized clinical trials (n=11,956) in adults with overactive bladder in which an anticholinergic agent was compared with placebo or no treatment. Grade A

EBM Source:Nabi G, et.al. “Anticholinergic drugs versus placebo for overactive bladder syndrome in adults.” Cochrane Database Syst Rev2006, Issue 4. Art. No.: CD003781. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003781/frame.html.

Practice Recommendation

Clinicians should consider an

anticholinergic agent in combination with bladder training for adults with OAB, as the combination improves symptoms compared to each modality alone.

The evidence supporting this recommendation is based on the meta-analysis of 13 randomized/quasi-randomized clinical trials (n=1170) in adults with OAB or UUI in which at least one management arm involved a non-drug new therapy. Grade A

EBM Source:Alhasso AA, et.al. “Anticholinergic drugs versus non-drug active therapies for overactive bladder syndrome in adults.” Cochrane Database Syst Rev2006, Issue 4. Art. No.: CD003193.

http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003193/frame.html.

Practice Recommendation

Bladder education (normalizing the micturition interval) should be recommended to patients with mild urge urinary incontinence.

Practice Recommendation

Pelvic-floor muscle training should be included in the first-line management

of women with stress, urge, or mixed urinary incontinence.

Future RX of OAB

• Posterior Tibial nerve stimulator (same nerve root as bladder control)

• BoTox(effective, even beyond 2 yrs with repeated injections at least 12 wks apart)

• Sacral Neuromodulation

• For patients who fail standard therapy

Success

At age 4 success is. . .not peeing in your pants At age 12 success is. . .having friends At age 16 success is . . .having a driver’s license

At age 20 success is . . .having sex Age age 35 success is . . .having money

Success

At age 50 success is. . . having money At age 60 success is. . . having sex At age 70 success is. . . having a driver’s license

At age 75 success is. . .having friends

Websites for Additional

Information on OAB

National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC): kidney.niddk.nih.gov/kudiseases/pubs/uiwomen/index.htm •

• National Association for Continence: www.nafc.org www.mayoclinic.com • • www.simonfoundation.org www.seekwellness.org www.Medscape.org/viewarticle/762305 www.auanet.org/resource4s.cfm?ID=694 References

National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC): kidney.niddk.nih.gov/kudiseases/pubs/uiwomen/index.htm www.Medscape.com/viewarticle/713263

Frequently asked questions in the evaluation & management of overactive bladder. Supplement to The Journal of Family Practice. Oct. 2009;58:S1-S12.

www.Medscape.com/viewarticle/718789 www.cmecorner.com/wp/overactive-bladder

Chapple CR, et al. The effects of antimuscarinic treatments in OAB. Eurpoean Urology. 2008;54:543-62.

EXTRAS

Muscarinic Receptor Distribution

Bladder (detrusor muscle) Salivary

glands Dry mouth

Colon Constipation

Heart

Stomach and esophagus Dyspepsia Iris/ciliarybody Lacrimal gland Blurred vision Dry eyes Tachycardia • Dizziness • Somnolence • Impaired memory and cognition CNS

Efficacy of Antimuscarinic Agents

Meta-analyses indicate that use of antimuscarinic agents in adults:

• Results in statistically significant improvement in OAB symptoms compared to placebo

• In combination with bladder training, results in increased OAB symptom improvement during initial treatment as compared to each modality alone

Impact of OAB on the Patient

•Poses significant quality-of-life issues1

• May affect:

–Physical function –Daily activities –Social interactions

• Most OAB sufferers use coping strategies:

–Planned voiding –Travel restriction –Fluid restriction

Comorbidities Associated with OAB

•Depression •Sleep deprivation •Urinary tract infections •Skin breakdown

•Orthopedic injuries (from falls related to urgency and nocturia)

Risk Factors for OAB

•Obesity Age

•Trauma Cognitive Impairment

•Prolapse Parity

•Surgery OSA

•Neurologic disease/injury

Stress and Urge Incontinence

Screening Questions

•During the last week, how many times did you accidentally leak urine with

–A physical activity like coughing, sneezing, lifting, or exercising?

–A feeling of strong, sudden need to pass your urine that did not allow you to get to the toilet fast enough?

Primary Underlying Causes

of Incontinence

Urge Urge Incontinence Detrusor instability Stress Stress Incontinence Diminished urethral sphincter function and/or Urethra hypermobility

 Any factor that pushes the equation towards a positive urethral pressure gradient has the potential to be effective

UI Occurs When

Bladder Pressure > Urethral Pressure

Cough Control, Weight Loss Surgery Exercises, Medication

Pathophysiology

• Enhanced Rxn to wall tension & stretching of detrusor muscle

• Leads to increased afferent signaling • Increased Ach release

• Increased sensitivity of detrusor to neurotransmitters

Epidemiology of OAB

• One-third of US adults with OAB experience UUI1

• UUI affects as many as 20% of US women aged 75 and older1

• Total cost of UUI in 2000 estimated at $32 billion2

Behavioral Interventions:

General Considerations

• Safe, inexpensive, comfortable for patient • Efficacy influenced by patient:

−Motivation and commitment

−Time constraints

−Ability to identify and contract pelvic muscles

−Condition of pelvic muscles (e.g., age-associated atrophy, denervation)

Lifestyle Interventions:

Decreasing Caffeine Intake

• No association shown between UI and consumption of coffee or alcohol1

• Caffeine intake > 400 mg/day has been associated with detrusor instability2

• Reducing or restricting caffeine intake may help reduce UI, especially in patients with high intakes (> 5 drinks/day)

• Caffeine intake should be tapered slowly to avoid the onset of migraine-type headaches

All antimuscarinic agents

• Increase volume to 1st_contraction

• Increase time between voids • Decrease contraction magnitude • Do not eliminate contractions • Do not increase “warning time”

Oxy Patch

• Muscarinic blockade: Non-selective • Name : Oxytrol

• Dosing: 3.9 mg patch 2X/week • Dry Mouth: 5-10%

• Blood Brain barrier: Crosses • Also comes in immediate release, &

extended release PO

Tolteradine ER

• Muscarinic blockade: Non-selective • Name : Detrol LA

• Dosing: 4 mg Q Day • Dry Mouth: 7-25%

• Blood Brain barrier: Crosses • Also comes in immediate release

Trospium

• Muscarinic blockade: Selective • Name : Sanctura

• Dosing: 20 mg BID or ER @ 60 mg Q Day

• Dry Mouth: 20%

• Blood Brain barrier: Minimal

Darifenacin IR

•Muscarinic blockade: Selective

•Name : Enablex

•Dosing:7.5-15 mg Q Day

•Dry Mouth: 20-35%

•Blood Brain barrier: Minimal

Fesoterodine

• Muscarinic blockade: Non-selective • Name : Toviaz

• Dosing: 4-8 mg Q Day • Dry Mouth: 7-25%

• Blood Brain barrier: Crosses • Active metabolite is tolteradine

Solifenacin

• Muscarinic blockade: Selective • Name : Vesicare

• Dosing: 5-10 mg Q Day • Dry Mouth: 11-28% • Blood Brain barrier: Minimal

??QUESTIONS??

Contact Info

•

[email protected]

•

[email protected]