How to manage overactive bladder (OAB) symptoms in patients taking antipsychotics?

From the Guidelines

Managing overactive bladder symptoms in patients taking antipsychotics requires a multifaceted approach combining behavioral modifications and pharmacological interventions, with first-line management including behavioral strategies such as scheduled voiding, fluid management, and pelvic floor exercises, as recommended by the most recent guidelines 1. The approach to managing overactive bladder (OAB) symptoms in patients taking antipsychotics should prioritize minimizing morbidity, mortality, and improving quality of life.

• Behavioral therapies, including bladder training, fluid management (limiting intake to 1.5-2 liters daily, especially before bedtime), avoiding bladder irritants like caffeine and alcohol, and pelvic floor exercises, are recommended as first-line treatment for all patients with OAB, according to the AUA/SUFU guideline on the diagnosis and treatment of idiopathic overactive bladder 1.
• If these measures are insufficient, anticholinergic medications like oxybutynin (5mg 2-3 times daily), solifenacin (5-10mg daily), or tolterodine (2-4mg daily) can be added, though with caution due to potential additive anticholinergic effects when combined with antipsychotics 1.
• Beta-3 adrenergic agonists such as mirabegron (25-50mg daily) may be preferable as they work through a different mechanism and avoid anticholinergic side effects, as suggested by the guideline on the diagnosis and treatment of idiopathic overactive bladder 1.
• For patients with severe symptoms, consultation with a urologist is recommended to consider advanced options like botulinum toxin injections or neuromodulation, as stated in the AUA/SUFU guideline on the diagnosis and treatment of idiopathic overactive bladder 1. It's essential to monitor for worsening constipation, dry mouth, cognitive effects, and urinary retention when adding OAB medications to antipsychotic regimens, considering the potential risks and benefits of each treatment option, as emphasized in the guideline on the diagnosis and treatment of idiopathic overactive bladder 1. The underlying mechanism of antipsychotic-induced OAB involves dopamine receptor blockade disrupting normal bladder function, while some antipsychotics with anticholinergic properties directly affect bladder contractility, making symptom management particularly challenging in this population, as noted in the guideline on the diagnosis and treatment of idiopathic overactive bladder 1. Overall, a personalized treatment approach, taking into account evidence-based recommendations and patient values and preferences, is crucial for effective management of OAB symptoms in patients taking antipsychotics, as recommended by the AUA/SUFU guideline on the diagnosis and treatment of idiopathic overactive bladder 1.

From the FDA Drug Label

CLINICAL STUDIES Tolterodine tartrate tablets were evaluated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency in four randomized, double-blind, placebo-controlled, 12-week studies. The FDA drug label does not answer the question.

From the Research

Managing Overactive Bladder Symptoms in Patients Taking Antipsychotics

• Overactive bladder (OAB) is a common syndrome characterized by unstable bladder contractions, resulting in urinary urgency, frequency, and nocturia in the absence of detectable disease 2.
• The management of OAB in patients taking antipsychotics requires a stepwise approach, starting with conservative measures such as weight reduction, decrease in exposure to bladder stimulants, fluid optimization, and pelvic floor exercises 2.
• Pharmacological treatments for OAB include anticholinergic medications such as oxybutynin, which can be effective in controlling urinary urge incontinence and decreasing incontinence episodes 3, 4.
• However, anticholinergic drugs can have significant adverse effects, such as dry mouth, which can be minimized by using transdermal formulations or switching to a lower dose or extended release formulation 3, 4.
• Other treatment options for OAB include bladder training, functional electrical stimulation, and sacral nerve stimulation, which can be used alone or in combination with anticholinergic therapy 3, 5.
• Emerging treatments for OAB, such as newer β3-agonists, targeted secretion inhibitors, and liposome integrated botulinum toxin A, are being developed and may offer improved efficacy and reduced adverse effects 6.

Treatment Options for OAB

• Anticholinergic drugs:
  • Oxybutynin (oral and transdermal) 3, 4
  • Tolterodine (oral) 3
  • Trospium (oral) 3
  • Solifenacin (oral) 3
  • Darifenacin (oral) 3
• Non-pharmacological therapies:
  • Bladder training 3, 5
  • Pelvic floor muscle training with or without biofeedback 5
  • Behavioural modification 5
  • Electrical stimulation (e.g. intravaginal electrical stimulation, transcutaneous electrical nerve stimulation) 5
• Emerging treatments:
  • Newer β3-agonists 6
  • Targeted secretion inhibitors (TSI) 6
  • Liposome integrated botulinum toxin A 6

Considerations for Patients Taking Antipsychotics

• Antipsychotic medications can exacerbate OAB symptoms, and therefore, treatment of OAB in these patients requires careful consideration of the potential interactions between antipsychotic and OAB medications 3.
• The choice of anticholinergic therapy should be guided by individual patient comorbidities, and dose escalation should be avoided to minimize adverse effects 3.