Are oxybutynin and trospium efficacious in the treatment of detrusor overactivity in spinal cord injury patients?

Abstract

Objectives: To evaluate the efficacy of anticholinergic agents in the treatment of neurogenic overactive bladder (NOAB) and neurogenic detrusor overactivity (NDO) in spinal cord injury (SCI) patients on clean intermittent catheterisation (CIC). Methods: Chronic suprasacral SCI patients on CIC presenting with at least one urinary leakage a day were included. Urodynamics and voiding diaries were performed at baseline and 1 month follow-up. In case of NDO at baseline, an anticholinergic drug was prescribed. Results: The 231 SCI patients presented with one to five urinary leakages per day (mean 2.1). Urodynamics showed NDO in all patients. A new anticholinergic treatment was started in all, either in monotherapy (134 patients) or in association with the existing anticholinergic drug (oxybutynin þ trospium bitherapy, 97 patients). The mean maximum bladder capacity significantly increased from 225 to 441 ml, and the mean involuntary detrusor contractions (IDC) significantly decreased from 67 to 41 cm H 2 O. Only 75 SCI patients (32%) were fully continent. However, 25 out of these 75 patients showed persistent NDO, with amplitudes of IDC above 40 cm H 2 O in 12 patients. Incontinence was still found in 156 SCI patients (67%), with an average of 1,2 leakages a day. In 100 patients, amplitudes of IDC remained above 40 cm H 2 O. There was no statistical difference between patients on anticholinergic monotherapy or bitherapy at follow-up. Conclusion: Anticholinergic treatment is not always satisfactory in terms of control of NDO and rarely allows full continence. INTRODUCTIONThe quality of life of patients presenting with spinal cord injury (SCI) is frequently impaired by lower urinary tract dysfunction. In supra-sacral SCI lesions, neurogenic overactive bladder (NOAB) is common, with symptoms including urgency, with or without urge incontinence, frequency and nocturia. 1 Patients with NOAB are often found to have neurogenic detrusor overactivity (NDO), an urodynamic observation characterised by involuntary detrusor contractions (IDCs) during the filling phase that is either spontaneous or provoked. 2 Amplitudes of IDC greater than 40 cm H 2 O pose a threat to the upper urinary tract. 3 Oral antimuscarinic agents have been widely used as first-line treatment for patients with NDO. However, they are ineffective in some patients and are often associated with bothering side effects such as dry mouth, constipation and blurred vision. 2,4 The clinical and urodynamic efficacy of anticholinergic agents in SCI patients has been evaluated in a limited number of studies. [5][6][7][8][9] They all showed a significant decrease in the number of leakages per day with improved quality of life. Urodynamic testing showed significant improvement in maximum bladder capacity (BCmax) and significant reduction in amplitudes of IDC. However, these were mainly short-term studies, using different evaluation criteria, with different drugs at flexible doses. Surprisingly, patients presenting with daily leakages and persistence of IDC (as high as 35...

Efficacy and safety of onabotulinumtoxinA therapy are sustained over 4 years of treatment in patients with neurogenic detrusor overactivity: Final results of a long‐term extension study

“…Consistent and clinically meaningful reductions in the number of daily UI episodes were observed following long‐term, repeated treatment with onabotulinumtoxinA. High proportions of patients with ≥50% reduction in UI episodes were observed over 4 years, similar to the phase III studies, and the proportion of patients who achieved complete continence with onabotulinumtoxinA (43–56%) is markedly higher than has been reported for other NDO treatments . OnabotulinumtoxinA also continued to improve the ability of the bladder to store urine, as evidenced by the consistent increases in volume/void with each treatment.…”

“…High proportions of patients with !50% reduction in UI episodes were observed over 4 years, similar to the phase III studies, 5,6 and the proportion of patients who achieved complete continence with onabotulinumtoxinA (43-56%) is markedly higher than has been reported for other NDO treatments. 14,15 OnabotulinumtoxinA also continued to improve the ability of the bladder to store urine, as evidenced by the consistent increases in volume/void with each treatment. Furthermore, the sustained improvements in urinary symptoms with onabotulinumtoxinA were complemented by clinically meaningful improvements in QOL, which were again consistent with the phase III studies.…”

Shifting to 4 × 1 intermittent catheterization without an early follow-up urodynamic study is possible in most patients with subacute spinal cord injury

“…12 That study with a larger number of patients had results similar to ours as regards the significant increase in the maximum cystometric capacity and it was emphasized that urodynamic follow-up was mandatory as full continence was not achieved in most patients and anticholinergic treatment could not always adequately suppress neurogenic detrusor overactivity. We found in our study that patients who were undergoing IC 6 times a day and used anticholinergic treatment appropriately could go on to a catheterization frequency of 4/day after a mean duration of approximately 30 days in 92.6% of the cases.…”

Inosine attenuates spontaneous activity in the rat neurogenic bladder through an A2B pathway

“…Pharmacological management of NDO has focused significantly on attenuation of cholinergic signalling, either through anti-muscarinic receptor blockade or by inhibition of neurotransmitter release. Current first-line treatment with oral anti-muscarinic agents is often associated with undesirable systemic side effects that limits its long-term use, and its efficacy has been reported to be variable2. Botulinum toxin A has demonstrated significant improvements in a variety of urodynamic parameters3 but requires repeat endoscopic administration due to limited durability.…”