The recent commentary, “Is It Time to Rethink Our Approach to Overactive Bladder Treatment?” by Alagh and Ramm published in the November 2023 issue of this journal,1 details the impact of overactive bladder (OAB) on patients and examines emerging concerns with anticholinergic treatments for OAB. Discussion of anticholinergic safety is timely given recent evidence describing anticholinergic-associated risks, including a systematic review and meta-analysis that found an estimated 46% increased risk of dementia with ≥3 months of anticholinergic use compared with nonuse.2

It should be further emphasized that another class of effective pharmacotherapies, β3-adrenergic receptor agonists, exists that has not been associated with cognitive effects. A recent retrospective matched cohort study found that patients with OAB who were treated with a β3-agonist experienced a significantly lower risk of incident dementia than those who were treated with anticholinergic medications.3 Consistent with these results, a recent white paper on OAB anticholinergics and dementia risk from the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction recommends that trial of a β3-agonist should typically be preferred to an anticholinergic as the initial pharmacologic agent for OAB.4

Furthermore, a discussion of anticholinergic risks would be incomplete without noting that anticholinergic use is driven by insurance policies, including step therapy, previous authorization, and high copays, which limit patient access to treatments they may prefer. The possible harms of step therapy policies in OAB and potential for these policies to be better regulated have been reviewed elsewhere.5 Clinicians should continue to promote awareness of anticholinergic-related risks, particularly for nonspecialists, and consider nonanticholinergic treatment options for patients with OAB based on open discussion and individual patient needs.

Roger R. Dmochowski, MD
From the Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN

ACKNOWLEDGMENTS

Medical writing and editorial support were provided by Joseph Kruempel, PhD, of The Curry Rockefeller Group, LLC (Tarrytown, NY), and were funded by Sumitomo Pharma America, Inc (Marlborough, MA).

REFERENCES 1. Alagh A, Ramm O. Is it time to rethink our approach to overactive bladder treatment? Urogynecology. 2023;29(11):856–859. 2. Dmochowski RR, Thai S, Iglay K, et al. Increased risk of incident dementia following use of anticholinergic agents: a systematic literature review and meta-analysis. Neurourol Urodyn. 2021;40(1):28–37. 3. Welk B, McArthur E. Increased risk of dementia among patients with overactive bladder treated with an anticholinergic medication compared to a beta-3 agonist: a population-based cohort study. BJU Int. 2020;126(1):183–190. 4. Zillioux J, Welk B, Suskind AM, et al. SUFU white paper on overactive bladder anticholinergic medications and dementia risk. Neurourol Urodyn. 2022;41(8):1928–1933. 5. Dmochowski RR, Newman DK, Rovner ES, et al. Patient and clinician challenges with anticholinergic step therapy in the treatment of overactive bladder: a narrative review. Adv Ther. 2023;40(11):4741–4757.