"Interestingly, I think physicians are aware of the potential cognitive issues associated with long-term use of anticholinergics, so when they are being used, those aspects, the potential risks and potential benefits, are considered and balanced.
Part of the problem is insurance coverage. Anticholinergics are often Tier 1 drugs, so step therapy is a problem. You have to try certain formulations or medications and fail to be eligible to use other OAB medications that may minimize or have less potential side effects or have a safer side effect profile.
There are good data on the association of anticholinergic medications and potential cognitive effects, including the 2015 JAMA paper that showed an increased risk of dementia over 7-10 years in an elderly population. Based on this, you can prescribe anticholinergics and counsel patients on potential risks or you can skip them. However, you often have to trial them in order to be eligible for other options.
There are options, and patients should be presented with all options: maximizing conservative treatments, all the medical options—anticholinergics, beta-3 receptor adrenergic receptor agonists, possibly off-label medications—and then also be educated on third-line therapies.
On the overuse of medication, the number of prescriptions probably doesn’t reflect reality. Some studies have shown about a 20%-30% compliance rate with anticholinergics in 1 or 2 years; patients don’t necessarily stay on the medication. Prescriptions may be not filled, or not tolerated after a few weeks.
Some older data show that medication is most effective if done in combination with things like urge supression, moderating fluids, and strengthening muscles. It takes time, however, for medical providers to teach patients these things and also commitment from the patient to make these changes. But it can be effective.
There’s also sacral neuromodulation (Interstim), peripheral tibial nerve stimulation (Urgent PC), and onabotulinumtoxinA (Botox). Some patients manage their symptoms conservatively, some patients will take medication and be successful, and a certain percentage will be treated with more invasive therapies and be happy.”
Una Lee, MD