For interstitial cystitis and overactive bladder patients struggling with intense urinary frequency and urgency, physicians often prescribe anticholinergic medications such as Amitryptiline (Elavil), imipramine (Tofranil) or Nortryptiline (Pamelor), Oxybutynin (Ditropan, Oytrol) or Tolteradine (Detrol). Unfortunately, their use has now been linked to cognitive decline and dementia in some patients who use it daily for long periods of time.

New research from the United Kingdom studied the medical records of 58,769 people with dementia and 225,574 without dementia, all 55 years or older. They found that long-term, daily use (3 years or longer) of certain anticholinergic medications were associated with a 50% higher risk of dementia, including: bladder medications for overactive bladder, antidepressants, antipsychotic, anti-Parkinson’s and epilepsy drugs. The study found no significant risks for two other types of medications also used by IC patients (anthistamines and skeletal muscle relaxants)  although the number of patients using them were small. The authors strongly suggested that anticholinergic drugs should be prescribed with caution in middle-aged and older people.

We asked Dr. Robert Evans for his thoughts on this issue. “We have always known that elderly patients can develop mental status changes, confusion and even dementia if exposed to anticholinergics which is why so many of us prefer to use Mirabegron for pts with overactive bladder” he said. “I rarely use anticholinergics in patients with IC as I do not think they help decrease frequency.  The reason is that IC patients void frequently because of pain not because of overactivity. These meds will not decrease voiding frequency since they do not help with pain.  I especially want to avoid them on patients who are on other drugs with anticholinergic activity such as antihistamines, tricyclics or gabapentin.” 

Mirabegron (Myrbetriq®) is in a class of medications called beta-3 adrenergic agonists and works by relaxing the bladder muscles to prevent urgent, frequent, or uncontrolled urination.  It can be quite expensive at over $400 a prescription for just 30 pills.(2) Dr. Evans said “Unfortunately many insurance companies refuse to pay for this as there is no generic.” Patients are then forced to take medications that are potentially damaging to their cognition because of insurance refusal to pay for a safer alternative.

Astellas Pharma does offer a Patient Assistance Program for Myrbetriq® where you may be able to obtain the medication at no cost if you meet their eligibility requirements.(3) You must be uninsured or have insurance that excludes coverage of Myrbetriq®, have a US shipping address, been prescribed it for an FDA approved indication and, of course, meet their financial eligibility requirements. Learn how to apply here.

Patients using the medications mentioned in the study should ask their doctor if other medications are available that do not carry the same risks. Newer antidepressants (SSRIs & SNRIs) like citalopram (Celexa) and duloxetine (Cymbalta) have lower anticholinergic effects than older antidepressants. But they, too, can come with some risks. Cymbalta, for example, is known for causing severe withdrawal reactions in patients who are trying to stop the medication.  Some patients have experienced nightmares, vertigo and “brain zaps,” painful headaches that feel like electric shocks along the spine to the base of the skull. (4)

Thankfully self-help strategies can also help! Many IC patients have learned that their frequency and urgency is often triggered by certain foods and beverages.  If you are struggling with symptoms and still drinking coffees, sodas, green teas, black teas, there is hope. You could feel much better in a relatively quick period of time by modifying your diet and eliminating these risk foods. It’s certainly worth trying, right?

Menopausal women struggling with IC may also have a more sensitive bladder due to estrogen atrophy, known as the Genitourinary Syndrome of Menopause.(5) They should talk with their physician to determine if the use of a topical estrogen cream would be beneficial.

Spring/Summer 2019 IC Optimist MagazineYou can find a more extensive discussion of this topic in the Spring/Summer 2019 IC Optimist, the ICN Member magazine. Learn more here! 

References:

  1. Coupland C, et al. Anticholinergic Drug Exposure and the Risk of Dementia. JAMA Intern Med. Published online June 24, 2019. Accessed June 30, 2019 – https://jamanetwork.com/journals/jamai nternalmedicine/fullarticle/2736353
  2. Myrbetriq Prices, Coupons and Patient Assistance Programs. Accessed August 22, 2019 – https://www.drugs.com/price-guide/myrbetriq
  3. Astellas Patient Assistance Program. Accessed August 22, 2019
  4. Cymbalta Withdrawal & Detox. The Recovery Village. Accessed August 22, 2019 – https://www.therecoveryvillage.com/cymbalta-addiction/withdrawal-detox/#gref
  5. Hyun-Kyung K, et al. The Recent Review of Genitourinary Syndrome of Menopause. J Menopausal Med. 2015 Aug; 21(2);65-71