Everything You Need to Know About Overactive Bladder Medications
2 out of 3 U.S. adults take prescription medications. The whopping cost of popping legal pills was $329 billion in 2016. It’s safe to assume that this number has not decreased over the past several years.
Overactive bladder (OAB) medications certainly contribute to this total. According to the American Urological Association, up to 30% of men and 40% of women suffer with OAB symptoms. In a study focused on Medicare patients between 2013-2017, over 8 million prescriptions were written for overactive bladder medications. This doesn’t include those patients with private insurance.
At the moment there are about 10 overactive bladder medications on the market. Of course, each pharmaceutical company believes they have the “best one”. So how are you to decide? Well, that’s where we come in.
VirtuCare provides unbiased information from board-certified urologists. Urologists are the experts at helping people solve bothersome problems in the bathroom. Since we don’t have a pony in this race, we will do our best to provide accurate reviews of each overactive bladder medication.
Unlike other online “medical experts”, all of our content is created by a board-certified urologist. Most healthcare blogs are written by non-medical people and “reviewed” by some random doctor, usually without expertise in the particular field. Not VirtuCare. We have decades of experience treating people just like you.
So let’s do a deep dive on all of the overactive bladder medications. This way you can be a more informed patient.
Overactive bladder overview
First, let’s make sure you're in the right place. You may have an overactive bladder if you have:
- Frequent urination
- Strong urges to urinate that are difficult to delay
- Waking up at night to urinate
- Bladder leakage due to inability to delay urination
An overactive bladder occurs when the bladder can no longer hold the same volume of urine. Normally, the bladder fills with urine and at a volume of 300 ml (10 ounces), a signal is sent to the brain that says, “kindly find a bathroom at your earliest convenience.” When the bladder becomes overactive, it holds a smaller volume of urine, and sends a signal to the brain screaming “BATHROOM NOW!!!!! FORGET IT I’M GOING RIGHT HERE!”
Treatment of an overactive bladder starts with lifestyle changes. Obviously the more fluid you drink, the more often you’re going to have to go potty. Additionally, you need to monitor what you’re drinking. Caffeine, alcohol and sugar are all bladder irritants. I know . . . the fun stuff. Sorry.
Underlying medical conditions, including the medications to treat these illnesses, can play a role in causing frequent, urgent bathroom trips. These include:
- Water pills (diuretics) for high blood pressure, heart conditions.
- Obstructive sleep apnea
- History of pelvic radiation
If you still are spending too much time in the bathroom, despite addressing the above, then it may be time to consider an overactive bladder medication. That’s the reason you’re here. Let’s review the most common OAB medications.
When possible we will provide the cash prices of the overactive bladder medications. Obviously, the costs may vary depending on the medication coverage with your medical insurance plan. It’s always a good idea to shop around for the best medication prices.
Anticholinergic Overactive Bladder Medications
The majority of overactive bladder medications fall into this category. Anticholinergics work by blocking the nerve fibers responsible for telling the bladder to empty. In other words, these overactive bladder medications tell the bladder to not be so overactive.
How well do they work? In a review of multiple studies, the original anticholinergic medications (oxybutynin and tolterodine) improved or cured symptoms in 63% of patients. However when you consider that sugar pills (placebo) improved symptoms 45% of the time, the results are not as impressive. If you believe something will work, maybe it will.
The main downside of these medications is poor adherence due to bothersome side effects. We have cholinergic receptors all over our body. As a result, these medications block nerve fibers outside of the bladder. These side effects include, but are not limited to:
- Dry mouth
- Dry eyes, blurry vision
- Worsening of narrow-angle glaucoma
- Urinary retention (medication worked too well)
Dry mouth is by far the most bothersome side effect. It’s the most common reason why patients stop taking anticholinergics.
In my experience, as a general rule, all of these medications work about the same. I have happy patients on all of these medications, and plenty of patients who don’t like being on any of these medications. I’ll do my best to review the unique characteristics, good and bad, of each anticholinergic overactive bladder medication.
We will list the generic name first, followed by the name brand variations.
Oxybutynin (Ditropan, Ditropan XL, Oxytrol, Gelnique)
The O.G. (original gangsta for those over 45 years old) of the anticholinergics is oxybutynin, the oldest overactive bladder medication. There are a number of variations of oxybutynin.
