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Focus on Overactive Bladder: a Fine‐Tuned Approach to Attain Outcome Targets

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Focus on Overactive Bladder: a Fine‐Tuned Approach to Attain Outcome Targets Friday General Session Focus on Overactive Bladder: A Fine‐Tuned Approach to Attain Outcome Targets Scott A. MacDiarmid, MD, FRCPSC Director of the Bladder Control and Pelvic Pain Center Alliance Urology Specialists Greensboro, North Carolina Educational Objectives By completing this educational activity, the participant should be better able to: 1. Proactively evaluate and screen at‐risk individuals for overactive bladder (OAB). 2. Utilize communication strategies aimed to evaluate the impact of OAB on quality of life and educate patients on appropriate treatment options and expectations. 3. Select patients with OAB who would benefit from combination therapy to maximize efficacy and tolerability. Speaker Disclosure Dr. MacDiarmid has disclosed that he is on the advisory committee and speaker’s bureau for Allergan, Astellas, and Urovant. Supporter Disclosure This educational activity is supported by an educational grant from Astellas. It has been planned and produced by VemCo MedEd with Texas Academy of Family Physicians strictly as an accredited continuing medical education activity. 2 FACULTY AND DISCLOSURE Jointly proved by Center for Independent Healthcare Education and Vemco MedEd Supported by an educational grant from Astellas Scientific and Medical Affairs, Inc. Scott A. MacDiarmid, MD, FRCPSC Alliance Urology Specialists Clinical Associate Professor Department of Urology University of North Carolina Chapel Hill, NC Scott MacDiarmid, MD has relevant financial relationships with ineligible companies to disclose: Speaker’s Bureau: Astellas Pharm, Urovant Sciences Consultant: Astellas Pharm, Urovant Sciences, Allergan All relevant financial relationships have been mitigated. Dr. MacDiarmid does not intend to discuss the off-label use of a product. No (other) speakers, authors, planners or content reviewers have any relevant financial relationships to disclose. Content review confirmed that the content was developed in a fair, balanced manner free from commercial bias. Disclosure of a relationship is not intended to suggest or condone commercial bias in any presentation, but it is made to provide participants with information that might be of potential importance to their evaluation of a presentation. 12 ACTIVITY DESCRIPTION Audience Polling Question #1 Target Audience How often do you ask your adult patients about urinary symptoms? This educational initiative is designed as a comprehensive approach to address the practice needs of primary care providers, including primary care physicians, osteopathic physicians, physician assistants, nurse practitioners, and allied healthcare professionals, who are at the 1. Always forefront of caring for adult patients who may be suffering from OAB. 2. Frequently 3. Seldomly Learning Objectives Upon completing this activity, participants will be able to: 4. Never . Proactively screen and evaluate at-risk individuals for overactive bladder (OAB) . Utilize communication strategies aimed to evaluate the impact of OAB on quality of life and educate patients on appropriate treatment options and expectations . Identify patients with OAB who would benefit from combination therapy to maximize efficacy and tolerability 34 Audience Polling Question #2 Audience Polling Question #3 How confident are you in talking to your patients about overactive How confident are you in screening and diagnosing patients for bladder? overactive bladder? 1. Very confident 1. Very confident 2. Confident 2. Confident 3. Somewhat confident 3. Somewhat confident 4. Not confident 4. Not confident 56 1 Overactive Bladder Defined Prevalence of OAB Symptoms in Adults OAB is equally prevalent in men and women and increases with age International Continence Society Definition OAB is a more prevalent condition than chronic sinusitis or heart disease • Presence of urinary urgency, usually accompanied by frequency and 35 Men nocturia, with or without urgency urinary incontinence (UUI) 30 Women • No proven infection or other obvious pathology 25 Four components of OAB symptoms: 20 • Urgency 15 10 Prevalence* Prevalence* (%) • Frequency Prevalence* (%) 5 •Nocturia 0 *Overall prevalence, with and without urgency incontinence < 25 25-34 35-44 45-54 55-64 65-74 ≥ 75 • Urgency urinary incontinence N = 5204, P = NS women vs. men Age (years) Abrams P, et al. Neurourol Urodyn. 2002;21:167-178. Wein AJ, et al. Urology. 2002;60(suppl 5A):7-12. Adapted from Stewart WF, et al. World J Urol. 2003;20:327-336. Pleis JR, et al. Summary Health Statistics for U.S. Adults: National Lightner DJ, et al. J Urol. 2019;202:558. Health Interview Survey, 1998. National Center for Health Statistics. Vital Health Stat. 2002:10(209). 