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La Revue Du Praticien Nov 2023MALE URINARY INCONTINENCE. Male urinary incontinence is a common condition that tends to increase with age and can significantly impact the quality of life. Beyond the...
MALE URINARY INCONTINENCE. Male urinary incontinence is a common condition that tends to increase with age and can significantly impact the quality of life. Beyond the clinical diagnosis made through patient history and examination, healthcare practitioners must strive to identify the underlying mechanism(s) and assess the degree of discomfort to initiate appropriate treatment. Two main types of urinary incontinence are distinguished: stress urinary incontinence, which can often benefit from pelvic floor muscle training, and urgency urinary incontinence, which typically responds to drug therapies (such as anticholinergics or β3-adrenergic agonists) and posterior tibial nerve stimulation as first-line options. Moreover, a certain number of red flags must be systematically sought to avoid missing, among other things, a urinary retention or an underlying local condition, and to identify as early as possible men requiring specialized urological care. It is also crucial for the general practitioner to discuss with the patient the various palliative approaches when necessary, such as the use of protective pads, penile sheaths, or a clamp, to improve the patient's comfort and quality of life.
Topics: Humans; Male; Quality of Life; Urinary Incontinence; Cholinergic Antagonists; General Practitioners; Urinary Retention
PubMed: 38294456
DOI: No ID Found -
Optometry and Vision Science : Official... Mar 2024The availability of a range of effective myopia control modalities enables the clinician to exercise judgment when discussing the treatment plan with the patient and... (Review)
Review
The availability of a range of effective myopia control modalities enables the clinician to exercise judgment when discussing the treatment plan with the patient and their parents. This article outlines important considerations beyond efficacy.Clinically meaningful myopia control may be attained with some spectacle lenses, select soft contact lenses, some concentrations of atropine, and overnight orthokeratology. Given that satisfactory efficacy can be achieved with a range of modalities, other factors should be considered when deciding upon the best intervention for a given child. Four key factors-compliance, quality of vision, quality of life, and safety-are discussed in this review. Compliance directly impacts efficacy regardless of the modality and is the most important consideration, as it is influenced by quality of vision and comfort. Daily disposal myopia control contact lenses and overnight orthokeratology are generally associated with high compliance, provide better vision-related quality of life than spectacles, and carry a very low risk when used appropriately. A further benefit of overnight orthokeratology is the elimination of a need for optical correction during the day.
Topics: Child; Humans; Quality of Life; Myopia; Atropine; Contact Lenses, Hydrophilic; Exercise
PubMed: 38546754
DOI: 10.1097/OPX.0000000000002119 -
Drugs & Aging Nov 2023Medications with anticholinergic effects are commonly used in nursing homes, and their cumulative effect is of particular concern for the risk of adverse effects on...
BACKGROUND
Medications with anticholinergic effects are commonly used in nursing homes, and their cumulative effect is of particular concern for the risk of adverse effects on cognition.
OBJECTIVE
The relation between cognitive function and anticholinergic burden measured with four scales, the Anticholinergic Cognitive Burden (ACB) Scale, the Anticholinergic Risk Scale, the German Anticholinergic Burden Scale, and the CRIDECO Anticholinergic Load Scale, is assessed according to the hypothesis that a higher anticholinergic burden is associated with reduced cognitive performance.
METHODS
This retrospective cross-sectional multicenter study was conducted in a sample of Italian long-term-care nursing homes (NH). Sociodemographic details, diagnosis, and drug treatments of each NH resident were collected using medical records four times during 2018 and 2019. Cognitive status was rated with the Mini-Mental State Examination (MMSE). The prevalence of anticholinergic use and its burden were calculated referring to the last time point for each patient. A longitudinal analysis was done on NH residents with at least two MMSE between 2018 and 2019 to assess the relation between the anticholinergic load and decline in MMSE. The relationship between drug-related anticholinergic burden and cognitive performance was analyzed using Poisson regression model theory. Multivariate analyses were adjusted according to the known risk factors of reduced cognitive performance available [age, sex, history of stroke or transient ischemic attack (TIA), and number of non-anticholinergic drugs] and for cholinesterase inhibitors. In view of the high number of subjects with an MMSE score = 0 among residents with dementia, for this group a zero-inflated Poisson regression model was used to give more consistent results. The association of anticholinergic burden with mortality was examined from each patient's last visit using a multivariate logistic model adjusted for age, sex, and Charlson Comorbidity Index (CCI).
