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CONTINUING PROFESSIONAL DEVELOPMENT
hypertension that is controlled with
atenolol 50 mg daily, and mild chronic
obstructive pulmonary disease (COPD),
for which she uses ipratropium inhaler
(Atrovent) when required.
Due to an increase in her COPD
symptoms six weeks ago, she was
prescribed the fixed-dose combination
inhaler tiotropium/olodaterol (Spiolto)
to be used once daily, and a salbutamol
inhaler to be used when required.
Four weeks ago, June started taking
oxybutynin tablets 5 mg twice daily for
urge incontinence as she experienced
some embarrassing leakage of urine in
A number of potential issues could be
causing June's symptoms.
Hyperglycaemia in its severe form can
present as dehydration with dry mouth,
confusion and delirium. Could June's
diabetes be uncontrolled causing severe
hyperglycaemia requiring urgent action
and admission to hospital?
You speak with June about her
recent blood glucose levels. June says
that her blood sugar levels have been in
the normal range and that she has been
taking her metformin as directed.
However, you decide to do a blood glucose
test to exclude hyperglycaemia as the
cause of June's symptoms. Her blood
glucose level is 5.5 mmol/L, so it appears
unlikely that hyperglycaemia is causing
Sjögren's syndrome is a chronic
autoimmune systemic inflammatory
disorder characterised by dry eyes
and mouth and symptoms of fatigue,
myalgia and mild cognitive dysfunction.
The cause is unknown. The parotid
gland enlarges in about 33% of patients.
Sjögren's syndrome occurs most
frequently in middle-aged women.
It develops in about 30% of patients
with autoimmune disorders such as
rheumatoid arthritis (RA) and systemic
lupus erythematosus (SLE).1
June has no family history of RA and
does not appear to have the classic
features such as early morning stiffness
lasting more than one hour, symptoms in
three or more joints and family history of
the disease.2 Similarly, she does not show
features of SLE such as a malar or discoid
rash, oral ulcers or pain in two or more
joints.2 This makes it somewhat less likely
that she has Sjögren's syndrome, but
specific serological testing can determine
if she has it if all other potential causes are
Medicines with anticholinergic
effects can cause dry mouth and
eyes, constipation, urinary retention,
tachycardia, blurred vision and cognitive
effects such as delirium and confusion.3
They include phenothiazines, tricyclic
antidepressants, antihistamines, some
inhaled bronchodilators and agents
used for urinary incontinence.
June appears to be using at least
three medicines with anticholinergic
effects. She started on oxybutynin four
weeks ago and appears to be using both
inhaled ipratropium (Atrovent) and
inhaled tiotropium/olodaterol (Spiolto).
Australian guidelines recommend that
patients cease ipratropium when
tiotropium is started.4 June can't
remember if she was given this advice but
states she has been using the Atrovent up
to four times daily recently due to an
exacerbation of her COPD in addition to
As June's symptoms are consistent with
anticholinergic effects, and started about
the time she started taking oxybutynin,
it seems most likely that anticholinergic
toxicity is the main cause of her problems.
She is most likely experiencing the
additive anticholinergic effects of
oxybutynin, ipratropium and tiotropium.
The cumulative effect of taking a number
of medicines with anticholinergic effects
is known as the anticholinergic burden.
Because her dry mouth is causing difficulty
in swallowing and her agitation, confusion
and general decline in cognition threatens
independence, you give June a referral note
to see her doctor for an urgent review of her
medicines. Her doctor may need to consider
ceasing oxybutynin and Atrovent.
Urge incontinence, also known
as unstable bladder, is caused by
detrusor muscle overactivity that can
occur without warning and results in
involuntary loss of urine. It is the most
common form of incontinence in the
elderly, especially in older women.5
Contributing factors may include urinary
tract infection (UTI), constipation and
some medicines such as diuretics,
selective alpha-blockers (e.g. prazosin)
and anticholinesterases (e.g. donepezil).
Other types of urinary incontinence
include stress incontinence in which
there is involuntary leakage on effort,
exertion, sneezing or coughing, and
overflow incontinence caused by urinary
retention and bladder distension as a
result of outlet obstruction.
Table 1. Anticholinergic agents used for urge incontinence
Generic name Brand name examples Formulations
transdermal patch Yes
Oxytrol Transdermal System
is PBS listed for detrusor
overactivity in a patient
who cannot tolerate oral
oxybutynin or who cannot
swallow oral oxybutynin.
Reference: AMH3; Hersch5
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