What is the first-line medication for overactive bladder?

First-Line Medication for Overactive Bladder

Behavioral therapies—not medications—are the first-line treatment for overactive bladder, and all patients must begin with these interventions before considering pharmacologic options. 1, 2

First-Line Treatment: Behavioral Interventions (Not Medications)

The American Urological Association explicitly designates behavioral therapies as first-line treatment for all patients with overactive bladder 1, 2. These include:

• Bladder training and bladder control strategies should be offered to every patient as initial management 2
• Pelvic floor muscle training is equally effective as antimuscarinic medications in reducing symptom levels, with high-strength evidence 2
• Fluid management with reduction in fluid intake can reduce frequency and urgency 2
• Weight loss in obese patients can reduce incontinence episodes by up to 47% 2

Second-Line Treatment: Pharmacologic Options

Only after behavioral therapies have been tried should medications be considered 1, 2, 3. When pharmacotherapy is indicated, you have two main classes:

Beta-3 Adrenergic Agonists (Preferred in Most Patients)

Mirabegron is typically preferred before antimuscarinic medications due to cognitive risk concerns, especially in elderly patients. 2

• Mirabegron 25 mg once daily is the recommended starting dose, with escalation to 50 mg after 4-8 weeks if needed 4
• Better tolerated than antimuscarinics with lower incidence of dry mouth and constipation 2
• No cognitive impairment risk unlike antimuscarinics 2

Antimuscarinic Medications (Alternative Second-Line)

If beta-3 agonists are not suitable, antimuscarinic options include:

• Darifenacin (selective M3 receptor antagonist) has lower risk of cognitive effects 2
• Fesoterodine (non-selective muscarinic receptor antagonist) is effective for OAB 2
• Solifenacin is indicated as second-line therapy after behavioral therapies 3
• Oxybutynin has the highest risk of discontinuation due to adverse effects and should generally be avoided as first choice 2

Critical Safety Considerations

Antimuscarinic medications should be used with extreme caution in patients with narrow-angle glaucoma, impaired gastric emptying, or history of urinary retention. 2, 3

• Potential cumulative and dose-dependent risk for dementia and cognitive impairment exists with antimuscarinic medications 2
• Cognitive concerns in elderly patients strongly favor beta-3 agonists over antimuscarinics 2

Treatment Algorithm

1. Start all patients with behavioral therapies: bladder training, pelvic floor muscle training, fluid management, and weight loss if applicable 2

2. If behavioral therapies are insufficient, add pharmacotherapy with beta-3 agonist (mirabegron) as preferred first medication 2

3. For patients with cognitive concerns or elderly, beta-3 agonist medications are strongly preferred 2

4. If inadequate symptom control or unacceptable adverse events with one medication, try dose modification, a different antimuscarinic, or switch between classes 1

5. Combination therapy with solifenacin 5 mg plus mirabegron 50 mg is statistically superior to monotherapy for patients failing single-agent therapy 2

Common Pitfalls to Avoid

• Failing to optimize behavioral therapies before starting medications is the most common error 2
• Not considering cognitive risks when prescribing antimuscarinics, especially in elderly patients 2
• Abandoning antimuscarinic therapy after failure of one medication instead of trying another agent or switching to beta-3 agonist 1, 2
• Using antimuscarinics in patients with contraindications such as narrow-angle glaucoma, impaired gastric emptying, or urinary retention history 2