What are the first-line medications for managing urinary incontinence, specifically urge incontinence?

First-Line Medications for Urge Urinary Incontinence

For urge incontinence, bladder training should be the first-line treatment, with antimuscarinic medications (such as tolterodine or darifenacin) recommended as first-line pharmacologic therapy only if bladder training is unsuccessful. 1

Treatment Algorithm for Urge Incontinence

First-Line Non-Pharmacologic Therapy

• Bladder training is the recommended first-line treatment for urgency urinary incontinence (Grade: strong recommendation, moderate-quality evidence) 1
• This non-pharmacologic approach has a large magnitude of benefit for increasing continence rates with low risk for adverse effects 1

First-Line Pharmacologic Therapy (if bladder training unsuccessful)

When bladder training fails, pharmacologic treatment should be initiated based on:

1. Antimuscarinic agents:

   • Tolterodine - Has risk for discontinuation due to adverse effects similar to placebo (high-quality evidence) 1
   • Darifenacin - Also has risk for discontinuation due to adverse effects similar to placebo (high-quality evidence) 1
   • These two medications should be considered first due to their favorable tolerability profiles 1

2. Other antimuscarinic options:

   • Solifenacin - Associated with the lowest risk for discontinuation due to adverse effects among other antimuscarinics (high-quality evidence) 1
   • Fesoterodine, trospium, and propiverine - Effective but with higher discontinuation rates than placebo 1
   • Oxybutynin - Associated with the highest risk for discontinuation due to adverse effects (high-quality evidence; NNTH, 16) 1

3. β-3 adrenoceptor agonists:

   • Mirabegron - FDA-approved for treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency 2
   • Has fewer anticholinergic side effects compared to antimuscarinic medications 3
   • Common side effects include nasopharyngitis and gastrointestinal disorders 1

Comparative Effectiveness and Tolerability

• All pharmacologic therapies are equally efficacious at managing urgency UI with moderate benefit in achieving continence rates 1
• Tolerability differs significantly between agents:
  • Tolterodine has fewer adverse effects than oxybutynin (high-quality evidence; NNTH for oxybutynin vs. tolterodine: 14) 1, 4
  • Discontinuation due to adverse effects was higher with fesoterodine than tolterodine (moderate-quality evidence; NNTH: 58) 1
  • No significant difference in discontinuation rates between solifenacin and tolterodine (moderate-quality evidence) 1

Common Adverse Effects to Monitor

• Antimuscarinic agents: dry mouth, constipation, and blurred vision 1, 4
• Oxybutynin: highest incidence of dry mouth and central nervous system effects 5, 6
• Mirabegron: nasopharyngitis and gastrointestinal disorders 1

Important Clinical Considerations

• Patient adherence to pharmacologic treatments for UI is generally poor due to adverse effects 1
• When selecting a medication, consider tolerability, adverse effect profile, ease of use, and cost 1
• For patients with mixed incontinence (both urge and stress components), treatment should address both components 7
• Pharmacologic therapy is not recommended for stress urinary incontinence (Grade: strong recommendation, low-quality evidence) 1
• For obese women with urinary incontinence, weight loss and exercise are strongly recommended (Grade: strong recommendation, moderate-quality evidence) 1

Special Populations

• Safety profiles of tolterodine are similar in patients aged ≥65 years and younger adults 4
• Dosage adjustments may be needed for patients with hepatic impairment or those taking cytochrome P450 inhibitors 8
• For patients with both urinary incontinence and retention, careful consideration is needed as treatments for one condition might affect the other 7