Leicestershire Medicines Strategy Group Overactive Bladder Prescribing Pathway Review due June 2017 PGI-I Score 1-2: Continue Conservative Management (via Continence Team) Bladder retraining Pelvic floor exercises Manage constipation Weight loss Review of medication (e.g. diuretics / anti-hypertensive, antidepressant) PGI-I Patient Global Impression of Improvement Scale Check the one number that best describes how your urinary tract condition is now, compared with how it was before you began taking medication. Assess: PGI-I after 3 months PGI-I Score 3-7: Prescribe medication 1. 2. 3. 4. 5. 6. 7. Very much better Much better A little better No change A little worse Much worse Very much worse First line medication therapy [NICE CG171] • Generic oxybutynin IR* – 2.5mg bd – 5mg tds as tolerated £1.96 - £4.65 /28 days OR • Generic tolterodine IR 2mg bd Assess: PGI-I after 4 weeks £3.36 /28 days *Do not offer oxybutynin IR to frail, elderly patients [NICE CG171] – offer a second line anticholinergic or a β3-adrenoceptor agonist (see below for LMSG approved medication choices) PGI-I Score 1-2: Continue PGI-I Score 3-7 or side effects Second line - anticholinergic therapy • If the first treatment for OAB or mixed UI is not effective or well-tolerated, NICE recommends the trial of another drug with the lowest acquisition cost. A transdermal OAB drug should only be offered to women unable to tolerate oral medication [NICE CG171] • Drugs considered by NICE and approved by LMSG are as follows, along with costs as at December 2013 tariff: • • • • • Tolterodine ER (Neditrol XL®)€ Trospium IR (Flotros®) ∆ Oxybutynin ER Solifenacin Oxybutynin (transdermal) 4mg od 20mg bd 5mg-20mg od 5mg-10mg od 3.9mg / 24 hrs Assess: PGI-I after 4 weeks £12.89 / 28 days £14.44 /28 days £13.77 - £55.08 /28 days £25.78 - £33.52 /28 days £27.20 /28 days € At the time of ratification Neditrol XL® brand is less expensive than alternatives ∆ At the time of ratification Flotros® brand is less expensive than alternatives PGI-I Score 1-2: Continue PGI-I Score 3-7 or side effects Third line – β3-Adrenoceptor agonist therapy Consider a β3-adrenoceptor agonist following 2 anticholinergics prior to referral to secondary care if patient is willing to accept another medication [NICE TA290] • Mirabegron 50mg od (25mg od for special populations – see SPC) Assess: PGI-I after 4 weeks £27.07 /28 days ( black triangle drug, if any adverse events please report to MHRA and to CCG prescribing lead pharmacist) 2013-14 NHS HRG referral tariff prices (first outpatient appointment) Urology Urogynaecology Geriatric medicine £157 £133 £257 Key to abbreviations IR Immediate release ER Extended release OAB Overactive bladder UI Urinary incontinence PGI-I Score 1-2: Continue PGI-I Score 3-7 or side effects Referral to Secondary Care Refer to urogynaecology / urology / medical continence clinic if minimal or no improvement. References NICE CG171 – Urinary incontinence in women NICE TA290 - Overactive bladder - mirabegron February 2014 Drug Tariff and electronic MIMS Payment by Results in the NHS: tariff for 2013 to 2014