Therapeutic AreaFormulary ChoicesCost for 28
(unless otherwise stated)
Rationale for decision / comments
7.4.2 Drugs for urinary frequency, enuresis, and incontinence
Related guidance: NICE Clinical Guideline CG111 (2010): Bedwetting in under 19s
NICE Clinical Guideline NG123 (2019): Urinary incontinence and pelvic organ prolapse in women: management
Before initiating treatment a thorough investigation of the underlying cause of incontinence should be carried out and drug treatments should be reviewed 4 weeks after starting. If there is no or suboptimal improvement or intolerable adverse effects change the dose, or try an alternative antimuscarinic drug, and review again 4 weeks later.
Thereafter, treatments should be reviewed annually, or every 6 months if patient is over 75 years.

Pelvic floor muscle training. NICE recommends a trial of supervised pelvic floor muscle training of at least 3 months' duration as first-line treatment to women with stress or mixed UI, comprising at least 8 contractions performed 3 times per day.
NHS choices guide to pelvic floor exercises
First-line:Oxybutynin
(immediate release)
2.5mg tablets: £1.26 (56)
5mg tablets: £3.19 (56)
As per NICE guidance offer the anticholinergic medicine with the lowest acquisition cost to treat overactive bladder or mixed urinary incontinence in women. If the first medicine for overactive bladder or mixed urinary incontinence is not effective or well-tolerated, offer another medicine with a low acquisition cost.
Do not offer oxybutynin (immediate release) to older women who may be at higher risk of a sudden deterioration in their physical or mental health.
Tolterodine
(immediate release)
1mg tablets: £1.95 (56)
2mg tablets: £2.01 (56)
Research has shown that concordance after 3 years is less than 10% regardless of class of drug use with little to differentiate treatment options (Shamliyan T, et al. Benefits and harms of pharmacologic treatment for urinary incontinence in women. A systemic review. Ann Intern Med 2012; 156:861-74)

NICE advises that some adverse effects are indications that treatment is having effect and that they may not see full benefits for 4 weeks.
If first treatment for OAB or mixed UI is not effective or not tolerated, offer another drug with the lowest acquisition cost.
Aim to avoid additional antimuscarinic drugs particularly in elderly and patients with dementia due to risk of delirium. See muscarinic load below.

As per NICE guideline [NG123] April 2019 -
When offering anticholinergic medicines to treat overactive bladder, take account of the woman's:
•coexisting conditions (such as poor bladder emptying, cognitive impairment or dementia)
•current use of other medicines that affect total anticholinergic load
•risk of adverse effects, including cognitive impairment

For women who have a diagnosis of dementia and for whom anticholinergic medicines are an option, follow the recommendations on medicines that may cause cognitive impairment in the NICE guideline on dementia.

Second-line:Oxybutynin MR5mg m/r tablets: £13.77 (30)
10mg m/r tablets: £27.54 (30)
Tolterodine MR as Neditol XL®

or Mariosea XL®
2mg m/r capsules: £11.60 (28)
4mg m/r capsules: £12.89 (28)

2mg m/r capsules: £11.59 (28)
4mg m/r capsules: £12.88 (28)
Trospium (immediate release)
20mg tablets:£5.06 (60)
Trospium MR as Regurin XL®60mg tablets: £23.05 (28)
Propiverine
(immediate release)

Propiverine MR
15mg tablets: £18.00 (56)


30mg capsules: £24.45 (28)
Darifenacin
(once daily)
7.5mg tablets: £25.48 (28)
15mg tablets: £25.48 (28)
Third-lineSolifenacin
tablets

liquid as Vesicare®
5mg tablets: £27.62 (30)
10mg tablets: £35.91 ( 30)

1mg/ml oral suspension: £27.62 (150ml)
Evidence indicated that higher dose of solifenacin is more likely to cause side effects than tolterodine MR or Trospium MR
Once daily dosage only
Duloxetine20mg capsules: £2.94 (28)
40mg capsules" £4.89 (28)
May be offered as second‑line therapy if women prefer pharmacological to surgical treatment or are not suitable for surgical treatment. If duloxetine is prescribed, counsel women about its adverse effects
Fesoterodine4mg m/r tablets: £25.78 (28)
8mg m/r tablets: £25.78 (28)
Mirabegron25mg tablets: £29.00 (28)
50mg tablets: £29.00 (28)
To use as an option where antimuscarinic drugs are contra-indicated or clinically ineffective or side-effects are unacceptable, before surgery or botox therapy
Lower dose used where hepatic or renal impairment exists.
Mirabegron is now contraindicated in patients with severe uncontrolled hypertension (systolic blood pressure ≥180 mm Hg or diastolic blood pressure ≥110 mm Hg, or both).Blood pressure should be measured before starting treatment and monitored regularly during treatment, especially in patients with hypertension. MHRA alert October 2015
Do not combine treatment of mirabegron and another OAB drug
Non oral therapyOxybutinin PatchesOxybutinin 3.9mg/24 hours: £27.20 (8)Oxybutinin patches remain an option at any stage for those unable to tolerate oral therapy or for patients with swallowing problems to avoid the need for unlicensed liquid formulations.
Patches are applied twice weekly to clean, dry, unbroken skin on abdomen, hips or buttocks.
For the use of desmopressin in the treatment of nocturnal enuresis, please refer to section 6.5.2 Posterior pituitary hormones and antagonists

Aging Brain Anticholinergic load

OAB Pathway