RESULTS
Among 1412 residents recruited, a clear direct relationship was found between higher anticholinergic burden and cognitive impairment only for the Anticholinergic Cognitive Burden Scale. Residents taking an anticholinergic who scored 5 or more had 2.5 points more decline than those not taking them (p < 0.001). Among residents without dementia there was a trend toward direct relationship for the Anticholinergic Cognitive Burden Scale and the Anticholinergic Risk Scale. Residents with higher scores had about 2 points more decline than residents not taking anticholinergic drugs. No relation was found between anticholinergic burden and cognitive decline or mortality.
CONCLUSIONS
The cumulative effect of medications with modest antimuscarinic activity may influence the cognitive performance of NH residents. The anticholinergic burden measured with the ACB scale should help identify NH residents who may benefit from reducing the anticholinergic burden. A clear direct relationship between anticholinergic burden and cognitive impairment was found only for the ACB Scale.
Topics: Humans; Cholinergic Antagonists; Retrospective Studies; Cross-Sectional Studies; Cognitive Dysfunction; Nursing Homes; Dementia
PubMed: 37620654
DOI: 10.1007/s40266-023-01058-w -
Acta Odontologica Scandinavica Aug 2023The aim was to study the association between high anticholinergic burden and hyposalivation and xerostomia among older people.
OBJECTIVE
The aim was to study the association between high anticholinergic burden and hyposalivation and xerostomia among older people.
BACKGROUND
Anticholinergic drugs have been shown to cause xerostomia and hyposalivation. Yet there are few studies on the association between anticholinergic burden and hyposalivation and xerostomia in the elderly.
MATERIAL AND METHODS
The study population consisted of community-dwelling older people ( = 321, mean age 81.6 years) from the Oral health GeMS study. Participants provided salivary samples and xerostomia was determined with a questionnaire. The baseline data were collected by interviews, oral clinical examinations and from patient records. Each participant's anticholinergic burden was determined by eight anticholinergic scales. Poisson regression models with robust error variance were used to estimate relative risks (RR) with a 95% confidence interval (CI).
RESULTS
RRs of high anticholinergic burden in anticholinergic scales for xerostomia (multiple symptoms) ranged from 1.02 to 1.68; for low unstimulated salivary flow (≤0.1 mL/min) from 1.47 to 1.67; and for low stimulated salivary flow (≤0.7 mL/min) from 0.99 to 2.07. A high anticholinergic burden according to seven out of eight scales was associated ( < .05) with hyposalivation or xerostomia.
CONCLUSIONS
A high anticholinergic burden was associated more strongly with hyposalivation (both unstimulated and stimulated) than with xerostomia.
Topics: Humans; Aged; Aged, 80 and over; Saliva; Cholinergic Antagonists; Xerostomia; Oral Health; Surveys and Questionnaires
PubMed: 36628441
DOI: 10.1080/00016357.2023.2166105 -
Amyotrophic Lateral Sclerosis &... Feb 2024Nuedexta is a combination of dextromethorphan hydrobromide and quinidine sulfate and was approved by the Food and Drug Administration (FDA) in 2010 to treat pseudobulbar... (Review)
Review
Nuedexta is a combination of dextromethorphan hydrobromide and quinidine sulfate and was approved by the Food and Drug Administration (FDA) in 2010 to treat pseudobulbar affect (PBA). There have since been anecdotal case reports of bulbar function improvements after Nuedexta treatment. Here, we review the off-label use of Nuedexta for improving bulbar function in people with ALS. Nuedexta has plausible mechanisms for protecting brain stem motor neurons via its effects on S1R and glutamate excitotoxicity. Recent clinical trials support that Nuedexta can improve bulbar function in PALS, with or without PBA. Nuedexta causes mild to moderate side effects. Based on this information, we support considering Nuedexta treatment for bulbar dysfunction in ALS patients with or without PBA.
Topics: Humans; Amyotrophic Lateral Sclerosis; Dextromethorphan; Drug Combinations; Quinidine
PubMed: 37493197
DOI: 10.1080/21678421.2023.2239292 -
JAMA Ophthalmology Aug 2023
Topics: Humans; Atropine; Myopia; Mydriatics; Ophthalmic Solutions; Disease Progression; Refraction, Ocular
PubMed: 37440252
DOI: 10.1001/jamaophthalmol.2023.3076 -
JAMA Internal Medicine Oct 2023Dementia is a life-altering diagnosis that may affect medication safety and goals for chronic disease management.
