Para/Medic: Options to Manage Bladder Spasms


BobOct14

Q. I’m 24, in my second year as a T4 para and manage my bladder with intermittent catheterization. I started leaking and having accidents while I was still in rehab, though I was careful not to let my bladder get too full. A urodynamic workup showed I was having bladder spasms, so I was put on 10mg Ditropan XL every day, which keeps me dry. A follow-up urodynamic eval confirmed the medication is keeping my bladder quiet. My problem is the medication gives me dry mouth, and seems to make me drowsy.  

I know it is important to keep my bladder quiet, but I’m tired of the side effects. I’ve heard there are other options that will quiet my bladder but help me ditch the dry mouth and fatigue. What are the ones that produce the fewest side effects?

— Darryl

A. Darryl, less than two decades ago the only medication option to manage bladder spasms caused by neurogenic bladder was Ditropan, which often produces side effects, including severe dry mouth. This changed in early 2000s, when the pharmaceutical industry saw the financial potential in creating medications for millions of nondisabled adults over 40 who experience bladder spasms. The term “overactive bladder” was coined and medications to control bladder spasms has became big business — a bonus for those of us with neurogenic bladder as we now have a variety of options to choose from, including oral medications, gels, transdermal patches and Botox.

It is extremely important to find an option to calm neurogenic bladder spasms early on so you can maintain a bladder that will fill to a normal size, explains Dr. Michael Kennelly, director of urology at Carolinas Rehab in Charlotte, N.C. When a bladder spasms, it develops high bladder pressures that can cause dysreflexia. Unmanaged, spasms can also cause reflux, kidney damage and loss of elasticity in the bladder, which permanently reduces bladder capacity. At that point the only option is some type of surgery, for instance a suprapubic or bladder augmentation.

Kennelly has been working with people who have SCI for over 20 years and has done studies and published papers on many options for treating bladder spasms. “All medications that are FDA-approved for overactive bladder can be used for people with neurogenic bladder. The FDA doesn’t have a separate category. Neurogenic bladder is a sub-category of overactive bladder,” says Kennelly. “The big money is in overactive bladder, so that’s where pharmaceutical companies do their first studies. Then, if they choose to, they do studies in smaller populations, including neurogenic bladder.”

The current options for treating overactive bladder are:

  1. Oxybutynin: Ditropan and Ditropan XL extended release tablets; Oxytrol Patch; Gelnique topical gel 10 percent packets, and 3 percent gel pump.
  2. Tolterodine (brand names Detrol and Detrol LA).
  3. Trospium chloride (Sanctura and Sanctura XR tablets).
  4. Myrabegron (Myrbetriq tablets).
  5. Darifenacin (Enablex).
  6. Fesoterodine (Toviaz)
  7. Solifenacin (VESIcare).
  8. Botox injections.

Of all these, only oxybutynin, tolterodine, trospium chloride and Botox injections have been studied on people with neurogenic bladder.

In terms of oral drugs, there isn’t one medication that quiets the bladder more than another one. Everything comes down to higher dosing, says Kennelly, but the higher the dose, the more side effects you have, including dry mouth, constipation, blurred vision and cognitive effects.  However, extended release formulas have fewer side effects than immediate release formulas.

Kennelly created a handout that includes a comprehensive chart comparing FDA-approved medication options for overactive bladder. The oral medications that had the fewest side effects are Sanctura (twice a day) and Sanctura XR (once daily). Based on studies, they have dry mouth rates of less than 20 percent, less than 10 percent constipation, and a low rate of sedation. But the oral medication with the fewest side effects by far is Myrbetriq, a once daily pill — introduced in mid-2012— that has a less than 10 percent rate of dry mouth, less than 3 percent constipation, and a very low rate of sedation. “I’m currently utilizing Myrbetriq for a lot of people with SCI and they notice, ‘Wow, I don’t have a dry mouth,’” says Kennelly.

When starting any medication for neurogenic bladder, the important thing, says Kennely, is to follow up with urodynamics to make sure bladder pressures are doing well. “There are studies underway with this medication

[Myrbetriq], but they are being done by people like me and not the pharmaceutical companies.” As with all medications, check in advance to see if it is reimbursable by your insurance, and check price if you have a share of cost — a month’s supply of Sanctura XR lists for $215 and Mybetriq lists for $293.

There are two topical options, both oxybutynins, that have good efficacy keeping the bladder quiet and side effects as low as Mybetriq — the Gelnique gels and the transdermal patch, Oxytrol. They avoid side effects by going from the skin directly into the bloodstream, thus bypassing the metabolism in stomach and liver that creates unwanted side effects associated with oral oxybutynin. The gel is rubbed on the abdomen, thigh, or upper arm once a day. Kennelly says those he treats prefer the 10 percent gel because they only have to apply one-third as much, so it dries faster. For share of cost, a month’s supply of 3 percent gel lists for $222, while 10 percent gel lists for $241.

The Oxytrol patch is applied to the abdomen, hip or buttock and is changed every three to four days. Kennelly says about 4 percent developed a rash with the patch. Some in his practice also say the patch can catch on sweaters and clothing and create a sticky ring on the clothing. Oxytrol is now sold over the counter, in the same prescription strength, meaning insurance will no longer cover it. A month’s supply retails for around $30.

Still, the option with the fewest overall reported side effects is Botox injections, which was FDA-approved to treat overactive bladder and neurogenic bladder in 2011. Kennelly has been using Botox to treat neurogenic bladder for the past 15 years. “It works really well for people who have a lot of spasms,” he says. The procedure is done through a cystoscope — an instrument like a catheter with a camera on the end that goes into your bladder and is used to inject 200 units of Botox in a pattern of 30 injections on the bladder wall. It usually takes about seven to 10 days for the procedure to take effect, and it should last up to six to nine months, says Kennelly. “It is covered by Medicare, and if you have secondary insurance, you pay zero out of pocket,” he says. “Here in my office if someone has a Medicare co-pay [and no secondary insurance], the most it should run them out of pocket is about $125.”

Darryl, hopefully one of these options will work for you — and your insurance — so you can ditch the dry mouth and fatigue.

Resources
• Neurogenic and  medication comparison chart: www.newmobility.com/pdf/ParaMedic_Chart_May15.pdf
• FDA Approves Botox: www.newmobility.com/2011/10/fda-approves-botox/

If you have a health question, contact Bob Vogel at rhvshark@mac.com.


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