Accurate assessment and diagnosis of the cause of incontinence is vital for treatment success. Non-drug treatments have an important role in management

Modified release preparations tablets are included in the formulary as options for patients unable to tolerate standard release oxybutynin because of anticholinergic side effects.

Desmopressin (refer to section 6.5 Hypothalamic and pituitary hormones and anti-oestrogens) is licensed for nocturnal enuresis.

Please refer to:

• NICE CG171 The management of urinary incontinence in women (September 2013)
• NICE CG97 The management of lower urinary tract symptoms in men (May 2010)

Please note NICE CG171 recommends, for women;

• Before over active bladder drug treatment starts, discuss with women that they may not see the full benefits until they have been taking the treatment for 4 weeks.
• Offer one of the following choices first to women with over active bladder or mixed urinary incontinence:
  • oxybutynin (immediate release), or
  • tolterodine (immediate release), or
  • darifenacin (once daily preparation).
  • If the first treatment for is not effective or well-tolerated, offer another drug with the lowest acquisition cost.

Drugs used not listed here:

• Duloxetine, see section 4.3.4 Other antidepressant drugs

Tolterodine tartrate

• Tablets 1mg, 2mg (£2.90 = 2mg twice daily)
• Modified-release capsules 4mg (click here for preferred brand)

Indications

• Urinary frequency, urgency and incontinence

Dose

• 2mg twice daily, reduce to 1mg twice a day if necessary to reduce side-effects
• Modified-release: 4mg once daily

Notes

1. Tolterodine should be used with caution in patients with a history of QT-interval prolongation or in those patients also taking drugs that prolong the QT interval
2. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above)

Oxybutynin hydrochloride

• Tablets 2.5mg, 5mg (1.92 = 5mg three times daily)
• Modified-release tablets 5mg, 10mg (£29.13 = 10mg daily)
• Patches 36mg (3.9mg oxybutynin/24 hours) (£27.20 = 8 patches)

Indications and dose

• Urinary frequency, urinary urgency, urinary incontinence, neurogenic bladder instability:
  • Immediate-release: Initially 5mg 2–3 times daily, increased if necessary to maximum 5mg 4 times daily; elderly initially 2.5mg twice daily, increased to 5mg twice daily according to response and tolerance
  • Modified-release: Initially 5mg once daily, adjusted according to response in steps of 5mg at weekly intervals; maximum 20mg once daily
• Hyperhidrosis: which has not responded to a topical aluminium antiperspirant and self-care management strategies (second line) (off-label):
  • Immediate-release: Initially 2.5mg once daily, adjusted according to response and tolerability; maximum 10mg daily given in two to four divided doses.
  • Modified-release: Where immediate release products are not tolerated. Initially 5mg once daily, increased if required to a maximum dose of 10mg once daily.

Notes

1. Medicine Supply Notification MSN/2023/116 (18 December 2023): Oxybutynin 5mg modified-release tablets
   1. Oxybutynin 5mg modified-release tablets are out of stock until mid-July 2024.
   2. Oxybutynin immediate-release formulations (tablets and liquids) remain available and can support increased demand, as can alternative anticholinergic agents.
   3. Refer to the MSN for advice on prescribing.
2. Do not offer oxybutynin-immediate release to frail older patients.
3. Oxybutynin immediate-release tablets may be particularly suitable for those who wish to take medication on an occasional basis or to titrate doses themselves. If these have failed, there is little benefit trying tolterodine or MR preparations.
4. Although it is an off-label use, specialists advise that for patients with hyperhidrosis, oxybutynin is considered ahead of the licensed alternative (propantheline bromide) owing to greater evidence of efficacy and lower cost.
   

Trospium chloride

• Tablets 20mg (£9.69 = 20mg twice daily)

Indications

• Urinary frequency, urgency and incontinence

Dose

• 20mg twice daily, before food.

Darifenacin

• Modified-release tablets 7.5mg, 15mg (£25.48 = 7.5mg daily)

Indications

• Urinary frequency, urgency and incontinence

Dose

• 7.5mg once daily, increased to 15mg once daily after 2 weeks if necessary

Fesoterodine fumarate

• Modified-release tablets 4mg, 8mg (£2.89 = 4mg daily)

Indications

• Urinary frequency, urgency and urge incontinence

Dose

• 4mg once daily, increased if necessary to maximum 8mg once daily

Notes

1. Fesoterodine has been added for use as a 'third-line' antimuscarinic when second-line treatments have failed

Solifenacin succinate

• Tablets 5mg, 10mg (£1.36 = 5mg daily)
• Oral suspension sugar free 1mg/1ml (£27.62 = 150ml)

Indications and dose

• Urinary frequency, urgency and urge incontinence in adults
  • 5mg once daily, increased if necessary to 10mg once daily
• Neurogenic detrusor overactivity in children aged 2-17 years, using oral suspension (specialist)
  • Body-weight 9-15kg: initially 2mg once daily, increased if necessary up to 4mg once daily
  • Body-weight 16-30kg: Initially 3mg once daily, increased if necessary up to 5mg once daily
  • Body-weight 31-45kg: Initially 3mg once daily, increased if necessary up to 6mg once daily
  • Body-weight 46-60kg: Initially 4mg once daily, increased if necessary up to 8mg once daily
  • Body-weight 61kg and above: Initially 5mg once daily, increased if necessary up to 10mg once daily

Notes

1. Tablets are not licensed for use in children
2. See SPC for dosing recommendations/contraindications in hepatic and renal impairment and with concomitant use of certain medications
3. Oral suspension should be taken orally followed by a glass of water
4. The need for continuing therapy for urinary incontinence should be reviewed every 4–6 weeks until symptoms stabilise, and then every 6–12 months
5. The need for continuing therapy for neurogenic detrusor overactivity should be reviewed at least every 12 months

Mirabegron

• Modified-release tablets 25mg, 50mg (£27.07 = 50mg daily)

Indications

• Urinary frequency, urgency and urge incontinence

Dose

• 50mg once daily (see notes for guidance on renal or hepatic impairment)

Notes

1. Mirabegron is contraindicated for use in patients with severe uncontrolled hypertensive patients (systolic blood pressure 180 mm Hg or greater and/or diastolic blood pressure 110 mm Hg or greater). Blood pressure should be measured before and during treatment, especially in patients with hypertension.
2. Mirabegron is recommended as an option for patients only in whom antimuscarinic drugs are contraindicated, clinically ineffective, or have unacceptable side effects. It is expected that the majority of patients would have tried and failed on at least one formulary choice antimuscarinic drug before being prescribed mirabegron
3. Mirabegron should be used with caution in patients with a history of QT-interval prolongation or in those patients also taking drugs that prolong the QT interval
4. Renal impairment: avoid if eGFR is less than 15mL/min/1.73m2. If eGFR is 15-29mL/min/1.73m2 reduce dose to 25mg daily
5. Hepatic impairment: avoid in severe impairment. Reduce dose to 25mg once daily in moderate hepatic impairment
6. Please refer to NICE TA290 Overactive bladder (June 2013)