Which Urinary Antispasmodic Should I Choose?

Selecting a urinary antispasmodic (UA) can be complex given differences in tolerability, insurance coverage, and patient preference. One of the most highly utilized UA agents in the AHP population is Vesicare; it is also the most expensive. It is typically covered on a higher insurance tier than other generically-available agents and can cost over $400 out of pocket for cash-paying and high deductible patients.

Trospium is a non-selective UA, but is water-soluble and has lower blood brain barrier penetration than oxybutynin, tolterodine ER, or Vesicare. Lower CNS penetration is beneficial in patients where CNS effects, such as cognitive impairment, are a concern (e.g., elderly patients). It is also the only agent in the UA class not metabolized by CYP3A4 or CYP2D6, limiting drug interaction potential.

COMING SOON! Definitive comparative data is lacking as there are very few head-to-head trials, so the best strategy is often to select and trial an agent, and then select and trial another agent if the initial choice isn’t Clinical Pharmacist effective, tolerated, or covered. Medication Management Agents that may be a good option: Highlight  if affordability is a concern: oxybutynin ER, trospium ER  If prescribing for elderly patients: trospium ER In future editions we will Note: all UA agents remain on the AGS Beer’s Criteria, so caution with any therapy is recommended highlight real world examples of the support Extended release formulations increase tolerability of these agents without altering efficacy and are clinical pharmacists bring often preferred. However, there is still variability among these agents in terms of tolerability and cost. See below for a comparison of tolerability and cost for the long-acting UA agents. to the healthcare team. Comparison of Potential Side Effects and Cost for Long-Acting Urinary Antispasmodics

Oxybutynin Trospium Tolterodine Darifenacin Fesoterodine Solifenacin chloride ER chloride ER tartrate ER ER (Toviaz) (Vesicare)

Do you have a medication Dry Mouth1 45 10 23 27 27 20 management question? Constipation1 10 9 6 17 5 9 Contact 1 Jenny Radcliffe, PharmD Blurred vision 4 <1 <1 2 <1 4

AHP Clinical Pharmacist 1  (585) 758-7719 CNS effects 9 <1 2 2 <1 2 Jennifer_Radcliffe Brain High Low High Low Low High @urmc.rochester.edu Penetration2

Average $91 $179 $227 $348 $410 $428 monthly cash price*

1Percent incidence based on FDA-approved package insert 2 AUGS Consensus Statement: Association of Anticholinergic Medication Use and Cognition in Women with Overactive Bladder. Female Pelvic Medicine & Reconstructive Surgery 2017;23(3):177. *www.goodrx.com as of June 2018; prices will vary based on individual insurance coverage, product manufacturer, pharmacy, strength, and month supply