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AUA 2019

AUA 2019: AUA Guidelines Update: Overactive Bladder

Chicago, IL (UroToday.com) The AUA and SUFU initially released a joint guideline for non-neurogenic overactive bladder (OAB) in 2012, which was then updated in 2015. 1,2 This year there is a new update that has been announced. Dr. Vasavada presented on the latest updates to the OAB guidelines at today’s afternoon plenary session.

As an introduction, Dr. Vasavada explained that the goal of this guideline amendment was to optimize treatment of OAB while minimizing patient burden. To develop the guideline amendment, a systematic review was performed which identified 37 new articles that provided evidence for the update. In the guidelines on diagnosis, the patient presentation should be differentiated from transient factors such as infection that can cause urinary urgency and frequency. Other conditions in the differential diagnosis are carcinoma in situ and interstitial cystitis/bladder pain syndrome.

In 2015 the OAB guideline update made several changes:
  1.  beta 3 agonists were added as an option for second line therapy
  2. onabotulinumtoxinA was added as third line therapy after FDA approval
  3. time brackets were added to guide the appropriate duration of medications and behavioral modifications (4-8 weeks)
  4. PTNS was listed as a third line treatment.
This year’s guideline amendment is focused on second line therapy. However, Dr. Vasavada notes that the guidelines do not require that every patient go through each line of treatment in order. There are many patient factors to consider, and side effects of medications are significant. He also notes that behavioral therapy has a role in combination with each line of therapy and PTNS can be considered earlier in the algorithm due to its limited invasiveness.

The major addition to this year’s guideline amendment comes from the addition of combination medical therapy with anticholinergics and mirabegron to second line therapy. The addition of combination therapy to the guideline is based on several well-designed studies. In each of these, including Synergy I and II, and the BESIDE trial, all active treatment groups had improvement over placebo, but there was greater symptom improvement in the subjects who received dual therapy as compared to monotherapy. However, adverse events such as urinary retention were seen more commonly in patients who received dual therapy. Dr. Vasavada notes that it is important to consider side effects, polypharmacy in the elderly, cognitive effects of anticholinergic medications, and the blood pressure side effect of mirabegron.

Finally, Dr. Vasavada reviewed the use of 4th line treatments which include catheters, suprapubic tubes, bladder augmentation, and urinary diversion. These options should be considered in selective, refractory patients. The updated OAB guideline and algorithm for treatment is expected to be posted online at the AUA website today.

Presented by: Sandip Vasavada, MD, Professor of Surgery/Urology, Cleveland Clinic Glickman Urological Institute and Lerner College of Medicine

Written by: Dena Moskowitz, MD; Assistant Professor of Clinical Urology, University of California Irvine; @demoskowitz at the American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois

References:
  1. Gormley EA, Lightner DJ, Burgio KL, et al. Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic) in Adults: AUA/SUFU Guideline. J Urol. 2012;188(6):2455-2463. doi:10.1016/j.juro.2012.09.079
  2. Gormley EA, Lightner DJ, Faraday M, Vasavada SP. Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic) in Adults: AUA/SUFU Guideline Amendment. J Urol. 2015;193(5):1572-1580. doi:10.1016/j.juro.2015.01.087