Home' Australian Pharmacist : October 2011 Contents Vol. 30 -- October #10, 2011
Continuing Professional Development
The articles in this series are independently researched and compiled by PSA commissioned authors and peer reviewed.
Mrs MH has several intertwined
conditions. The benefits of improving
one of these conditions are likely to
be beneficial to the other conditions.
Mrs MH's poor quality of life is
particularly concerning. She is still
in her 50s but is unable to leave the
house for any extended period of time
due to bladder problems and pain.
Mrs MH is keen to lose weight and is
aware of the benefits it can have for
pain, depression and sleeping.
She is using several medications
to treat overactive bladder, bladder
prolapse and chronic urinary tract
infection, yet is still having severe OAB
symptoms. Her bladder prolapse may
be causing the symptoms of stress
incontinence and complicating therapy.
Mrs MH's depression is not well
controlled. She has trialled many
antidepressants in the past and
ceased taking them due to lack of
efficacy and/or adverse effects. She
is currently taking imipramine which
she tolerates reasonably well (the
dry mouth she is experiencing may
be in part due to this medication) but
her dose may be insufficient for her
Mrs MH feels that the incontinence
and depression she is experiencing
has more of an impact on her quality
of life than pain does. She feels that if
these were better controlled, than the
pain would be even more tolerable.
The addition of oxybutynin to Mrs MH's
medication regime three months
ago has resulted in no reduction to
her bladder symptoms, and she is
experiencing dry mouth which causes
her to drink more and exacerbate her
overactive bladder syndrome. She had
previously been resistant to increasing
the dose of oxybutynin when consulting
with her GP due to what she perceived
as lack of efficacy and concerns about
exacerbating her already dry mouth. The
oxybutynin patch was considered as it
has a lower incidence of dry mouth than
However, this was not recommended
due to the high rate (greater than
10%) of skin reactions at the
application site. Given Mrs MH's
history of dermatitis, it was decided
that other strategies were likely to
be more suitable initially. Of potential
benefit to Mrs MH may be cessation
of prazosin, substitution of oxybutynin
for a more selective anticholinergic
agent such as solifenacin, and
increasing imipramine dosage.
It was recommended that prazosin
should be ceased. Prazosin may
be worsening Mrs MH's urinary
incontinence as it blocks alpha1
receptors in the bladder neck,
decreasing resistance to urinary flow.21
Many other antihypertensives are
available. It is important to obtain a
complete list of the antihypertensives
previously tried and why they were
not tolerated. An ACE inhibitor, such as
perindopril erbumine 2 mg once daily,
would be an appropriate option with
titration to an appropriate response if it
was not on the 'not tolerated' list.
Referral back to the genitourinary
surgeon was recommended as any
medication changes were likely
to provide only a small benefit to
Mrs MH's urinary symptoms. Referral
to a continence clinic was also
recommended as certain strategies
and training may be beneficial, e.g.
appropriate fluid intake, timed voiding,
pelvic floor exercises.
If further medication was to be
trialled for OAB, solifenacin should be
initiated at a dose of 5 mg daily and
increased to 10 mg daily. This is the
dose range where most of the benefit
has been achieved in trial situations,9
and solifenacin is less likely than
oxybuyinin to cause dry mouth.
As Mrs MH's depression was not
under control, there may be room
to cautiously increase the dosage of
imipramine (especially if oxybutynin
is ceased), to assist in controlling
depression symptoms. The dosage
recommended for treatment of
depression is 75--150 mg daily.19 She
may benefit from having the daily
dose divided and therefore it was
recommended that she use 25 mg
in the morning and 50 mg at night.
The morning dose could be increased
further to 50 mg if necessary for control
of depression provided that adverse
effects like dry mouth are not still
apparent due to total anticholinergic
load. Imipramine may also assist in
controlling Mrs MH's pain.
Both oxybutynin and prazosin were
ceased by the doctor. Mrs MH no
longer had a dry mouth and her
urinary problems had a small but
noticeable improvement. Mrs MH had
an appointment to visit the surgeon to
have the prolapse repaired.
The GP decided to monitor blood
pressure for the time being and wait
until other medications had stabilised
to determine if introducing another
antihypertensive was still required.
The GP also decided to increase
Mrs MH's imipramine dose to 50 mg
twice daily and she found that her
mood improved and she was now
more able to cope with her pain.
She has been taking longer walks with
her dog, bladder permitting. She has
lost a small amount of weight and her
appetite has returned to normal.
Overactive bladder affects a large
proportion of the population with
many not seeking help. Pharmacists
are well placed to speak to patients
about this and advise on treatment
options available. There are many
opportunities to do this, including
counselling at the time of prescription
collection, during a home medicine
review interview, and using
community pharmacy promotions to
encourage potential sufferers to seek
information relating to the disorder.
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