Medications for treatment of women with urgency urinary incontinence (UUI) or overactive bladder (OAB)

Medication	Starting dose	Maximum dose	Selected characteristics
Anticholinergics
Darifenacin extended-release (7.5 and 15 mg tablets)	7.5 mg orally once daily	15 mg orally once daily	See "General antimuscarinic issues" below for contraindications, association with dementia, and adverse effects Dry mouth and constipation are common Metabolized in liver by CYP3A4; maximum 7.5 mg daily with strong CYP3A4 inhibitors^* Reduced dose for moderate hepatic impairment Not recommended for severe hepatic impairment Do not crush, divide, or chew tablet
Fesoterodine extended-release (4 and 8 mg tablets)	4 mg orally once daily	8 mg orally once daily	See "General antimuscarinic issues" below for contraindications, association with dementia, and adverse effects Dry mouth and constipation are common Metabolized in liver by CYP3A4; maximum 4 mg daily with strong CYP3A4 inhibitors^* Reduced dose for severe renal impairment Not recommended for severe hepatic impairment Do not crush, divide, or chew tablet
Oxybutynin immediate-release (5 mg tablet)	5 mg orally 2 or 3 times daily	5 mg orally 4 times daily	See "General antimuscarinic issues" below for contraindications, association with dementia, and adverse effects Dry mouth and constipation are common Dizziness and somnolence can occur Often not tolerated by older adults and medically ill patients due to anticholinergic (including CNS) side effects Reduced dose in older adults Short effect may be useful when continence is desired at specific times Compliance is difficult with frequent dosing
Oxybutynin extended-release (5, 10, and 15 mg tablets)	5 to 10 mg orally once daily	30 mg orally once daily	See "General antimuscarinic issues" below for contraindications, association with dementia, and adverse effects Dry mouth and constipation are common Somnolence (6%) can occur Compliance is improved with daily dosing Do not crush, divide, or chew tablet
Oxybutynin transdermal (10% gel sachet [packet] or pump)	Apply 1 sachet (packet) or 1 pump once daily; each packet or pump delivers 1 g of gel equivalent to 100 mg oxybutynin	Same as starting dose	See "General antimuscarinic issues" below for contraindications, association with dementia, and adverse effects Associated with low rates of dry mouth and constipation Apply to clean, dry, intact skin on abdomen, thighs, or upper arms/shoulders Keep area dry for at least 1 hour after application Do not use same application site more than once in 7 days Application site reaction including irritation and dermatitis
Oxybutynin transdermal (3.9 mg patch)	Apply 1 patch twice per week (ie, once every 3 to 4 days)	Do not exceed starting dose	See "General antimuscarinic issues" below for contraindications, association with dementia, and adverse effects Available without a prescription (OTC) in the United States and some other countries Associated with low rates of dry mouth and constipation Apply under clothing to abdomen, hip, or buttock Do not use same application site more than once in 7 days Application site pruritus; local erythema, rash
Solifenacin (5 and 10 mg tablets	5 mg orally once daily	10 mg orally once daily	See "General antimuscarinic issues" below for contraindications, association with dementia, and adverse effects Dry mouth and constipation are common Reduce dose for severe renal impairment or moderate hepatic impairment Not recommended for severe hepatic impairment Metabolized in liver by CYP3A4; maximum 5 mg daily with CYP3A4 inhibitors^* Modestly prolongs QTc interval; caution with other QTc prolonging drugs^* and in patients with congenital prolonged QT Can crush, divide, or chew tablet
Tolterodine extended-release (2 and 4 mg tablets)	2 mg orally once daily	4 mg orally once daily	See "General antimuscarinic issues" below for contraindications, association with dementia, and adverse effects Dry mouth and constipation are common Reduced dose for renal and/or hepatic impairment, not recommended for severe renal or hepatic impairment Metabolized in liver by CYPs 3A4 and 2D6; maximum 2 mg daily with strong CYP3A4 inhibitors^* Modestly prolongs QTc interval; caution with other QTc prolonging drugs^* and in patients with congenital prolonged QT Do not crush, divide, or chew extended-release tablet
Tolterodine immediate-release (1 and 2 mg tablets)	1 mg orally twice daily	2 mg orally twice daily
Trospium extended-release (60 mg tablet)	60 mg orally once daily	Same as starting dose	See "General antimuscarinic issues" below for contraindications, association with dementia, and adverse effects Need to take on empty stomach or 1 hour before meal Dry mouth and constipation are common Reduce dose for renal impairment, not recommended for severe renal impairment Not metabolized by CYP and therefore has a low risk of drug-drug interactions Avoid alcohol consumption within 2 hours of using extended-release preparation Do not crush, divide, or chew extended releases tablet
Trospium immediate-release (20 mg tablet)	20 mg orally once daily	20 mg twice daily
Beta-3 adrenergic agonists
Mirabegron extended-release (25 and 50 mg tablets)	25 mg orally once daily	50 mg orally once daily	Most common side effects include hypertension, nasopharyngitis, urinary tract infection, and headache Associated with increases in heart rate and blood pressure Monitor blood pressure in those with well-controlled and avoid in those with poorly controlled hypertension Metabolized in liver by CYP2D6; when used concomitantly with drugs metabolized by CYP2D6, especially narrow therapeutic index drugs, appropriate monitoring and possible dose adjustment of those drugs may be necessary Reduce dose for renal and hepatic impairment Rare angioedema reactions Minimal (<10mSec) QT interval prolongation Do not crush, divide, or chew tablet
Liquid granules 8 mg/mL (approved for pediatric dosing only)	25 mg orally once daily	50 mg orally once daily
Vibegron extended-release (75 mg tablets)	75 mg orally once daily	Same as starting dose	Most common side effects are headache, urinary tract infection, nasopharyngitis, diarrhea, nausea, and upper respiratory tract infection No hypertension warnings Does not prolong QT interval Can crush, divide, or chew tablet

General antimuscarinic issues:

All antimuscarinics are contraindicated in gastric retention, untreated narrow angle closure glaucoma, and supraventricular tachycardia; and should be used with caution in patients with urinary retention and/or obstruction.
Evidence suggests that cumulative exposure to potent antimuscarinics is associated with increased rates of dementia and Alzheimer disease.^[1]
All antimuscarinics exert peripheral anticholinergic effects (eg, dry mouth, constipation, tachycardia, palpitations).
All antimuscarinics may have additive side effects with other medications that have strong anticholinergic effects (eg, first-generation H1 antihistamines, muscle relaxants, tricyclic antidepressants, antipsychotics, inhaled anticholinergic bronchodilators).^*
Approach to agent selection and dose titration is reviewed in the topic section on pharmacologic therapy of urge incontinence.

General beta-3 adrenergic agonist issues:

Should be used with caution in patients with urinary retention and/or obstruction.
Patients taking digoxin may need additional monitoring and digoxin dose adjustments.
Should not be used in those with known allergic reaction to drug or components.
Not recommended for severe renal or hepatic impairment.

CNS: central nervous system; CYP: cytochrome P-450 metabolism; OTC: over-the-counter.

* To check for specific interactions, use the Lexi-Interact program included with UpToDate.

Reference:

Gray SL, Anderson ML, Dublin S, et al. Cumulative use of strong anticholinergics and incident dementia: S prospective cohort study. JAMA 2015; 175:401.

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Medications for treatment of women with urgency urinary incontinence (UUI) or overactive bladder (OAB)