Ditropan is the immediate release version typically prescribed as 5 mg two to three times a day. When possible, you should consider Ditropan XL, the extended release version instead, that can be taken once a day. It has a lower likelihood of causing a dry mouth. If you are more bothered by nighttime urination, or the side effects, then I’d recommend taking this before bedtime.
Oxytrol is a patch form of oxybutynin that’s available over-the-counter. It is currently recommended only for women. You should change the patch every 4 days, rotating sites of application on your body.
Gelnique, as you’d imagine, is a gel formulation. It needs to be applied every day to a clean dry area of skin. The medication to be transferred to someone else via skin contact, so be sure to wash your hands and make certain to allow Gelnique to dry.
The topical formulations of oxybutynin have the added benefit of less dry mouth. On the downside, they can cause skin irritation at the application site.
So why should you consider oxybutynin as your overactive bladder medication? The main benefit is cost. The least expensive version of oxybutynin on GoodRx is the immediate release for as cheap as $17 a month. About a month's worth of Oxytrol is available via Amazon for $31.50.
On the downside, oral oxybutynin tends to have the highest rates of dry mouth with the lowest long-term compliance. Again, the Oxytrol patch is a good choice if dry mouth is bothersome.
Tolterodine (Detrol, Detrol LA)
The other “old school” anticholinergic overactive bladder medication is tolterodine. Similar to oxybutynin it is available as an immediate release, as well as an extended release tablet.
There are very few differences between tolterodine and oxybutynin. Cost ($25.40 per month through GoodRx) long-term compliance (not great) and side effects are all comparable. If you have liver or kidney disease, then a lower dosage of this overactive bladder medication is necessary.
Overall, there are no distinguishing features that make tolterodine any better or worse than most other anticholinergic overactive bladder medications.
In 2004, we were introduced to a number of “new” anticholinergics including trospium. These overactive bladder medications were marketed as having fewer side effects than the immediate release forms of oxybutynin and tolterodine.
Trospium is the last of the generic overactive bladder medications with a reasonable monthly cost under $20 for the immediate release tablet (20 mg twice a day). There’s an extended release formulation (60 mg once a day) as well, but the price increases to around $50 per month.
A unique feature of trospium, is that it’s chemical structure limits it’s passage across the blood brain barrier. This limits side effects of the central nervous system, making it a better choice for the elderly. One trial confirms that the extended release version of trospium appears to have lower rates of headache (<2%) and dizziness (<1%) than some of the other immediate release overactive bladder medications.
Unlike other overactive bladder medications, trospium is metabolized by the kidneys. This means potentially fewer drug-drug interactions with other medications you’re taking (NOTE: it’s always a good idea to check for interactions with any overactive bladder medication). If you have any kidney disease, check with your primary care doctor or nephrologist to make sure trospium is safe.
Solifenacin is our first “bladder selective” overactive bladder medication that we’ll review. It has more of an affinity (liking) for the receptors of the bladder than the brain, intestines, salivary glands and eyes. Theoretically this leads to lower rates of confusion, constipation, dry mouth and dry eyes.
The price of solifenacin has dropped over the years and is now comparable to most other overactive bladder medications. It is available in 5 mg and 10 mg tablets once a day. Side effects may increase as you increase the dosage.
In terms of long-term compliance, one study comparing all of the overactive bladder medications demonstrated the highest patient adherence to solifenacin. Don’t get too excited, a measly 35% of patients were still taking solifenacin after 12 months. Remember, none of these anticholinergic overactive bladder medications stand out.
The other “selective” anticholinergic bladder medication is darifenacin. It is available in once daily dosing at 7.5 mg or 15 mg. It’s a little spendier, but with a GoodRx card (I’m a big fan for my patients), it costs $40-55 a month.
Compared to oxybutynin, which most of these medications are compared to in drug trials, darifenacin had lower rates of dry mouth, but higher rates of constipation. This is especially seen at the 15 mg dose. Remember, not pooping every day worsens an overactive bladder as well.
You may notice that fesoterodine sounds and looks similar to tolterodine (Detrol - above). The key difference is the manner in which fesoterodine is broken down (metabolized is the fancy doctor term) by the body. This unique metabolism may explain why fesoterodine may work better than tolterodine.
