Anticholinergics (genitourinary)
| Type | Recommendation |
|---|---|
| When to deprescribe | |
| CBR |
We suggest deprescribing decisions be made in consultation with the person and their specialist providers to ensure it aligns with their preferences, goals and overall treatment plans. We suggest deprescribing of genitourinary anticholinergics be offered to older people:
|
| Ongoing treatment | |
| CBR |
If multiple attempts at deprescribing are unsuccessful and non-pharmacological interventions or alternative medications with fewer anticholinergic effects are not effective/possible, we suggest continuing the genitourinary anticholinergic at the lowest effective dose; however, the need for long-term therapy should be reassessed periodically. |
| How to deprescribe | |
| CBR |
Generally, we suggest discontinuing genitourinary anticholinergics without the need for tapering. Tapering may be considered for high-dose therapy, and some individuals may prefer gradual tapering by reducing the dose or dosing frequency per week that the medicine is taken. |
| GPS |
Healthcare providers should consider offering adequate education on lifestyle interventions (e.g. bladder training, pelvic floor exercises, timed toileting) to individuals, as appropriate, in addition to referrals to a continence advisor (ungraded good practice statement). |
| Monitoring | |
| CBR |
We suggest periodic evaluation of individual preferences, and psychological effects of deprescribing, and advising individuals to report to their healthcare professionals any symptoms of recurrence or disease exacerbation (e.g. any return or worsening of urgency, frequency, incontinence, or nocturia). |
CBR, consensus-based recommendation; GPS, good practice statement
Overactive bladder is common in older people and presents as urinary frequency, urgency, incontinence, and nocturia [426]. It is twice as prevalent in women as in men [427]. Non-pharmacological management includes symptom diaries, bladder training, intravesical botulinum toxin injections, pelvic floor exercises, and avoiding bladder irritants such as caffeine, alcohol, carbonated beverages, and acidic juices.
We identified one study related to deprescribing drugs for urinary frequency and incontinence from the systematic review and meta-analysis [428]. This retrospective, observational, before-and-after study reported a pharmacist-led intervention to reduce the use of urinary anticholinergics in older people. Appropriateness of urinary anticholinergics was assessed using a clinical decision support software (MedWise) coupled with the pharmacist’s clinical judgement (considering the duration of use, presence of side effects and reasonable benefits). At nine months, pharmacist recommendations to deprescribe urinary anticholinergics were accepted by prescribers in 118 out of 187 participants (63%). Among the 118 participants, complete discontinuation was the most common pharmacist recommendation (n = 50), followed by switching to mirabegron (n = 32), and dose reduction (n = 18). By study conclusion, six participants (5%) either had their urinary antimuscarinic dose returned to the baseline or increased. However, it was unclear what the pharmacist recommendations were for these six participants. Anticholinergic exposure, as measured using standardised daily doses reduced from 2.6 ± 2.8 at baseline to 0.9 ± 2.1 at nine months. Overall, this study did not investigate any critical or important outcomes (i.e. mortality, adverse drug withdrawal effects, physical health outcomes, cognitive function, and quality of life). Therefore, recommendations for the deprescribing of drugs for urinary frequency and incontinence are developed based on consensus.
The approach to deprescribe was individualised - urinary anticholinergics were either completely stopped, switched to mirabegron, or reduced in daily dose.
Urinary anticholinergics, including darifenacin, oxybutynin, propantheline, solifenacin, and tolterodine, are primarily used to manage urge incontinence by reducing bladder muscle contractility and increasing bladder capacity [177]. A Cochrane review found that while these medications offer modest symptom improvement over placebo, they also have a higher incidence of adverse effects, leading to increased discontinuation rates (except for tolterodine) [429]. There is limited evidence to determine the most effective anticholinergic or whether more selective agents (e.g. solifenacin, darifenacin) have fewer side effects. For people unable to tolerate anticholinergics, mirabegron may be an alternative for urinary urge incontinence, though it is currently not subsidised by PBS at the time of writing.
Older people are particularly susceptible to anticholinergic side effects, including urinary retention, blurred vision, dry mouth, constipation, and cognitive impairment [177]. Deprescribing should be considered when an inappropriate prescribing cascade is identified [430]. For instance, oxybutynin is sometimes prescribed after initiating cholinesterase inhibitors (e.g. donepezil) for dementia, which may induce urge incontinence [431]. Additionally, many commonly used medicines, such as diuretics, calcium channel blockers, ACE inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, antipsychotics, opioids, and benzodiazepines, can worsen lower urinary tract symptoms (LUTS) [432]. Assessing whether LUTS are a side effect of other medicines before initiating treatment for urinary incontinence is essential to avoid inappropriate prescribing cascades.
Cumulative anticholinergic burden in older people is associated with an increased risk of falls, cognitive decline, and all-cause mortality [433]. Before prescribing medicines with anticholinergic properties, their risks and potential interactions should be carefully assessed. While some medicines are prescribed for their anticholinergic effects, others possess anticholinergic activity unrelated to their primary indication. A comprehensive medication review is crucial for older people receiving multiple medicines with anticholinergic properties. This should include an assessment of the anticholinergic burden using validated tools such as the Drug Burden Index, which quantifies cumulative anticholinergic and sedative drug exposure [434]. Deprescribing may be appropriate for people with cognitive impairment, delirium, dementia and/or a high risk of falls due to the risk of adverse cognitive outcomes and sedation potentially outweigh the benefits of continued use, especially in patients with high anticholinergic burden. In the absence of a clear indication for ongoing treatment, or when the benefits are not identifiable, deprescribing should be considered.