78 OAB Negatively Impacts Many Quality-of-Life Aspects OAB – A Major Cause of Concern for Many Patients1 Physical Psychological . Limitations/cessation . Depression . Disturbed sleep . Lack of self-esteem Wear dark, baggy . Difficulties concentrating . Lacking bladder control clothes to hide wet . Tiredness Quality – Urine odor spots or wear . Overeating diapers2 Use diapers or of Bathroom Social other absorbent mapping2,3 2,3 . Reduction in social products life interaction To cope with symptoms Sexual of OAB, many patients employ . Avoidance of sexual . Rely on toilet accessibility elaborate behaviors aimed at contact hiding and managing urine loss2 Domestic Occupational Carry extra Restrict fluid . Specialized underwear, . Absence from work clothes in case intake2,3 bedding . Decreased productivity of wetting 2 Try to urinate . Precautions with . Early retirement accident clothing on a schedule3 1. Rosenberg MT. Curr Urol Rep. 2008;9:428-32. Adapted from Tubaro A. Urology. 2004:64(suppl 6A):2-6. 2. Abrams et al. Am J Manag Care. 2000 Jul;6(11 Suppl):S580-S590. Irwin DE, et al. BJU Int. 2005;97:96-100. Muller N. Urol Nurs. 2005;25:109-115. 3. Ricci JA, et al. Clin Ther. 2001;23:1245-1259. 910 Key Populations: Patients With Diabetes and Obesity Effective Questioning to Detect OAB The first complaint may not be the chief complaint • Survey of 1359 patients with T2DM who were screened at a dedicated diabetes center1 • What brings you here today? What are your concerns? – 22.5% had OAB • What is your most distressing symptom? – 48.0% of those with OAB had incontinence • How are you handling your urinary symptoms? – What do you mean you urinate frequently? • Overweight and obese women with T2DM: high prevalence of UI – How long have you experienced these symptoms? – Higher than other complications commonly associated with diabetes • What have you tried to solve your problems? (retinopathy, 7.5%; microalbuminuria, 2.2%; neuropathy, 1.5%)2 • When asking these questions: • Important implications for screening for bladder dysfunction – Respect the patient’s situation – Consider a treatment plan – Aim for patient-centered medicine T2DM, type 2 diabetes mellitus. 1. Liu RT, et al. Urology. 2011;78:1040-1045. 2. Phelan S, et al; Action for Health in Diabetes Research Group. Diabetes Care. 2009;32:1391-1397. Marschall-Kehrel D, et al. Urology. 2006;68(suppl 2A):29-37. 11 12 2 Useful Questions to Direct the Diagnosis of OAB AUA/SUFU OAB Guidelines: Diagnostic Workup Do you have to rush to go to the toilet? Optional Additional Tests for Complicated or Initial Diagnostic Process Do you do this because of a sudden intense feeling Urgency Diagnostic Measures Refractory Patientsa so you have to urinate IMMEDIATELY? Do you feel that you urinate Urodynamics Frequency Urine culture too often during the day? History Postvoid residual Cystoscopy Physical Exam assessment Renal/bladder ultrasound Do you have to get up during the night to urinate? Nocturia Urinalysis Bladder diaries (should not be used in the Does the urge to urinate wake you? initial workup of Symptom questionnaires uncomplicated patients) When you feel the urge to go to the bathroom, do Urgency urinary you have leaks or wetting accidents? incontinence aPatients who failed multiple treatments Rosenberg MT, et al. Cleve Clin J Med. 2005;72:149-156. Lightner DJ, et al. J Urol. 2019;202:558. Irwin DE, et al. Eur Urol. 2006;50:1306-1315. 13 14 Differential Diagnosis of OAB AUA/SUFU OAB Treatment Guidelines • Behavioral therapies for all patients 1st Line • May be combined with pharmacologic management • Oral antimuscarinics or 3-agonist • ER formulations of antimuscarinics preferred over immediate-release • Transdermal oxybutynin may be offered nd • Dose modification or switch to different antimuscarinic or 3-agonist if inadequate 2 Line efficacy or poor tolerability with an antimuscarinic • Combination therapy with an antimuscarinic and 3-agonist can be considered for those refractory to monotherapy • Sacral nerve stimulation • Peripheral tibial nerve stimulation 3rd Line • Intradetrusor onabotulinum toxin A OAB, overactive bladder; SUI, stress urinary incontinence; UTI, urinary tract infection Gormley EA, et al. J Urol. 2015;193:1572-80. Lightner DJ, et al. J Urol. 2019;202:558. 15 16 Behavioral Modification OAB Pharmacotherapy: Different Receptor Pathways Acetylcholine Antimuscarinics – Timed ACH Diet voiding M3 muscarinic receptor Weight Loss (contraction) Quit smoking 3 agonist + Behavioral Detrusor smooth muscle Modification (relaxation) NE Norepinephrine Pelvic floor Delayed AR exercises voiding 3 Reinforcement Takeda M, et al. J Pharmacol Sci. 2010;2110:121-127. Fowler CJ, et al. Nat Rev Neurosci. 2008;8:453-466. 17 18 3 Antimuscarinics Used in OAB Treatment Antimuscarinics – Leader of the Pack? Immediate Release Drug Dose Dosing • Review of randomized trials revealed no Oxybutynin
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