Dr. Nazia Rashid, Associate Professor of Administrative Sciences for Keck Graduate Institute ‘s School of Pharmacy and Health Sciences, was recently invited by Pharmacy Times to be part of a subject matter expert panel titled “An American Journal of Managed Care Forum: Managed Care Perspectives on the Challenges and Opportunities to Improve Patient Outcomes in the Management of Overactive Bladder.”
This opportunity arose from a journal article on overactive bladder (OAB), which Rashid published from a managed care perspective while working for Kaiser eight years ago. Due to her experience in Health Economics Outcomes Research (HEOR), Pharmacy Times reached out to Rashid to be an expert on the panel.
“It was an incredible experience,” Rashid said. “I got to be on the panel with a urologist and an amazing clinical pharmacist from the University of Colorado.”
OAB causes a frequent, sudden urge to urinate that may be difficult to control. Often, those affected experience unintentional loss of urine, known as urgency incontinence.
Though the condition differs from a urinary tract infection (UTI), it can lead to or coexist with UTIs. Those afflicted may limit their fluid intake, which can, in turn, cause dehydration.
OAB impacts 33 million Americans and is most prevalent in women over 70, though it affects men and younger women.
It occurs in 50-70% of individuals in long-term care settings. Despite its prevalence, this condition is often overlooked.
“Everybody talks about hypertension, obesity, and diabetes,” Rashid said. “But most people don’t realize that overactive bladder is a major issue.”
One reason is that OAB often needs to be diagnosed. Rashid said,
“Patients are reluctant to bring it up to their provider because they’re embarrassed.”
Because people feel embarrassed about the condition and may be unwilling to leave their house for long periods and thus risk not having easy access to a bathroom, they can become isolated. This isolation can lead to depression and even Alzheimer’s.
“As you’re getting older, you want to be more socially active because it keeps your brain going,” Rashid said.
OAB is often caused by a weakening of the muscles around the bladder—particularly the detrusor muscle, which contracts during urination to push the urine out of the bladder and into the urethra. This weakening occurs naturally during the aging process. Women who have given birth are particularly vulnerable.
Annual costs associated with OAB have increased from $12.6 to $65.9 billion from 2000 to 2007. These include direct medical costs (diagnosis, treatments, consequences of OAB such as falls/UTIs/skin infections), indirect costs (caregiver wages), and intangible costs (negative impact on quality of life).
This sharp increase is primarily due to an aging population and increased awareness of OAB. Additionally, high levels of discontinuation with treatments contribute to the economic burden.
“In the managed care system, the major focus is preventative care, which can help reduce future costs,” Rashid said.
Such preventative measures include checking for biomarkers associated with the condition.
Addressing the condition before it progresses can also help to reduce costs. Because patients are often hesitant to report the condition, healthcare providers should make an extra effort to extract information from patients seeking treatment for other conditions (such as hypertension or diabetes) to check for OAB symptoms.
Many treatments are currently available for OAB. Providers should communicate with patients about their main treatment goals and shed light on the different treatment options, working with patients to find the best treatment.
First-line treatments include lifestyle modification, pelvic floor physiotherapy, and timed voiding. Second-line treatments include antimuscarinics (anticholinergics), which relax the bladder by blocking special receptors at the detrusor muscle.
One of the most common treatments in this category is Oxybutynin. The main issue with these treatments is that they are non-selective to the bladder, blocking receptors in the salivary gland, gut, brain, and heart.
Such drugs have high discontinuation rates due to adverse side effects, including dry mouth, constipation, dizziness, and cognitive impairment.
A newer class of second-line treatments are selective beta-3 adrenergic agonists, which also work to prevent involuntary bladder muscle contractions. However, because they are selective, they typically have fewer adverse effects.
One promising drug in this category is Mirabegron, which clinical trials have found particularly effective in reducing urinary incontinence, urgency, and frequency.
Third-line treatments include Botulinum toxin (Botox) injections into the bladder and neuromodulation, altering nerve messages or signals to the bladder using electrical stimulation.
Combination therapy should be explored if patients are not responding to monotherapy. At the same time, though, combination therapy is not recommended if patients already have issues with medication adherence.
“In the managed care system, the biggest goal is to get the patient on the right treatment program, recognizing that it’s not a one-size-fits-all approach,” Rashid said. “Different treatments may need to be tried if one is not working or is causing too many side effects. We need to help the patient manage their symptoms, increase their quality of life, and ensure that the benefits of any treatment protocol always outweigh the costs.”