Multiple studies, including this study from 2010, have demonstrated fewer episodes of bladder leakage with fesoterodine compared to the extended release formulation of tolterodine. Unfortunately, you’re also getting a higher likelihood of a bothersome dry mouth with these better results. With the good comes the bad.
Speaking of bad, get ready to pay up because this overactive bladder medication is expensive if not covered by your prescription drug plan. The cash price for fesoterodine without insurance is over $300 a month. Yikes.
Hyoscyamine and Flavoxate (Urispas)
I’ve combined these two particular overactive bladder medications because you’ll typically find them as part of a combination “bladder pill” such as Uribel, Urispas and Urogesic Blue. Although they shouldn’t be used as a primary medication for overactive bladder symptoms, you may be prescribed one of them without knowing it during a UTI flare-up. These anticholinergics are intended to decrease the frequency and urgency of urination associated with UTIs.
Beta-3 Agonist Overactive Bladder Medications
With bothersome side effects and persistent overactive bladder symptoms, there was room to improve on the anticholinergic medications. In June 2012, the FDA approved a new class of overactive bladder medications with the introduction of beta-3 agonists. Unlike the anticholinergics which work on blocking the parasympathetic nerves of the bladder, beta-3 agonists stimulate the sympathetic nerves of the bladder. Both actions lead to increasing bladder storage, and preventing bladder emptying.
The first beta-3 agonist on the market was mirabegron (Myrbetriq). It’s novel mechanism of action brought hope to all patients suffering with anticholinergic OAB medication side effects. First of all, does it work?
The answer is yes. A review of the studies leading to mirabegron’s approval in 2012 showed similar efficacy to the anticholinergic overactive bladder medications with a 3x lower incidence of dry mouth.
Of course when the new kid shows up, everyone wants to flex their muscles and challenge him. Head-to-head studies were performed comparing mirabegron to solifenacin and tolterodine. These studies confirmed that mirabegron works as well as these other agents. They again confirmed a lower incidence of dry mouth.
Some of these studies also looked at combination therapy with mirabegron and solifenacin. Results were not surprisingly better with combination overactive bladder medication therapy. But, there were also higher rates of constipation and dry mouth than with using a single overactive medication.
Mirabegron is available in 25 mg and 50 mg tablets that cannot be crushed. It can be taken with or without food.
Now the bad news: Mirabegron is not available as a generic overactive bladder medication. The cash price of mirabegron is over $400 a month.
The main side effect to monitor is an increase in blood pressure seen in about 10% of people taking mirabegron. Anecdotally, this is usually a minor increase in blood pressure, but you should definitely monitor your pressures at home. Overall, mirabegron is well tolerated.
The newest kid on the block, vibegron is the 2nd member of the beta-3 agonist medication class. The three differentiating factors compared to mirabegron are:
- No dose titration (75 mg for everyone).
- Ability to crush the medication for easier oral administration.
- No increase in blood pressure compared to placebo.
The EMPOWUR study confirmed that vibegron, improved overactive bladder symptoms compared to a sugar pill. Vibegron had a similar efficacy to the overactive bladder medication tolterodine without raising blood pressure or causing a dry mouth.
Similar to mirabegron, vibegron has a monthly price tag of over $400, so let's hope you’ve met your deductible for medications this year. Otherwise, you might need to open up the checkbook (that’s how us people over the age of 40 used to pay for items for the youngins’ in the room).
Hormonal Overactive Bladder Medications
Hormones have effects on almost every organ. The bladder is no exception. Let’s take a look at two hormonal medications, that although are not technically overactive bladder medications, they can definitely improve overactive bladder symptoms.
Desmopressin acetate (Nocdurna)
How often you go to the bathroom has a lot to do with how much urine is reaching the bladder. Certainly the more you drink the more you pee. Makes sense. The kidneys have to excrete out any excess fluids from your body. But, did you know that the amount of urine produced by the kidneys is also influenced by hormones?
At night the brain (specifically the pituitary gland) produces antidiuretic hormone (ADH). In regular guy language this means the “don’t pee hormone.” ADH tells the kidneys to shut down at night so y’all can get some rest (I’m a yankee in the South).
Unfortunately as we age, the kidneys don’t respond as well to this hormone. Anyone over the age of 50 can attest to waking up at night to urinate, which is one of the symptoms of an overactive bladder.
