Urinary incontinence is a common problem, with a mean annual incidence of 1 to 9 per cent and estimates of remission ranging from 4 to 30 per cent[1]. National institute for Health and Clinical Excellence guidelines [2] recommend bladder training as first-line treatment. if this is not effective, antimuscarinics should be offered with regular review. anecdotal evidence suggests medication is often continued long-term without consideration of effectiveness, adverse effects or patients’ perceptions of success.
Long-term prescribing of antimuscarinics is associated with an increased risk of cognitive impairment and mortality[3]. Benefits from medication are small, with fewer than 200 cases of continence attributable per 1,000 treated[4]. Patients may, therefore, be taking treatment with limited benefit and an increased risk of adverse effects.
To improve antimuscarinic prescribing for urinary incontinence, the primary care medicines management team worked with secondary care to produce joint guidance. Funding was then secured from the strategic health authority to run a pilot project at practice level with the aim of: collecting baseline data on all patients prescribed antimuscarinics for urinary incontinence, including duration of treatment, date of last review and antimuscarinic initially and currently prescribed; identifying patients suitable for a trial of stopping medication; and exploring patients’ views of their symptoms and condition on and off treatment.
Method
The project pharmacists, with a GP with a special interest in urology, used existing literature to develop a “patient overactive bladder questionnaire” to assess patients’ views of their symptoms and condition on and off treatment. a computer search in three practices identified 174 patients currently prescribed antimuscarinics for urinary incontinence. Baseline information for these patients was collected.
Patients’ GPs were contacted to confirm their suitability for a trial of stopping medication.
GPs identified 124 patients as suitable. Patients were excluded if the GP did not respond, or if there were clinical conditions such as multiple sclerosis or difficult social circumstances. Eighty-nine patients were then telephoned by a pharmacist and the project discussed. reasons for non-contact included contact details not on file, the patient being in hospital and the GP conducting the review.
Sixty-nine patients agreed to the trial and completed part 1 of the questionnaire. They were contacted at four weeks for follow up and questionnaire completion. At four weeks, medication was restarted for patients who believed their symptoms were better managed on treatment. Patients could contact their GP within the four-week period if needed.
Results
Of the 174 patients, 165 (94.8 per cent) had been prescribed an antimuscarinic for one year or more. However, only 41 patients (23.6 per cent) had their treatment reviewed in the previous six months. The most commonly prescribed antimuscarinics were oxybutynin (74 patients, 42.5 per cent) and tolterodine (66 patients, 37.9 per cent). Three patients (1.7 per cent) were prescribed more than one antimuscarinic. at the end of the trial, 39 patients did not restart treatment. This was 56.6 per cent of patients who participated in the trial and 22.4 per cent of the total sample. Patients’ reasons for not restarting included:
• “Did not feel the medication made a difference”
• “Has not had any problems with stopping. Body feels better for stopping”
•“Was initially prescribed with an ordinary catheter which was changed to a suprapubic catheter”
•“Symptoms Ok without it. Feels more alert without medication and is able to do more”
Over a year, the saving from stopping medication in the three pilot practices was £10,475.34.
Discussion
Oxybutynin and tolterodine were prescribed to equal extents. in some cases tolterodine was started without an initial trial of oxybutynin. This may be due to prescriber-perceived differences in efficacy or adverse effect profiles. a large proportion of patients had not been reviewed in the past six months and may have been continuing treatment with limited benefit. In future, local treatment guidance that recommends oxybutynin as the medicine of choice and treatment withdrawal at six months will have an influence on prescribing practice. Patients were generally responsive to the trial if they had assurance that medication would be restarted if needed.
In line with published reports[4], a major reason for patients not restarting treatment was that they experienced no difference in symptoms on or off treatment. Some patients developed other methods of symptom management, including stopping caffeine intake and planning journeys. For a few patients, an antimuscarinic had been prescribed to prevent bladder spasm on insertion of a catheter. On changing to a suprapubic catheter, the antimuscarinic had not been reviewed.
The questionnaire allowed a sensitive subject to be discussed in a structured way and patients were able to talk openly about their symptoms. It also allowed measurement of symptom change on and off treatment.
Conclusion
Routine practice should include advice on conservative management techniques and informing patients when medication is started that there will be a break in treatment at six months to see if there has been a natural remission in symptoms and if medication has been effective before long-term treatment is considered.
Acknowledgements
Elaine Sharpe and Maria Smith, prescribing support pharmacists, Aylesbury Vale and Chiltern CCG.
References
1 Vij M, Thomson A. Management options for female urinary incontinence. Prescriber 2012;(5 Oct):39–45.
2 NICE clinical guideline 40. Urinary incontinence. October 2006.
3 Fox C, Richardson K, Maidment ID et al. Anticholinergic medication use and cognitive impairment in the older population. Journal of the American Geriatric Society 2011;59:1477–83.
4 Shamliyan T, Wyman JF, Ramakrishnan R et al. Systematic review: benefits and harm of pharmacologic treatment for urinary incontinence in women. Annals of Internal Medicine 2012;156:861–74.
