From the Guidelines
For an 80-year-old female with new onset urge incontinence, hypertension, mild cognitive impairment, and osteoporosis, the most appropriate medication would be mirabegron (Myrbetriq), starting at 25 mg once daily, which can be increased to 50 mg daily if needed after 4-8 weeks. This recommendation is based on the latest evidence from the American Urological Association and the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (AUA/SUFU) guideline on the diagnosis and treatment of idiopathic overactive bladder 1. Mirabegron is preferred over anticholinergic medications like oxybutynin or tolterodine because it has a lower risk of cognitive side effects, which is particularly important given this patient's mild cognitive impairment.
Some key points to consider when prescribing mirabegron include:
- Monitoring for potential side effects, including increased blood pressure (relevant given her hypertension), urinary retention, and headache
- Implementing non-pharmacological approaches, including pelvic floor exercises, bladder training, and scheduled voiding
- Considering a topical vaginal estrogen preparation as a second-line option if mirabegron is not effective or not tolerated
The AUA/SUFU guideline recommends offering antimuscarinic medications or beta-3 agonists to patients with overactive bladder to improve urinary urgency, frequency, and/or urgency urinary incontinence 1. The American College of Physicians also recommends pharmacologic treatment in women with urgency UI if bladder training was unsuccessful, and clinicians should base the choice of pharmacologic agents on tolerability, adverse effect profile, ease of use, and cost of medication 1.
Given the patient's age and comorbidities, it is essential to prioritize medications with a favorable safety profile. Mirabegron, as a beta-3 adrenergic receptor agonist, has a different mechanism of action compared to anticholinergic medications and is associated with a lower risk of cognitive side effects, making it a suitable option for this patient 1.
From the FDA Drug Label
1 INDICATIONS AND USAGE
1.1 Adult Overactive Bladder (OAB) Mirabegron Monotherapy Mirabegron extended-release tablets are indicated for the treatment of OAB in adult patients with symptoms of urge urinary incontinence, urgency, and urinary frequency.
The most appropriate medication for an 80-year-old female with new onset urge incontinence, hypertension, mild cognitive impairment, and osteoporosis is Mirabegron.
- Key Points:
- Mirabegron is indicated for the treatment of Overactive Bladder (OAB) in adult patients with symptoms of urge urinary incontinence, urgency, and urinary frequency 2.
- The patient's symptoms align with the indications for Mirabegron.
- There is no direct contraindication with the patient's current medications (Lisinopril, Aricept, Prolia) in the provided drug labels. However, it is crucial to consider potential interactions and the patient's overall health status when prescribing any new medication. 2
From the Research
Medication Options for Urge Incontinence
Given Jane's medical history, including hypertension, mild cognitive impairment, and osteoporosis, it is essential to consider the potential interactions and side effects of medications for urge incontinence. The following points summarize the key considerations:
- Mirabegron: Studies have shown that mirabegron, a beta-3 adrenergic receptor agonist, is effective in treating overactive bladder symptoms, including urge incontinence 3, 4, 5, 6. However, it may have additive adverse effects, such as cardiac disorders, when combined with antimuscarinic drugs 7.
- Antimuscarinic agents: These drugs are commonly used to treat overactive bladder symptoms but may have side effects like dry mouth, constipation, and cognitive impairment 7, 4, 5.
- Combination therapy: Adding mirabegron to solifenacin, an antimuscarinic agent, has been shown to be effective in improving symptoms of incontinence and frequent urination in patients who remained incontinent despite initial solifenacin treatment 4.
Potential Interactions and Side Effects
When considering medication options for Jane, it is crucial to evaluate potential interactions with her existing medications, including:
- Lisinopril: There is no direct interaction between lisinopril and mirabegron or antimuscarinic agents.
- Aricept (Donepezil): There is no direct interaction between donepezil and mirabegron or antimuscarinic agents.
- Prolia (Denosumab): There is no direct interaction between denosumab and mirabegron or antimuscarinic agents.
However, mirabegron may cause a dose-dependent increase in blood pressure, which should be monitored in patients with hypertension 7, 3.
Conclusion is not allowed, so the response will be
Most Appropriate Medication
Based on the available evidence, mirabegron may be a suitable option for Jane, considering its efficacy in treating overactive bladder symptoms and relatively good safety profile 3, 4, 5, 6. However, it is essential to monitor her blood pressure and adjust the dosage as needed. Additionally, combination therapy with solifenacin may be considered if mirabegron monotherapy is not effective 4.