IMPORTANCE
Dementia is a life-altering diagnosis that may affect medication safety and goals for chronic disease management.
OBJECTIVE
To examine changes in medication use following an incident dementia diagnosis among community-dwelling older adults.
DESIGN, SETTING, AND PARTICIPANTS
In this cohort study of adults aged 67 years or older enrolled in traditional Medicare and Medicare Part D, patients with incident dementia diagnosed between January 2012 and December 2018 were matched to control patients based on demographics, geographic location, and baseline medication count. The index date was defined as the date of first dementia diagnosis or, for controls, the date of the closest office visit. Data were analyzed from August 2021 to June 2023.
EXPOSURE
Incident dementia diagnosis.
MAIN OUTCOMES AND MEASURES
The main outcomes were overall medication counts and use of cardiometabolic, central nervous system (CNS)-active, and anticholinergic medications. A comparative time-series analysis was conducted to examine quarterly changes in medication use in the year before through the year following the index date.
RESULTS
The study included 266 675 adults with incident dementia and 266 675 control adults; in both groups, 65.1% were aged 80 years or older (mean [SD] age, 82.2 [7.1] years) and 67.8% were female. At baseline, patients with incident dementia were more likely than controls to use CNS-active medications (54.32% vs 48.39%) and anticholinergic medications (17.79% vs 15.96%) and less likely to use most cardiometabolic medications (eg, diabetes medications, 31.19% vs 36.45%). Immediately following the index date, the cohort with dementia had a greater increase in mean number of medications used (0.41 vs -0.06; difference, 0.46 [95% CI, 0.27-0.66]) and in the proportion of patients using CNS-active medications (absolute change, 3.44% vs 0.79%; difference, 2.65% [95% CI, 0.85%-4.45%]) owing to an increased use of antipsychotics, antidepressants, and antiepileptics. The cohort with dementia also had a modestly greater decline in use of anticholinergic medications (quarterly change in use, -0.53% vs -0.21%; difference, -0.32% [95% CI, -0.55% to -0.08%]) and most cardiometabolic medications (eg, quarterly change in antihypertensive use: -0.84% vs -0.40%; difference, -0.44% [95% CI, -0.64% to -0.25%]). One year after diagnosis, 75.2% of the cohort with dementia were using 5 or more medications (2.8% increase).
CONCLUSIONS AND RELEVANCE
In this cohort study of Medicare Part D beneficiaries, following an incident dementia diagnosis, patients were more likely to initiate CNS-active medications and modestly more likely to discontinue cardiometabolic and anticholinergic medications compared with the control group. These findings suggest missed opportunities to reduce burdensome polypharmacy by deprescribing long-term medications with high safety risks or limited likelihood of benefit or that may be associated with impaired cognition.
Topics: Aged; Humans; Female; United States; Aged, 80 and over; Male; Dementia; Cohort Studies; Cholinergic Antagonists; Medicare Part D; Cardiovascular Diseases
PubMed: 37603340
DOI: 10.1001/jamainternmed.2023.3575 -
Expert Opinion on Pharmacotherapy 2023Overactive bladder (OAB) is a common syndrome in adults. Current pharmacologic treatment includes antimuscarinic agents and β-3 adrenoceptor agonists. For... (Review)
Review
INTRODUCTION
Overactive bladder (OAB) is a common syndrome in adults. Current pharmacologic treatment includes antimuscarinic agents and β-3 adrenoceptor agonists. For non-responders to oral medication, intravesical injection of botulinum toxin A (BoNT-A) is an effective option. However, these treatments have potential adverse events and should be cautiously selected for appropriate patients. This review presents the recently published results of clinical trials and studies for patients with OAB and the underlying pathophysiology of OAB. Appropriate medical therapy based on pathophysiology of OAB is also presented.
AREAS COVERED
Literature search from Pubmed from 2001 to 2023 including clinical background, pharmacology, and clinical studies for OAB medications.
EXPERT OPINION
Treatment of OAB syndrome with any antimuscarinic or β-3 adrenoceptor agonist is feasible as a first-line approach. For patients with suboptimal therapeutic effect to full-dose antimuscarinics or mirabegron, combination with both drugs can improve efficacy. Intravesical BoNT-A 100-U injection provides therapeutic effects for refractory OAB. Patients who are refractory to initial pharmacotherapies should be investigated for the underlying pathophysiology; then an appropriate medication can be added, such as an α1-blocker or anti-inflammatory agents. Patient education about behavioral modification and therapies should always be provided with oral medication or BoNT-A injection for OAB patients.