Desmospressin is a medication that mimics ADH and helps to decrease urine production at night. In patients with at least 2 nighttime urinations, desmopressin showed a decrease in nightly bathroom trips by 43% - 52% in men and women respectively.
It’s important to know that desmopressin itself has been around for a long period of time. It is prescribed in children for bedwetting. We are discussing desmopressin acetate or Nocdurna which is a sublingual tablet that comes in 27.7 mcg (micrograms NOT milligrams) and 55.2 mcg. The generic version used in children is prescribed at 100 mcg to 200 mcg, or doses 4-10 times what is used in adults. Make certain you’re prescribed the correct one!
The one thing to be careful about is limiting fluids at least 3 hours before bedtime. As you’d imagine, if you tell the kidneys not to produce urine, and you continue to consume a lot of fluids, you’ll burst . . . no you won’t burst but you could cause trouble. That trouble is called hyponatremia. This is the fancy doctor term for low sodium levels, which believe it or not can be life-threatening.
If you start desmopressin you’ll need your sodium levels checked with a blood draw before, 1 week after and 1 month after starting this overactive bladder medication. As long as you closely watch your sodium levels, then desmopressin is safe over the long-term. The likelihood of severely low sodium levels is less than 1% in women and 2% in men.
The reason for the difference in hyponatremia rates is that women are typically on lower doses of this overactive bladder medication. The FDA approved the 27.7 mcg tablet for women and the 55.2 mcg tablet for men.
Beyond the need for multiple blood draws with sodium monitoring, the other downside of desmopressin is the cost. It’s an expensive overactive bladder medication at over $400 a month. Again the generic version is too high of a dose and would be considered an off-label (not FDA approved) usage.
Estrogen (Estradiol, Estriol, Premarin)
After menopause, the effects of low estrogen begin to manifest in the lady business area. However, the vagina is not the only pelvic organ which suffers. The bladder is also sensitive to estrogens and requires adequate levels to function properly.
It’s beyond the scope of this article to dive into the pros and cons of hormone replacement therapy in post-menopausal women. However, we can definitively recommend vaginal estrogen cream for any post-menopausal women suffering with overactive bladder symptoms.
One randomized control trial compared the effects of tolterodine (Detrol) to combination therapy with tolterodine and vaginal estrogen cream. Women who received the combination therapy reported decreased urination during the day and improved quality-of-life.
Vaginal estrogen cream appears to be safe. A study with almost 20 years of follow-up showed no increased risk of heart disease or cancer with vaginal estrogen use. Of course if you have a history of breast cancer, or are at high risk, you should talk to your oncologist before starting vaginal estrogen therapy as an overactive bladder medication.
Although name brand variations can be pricey, vaginal estrogen cream can be made at reputable compounding pharmacies at a fraction of the price without sacrificing quality.
Injectable Overactive Bladder Medications
Why not bypass the middleman and inject the overactive bladder medication directly into the bladder? Although bladder injections are a more advanced therapy for treating overactive bladders, it is a medication nonetheless.
Onabotulinum toxin A (Botox)
No, your bladder doesn’t have wrinkles. The manner in which Botox works however is by paralyzing muscles. In this case, we are paralyzing the bladder muscles, temporarily to cut down on bladder spasms.
Botox needs to be injected directly into the bladder through a minor endoscopic procedure (cystoscopy). It works quite well but is obviously a bit more invasive than popping pills. We will table our discussion on bladder Botox for a different article.
Conclusions on Overactive Bladder Medications
Boy that was a lot of information! I bet you’re like me and need a bathroom break after reading this comprehensive guide on overactive bladder medications. But, before you do, let me offer some further advice.
Deciding on the best treatment for an overactive bladder is a complex decision that you don’t have to tackle alone. VirtuCare offers same day comprehensive consultations with a board-certified urologist from the comfort of your home. We can guide you through such questions as:
- Which overactive bladder medication is right for me?
- How can I manage overactive bladder medication side effects?
- What treatments are available if overactive bladder medications are not controlling my OAB symptoms?
Not only can we prescribe medications, but we can help you find an in-person overactive bladder expert in your area if more advanced treatments are necessary. Sure beats finding someone on your own and dealing with the frustrations of medical offices.
Click here if you’d like to request an appointment today.
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