Topics: Adult; Humans; Urinary Bladder, Overactive; Muscarinic Antagonists; Botulinum Toxins, Type A; Administration, Intravesical; Adrenergic beta-3 Receptor Agonists; Acetanilides; Receptors, Adrenergic
PubMed: 37752121
DOI: 10.1080/14656566.2023.2264183 -
Molecular Medicine (Cambridge, Mass.) Oct 2023Acute pancreatitis is a common and serious inflammatory condition currently lacking disease modifying therapy. The cholinergic anti-inflammatory pathway (CAP) is a...
BACKGROUND
Acute pancreatitis is a common and serious inflammatory condition currently lacking disease modifying therapy. The cholinergic anti-inflammatory pathway (CAP) is a potent protective anti-inflammatory response activated by vagus nerve-dependent α7 nicotinic acetylcholine receptor (α7nAChR) signaling using splenic CD4 T cells as an intermediate. Activating the CAP ameliorates experimental acute pancreatitis. Galantamine is an acetylcholinesterase inhibitor (AChEI) which amplifies the CAP via modulation of central muscarinic ACh receptors (mAChRs). However, as mAChRs also activate pancreatitis, it is currently unknown whether galantamine would be beneficial in acute pancreatitis.
METHODS
The effect of galantamine (1-6 mg/kg-body weight) on caerulein-induced acute pancreatitis was evaluated in mice. Two hours following 6 hourly doses of caerulein (50 µg/kg-body weight), organ and serum analyses were performed with accompanying pancreatic histology. Experiments utilizing vagotomy, gene knock out (KO) technology and the use of nAChR antagonists were also performed.
RESULTS
Galantamine attenuated pancreatic histologic injury which was mirrored by a reduction in serum amylase and pancreatic inflammatory cytokines and an increase the anti-inflammatory cytokine IL-10 in the serum. These beneficial effects were not altered by bilateral subdiaphragmatic vagotomy, KO of either choline acetyltransferase T cells or α7nAChR, or administration of the nAChR ganglionic blocker mecamylamine or the more selective α7nAChR antagonist methyllycaconitine.
CONCLUSION
Galantamine improves acute pancreatitis via a mechanism which does not involve previously established physiological and molecular components of the CAP. As galantamine is an approved drug in widespread clinical use with an excellent safety record, our findings are of interest for further evaluating the potential benefits of this drug in patients with acute pancreatitis.
Topics: Humans; Mice; Animals; Galantamine; alpha7 Nicotinic Acetylcholine Receptor; Acetylcholinesterase; Ceruletide; Acute Disease; Pancreatitis; Cytokines; Anti-Inflammatory Agents; Body Weight
PubMed: 37907853
DOI: 10.1186/s10020-023-00746-y -
Advances in Therapy Nov 2023Anticholinergics have been used in the treatment of overactive bladder (OAB), but their use is limited by poor tolerability and anticholinergic-related side effects.... (Review)
Review
Anticholinergics have been used in the treatment of overactive bladder (OAB), but their use is limited by poor tolerability and anticholinergic-related side effects. Increasingly, providers are discontinuing anticholinergic prescribing because of growing evidence of the association of anticholinergic use with increased risk of cognitive decline and other adverse effects. Newer medications for OAB, the β-adrenergic receptor agonists mirabegron and vibegron, do not have anticholinergic properties and are typically well tolerated; however, many insurance plans have limited patient access to these newer OAB medications by requiring step therapy, meaning less expensive anticholinergic medications must be trialed and/or failed before a β-agonist will be covered and dispensed. Thus, many patients are unable to easily access these medications. Step therapy and other drug utilization strategies (e.g., prior authorization) are often used to manage the growing costs of pharmaceuticals, but these policies do not always follow treatment guidelines and may harm patients as a result of treatment delays, discontinuations, or related increases in adverse events. Medical professionals have called for reform of drug utilization strategies through partnerships that include clinicians and policymakers. This narrative review discusses prescribing patterns for OAB treatment and the effect of switching between drugs, as well as the costs of step therapy and prior authorization on patients and prescribers.
Topics: Humans; Urinary Bladder, Overactive; Cholinergic Antagonists; Adrenergic beta-3 Receptor Agonists
PubMed: 37725308
DOI: 10.1007/s12325-023-02625-8