New society guidance on the use of anticholinergic medications for the treatment of OAB
AUGS Clinical Consensus Statement: Association of anticholinergic medication use and cognition in women with overactive bladder. Female Pelvic Med Reconstr Surg. 2021;27:69-71. doi:10.1097/ SPV.0000000000001008.
In 2021, AUGS updated its consensus statement on the use of anticholinergic medications for the treatment of OAB. This action was in response to growing evidence that supports the association of anticholinergic medications with long-term cognitive adverse effects, including cognitive impairment, dementia, and Alzheimer disease.
Here, we summarize the most recent modifications, which differentiate the updated statement from the preceding consensus document published in 2017.
Updated AUGS recommendations
- If considering anticholinergic medications, counsel patients about the risk of cognitive adverse effects and weigh these risks against the potential benefits to their quality of life and overall health.
- Use the lowest possible dose when prescribing anticholinergics and consider alternatives such as β3 agonists (for example, mirabegron or vibegron).
- Avoid using anticholinergic medications in women older than age 70. However, if an anticholinergic must be used, consider a medication that has low potential to cross the blood-brain barrier (for example, trospium).
For patients who are unresponsive to behavioral therapies for OAB, medical management may be considered. However, the risks of anticholinergic medications may outweigh the benefits—especially for older women—and these medications should be prescribed with caution after discussing the potential cognitive adverse effects with patients. β3 agonists should be preferentially prescribed when appropriate. Consider referral to a urogynecologist for discussion of third-line therapies in patients who prefer to forego or may not be candidates for medical management of their OAB symptoms.
HbA1c levels > 8% may increase complications risk in urogyn surgery
Ringel NE, de Winter KL, Siddique M, et al. Surgical outcomes in urogynecology—assessment of perioperative and postoperative complications relative to preoperative hemoglobin A1c—a Fellows Pelvic Research Network study. Female Pelvic Med Reconstr Surg. 2022;28:7-13. doi:10.1097/ SPV.0000000000001057.
Diabetes mellitus is a known risk factor for complications following surgery. Adoption of an HbA1c level threshold for risk stratification before urogynecologic surgery may help improve patient outcomes.
Study details
Ringel and colleagues conducted a multicenter retrospective cohort study that included women with diabetes mellitus who underwent prolapse and/or SUI surgery between 2013 and 2018. The aim of the study was to identify a hemoglobin A1C threshold that would help predict increased risk for perioperative complications in women undergoing pelvic reconstructive surgery. Demographics, preoperative HbA1c levels, and surgical data were collected.
Complication risks correlated with higher HbA1c threshold
The study included 807 women with HbA1c values that ranged from 5% to 12%. The overall complication rate was 44%. Sensitivity analysis was performed to compare complication rates between patients with varying HbA1c levels and determine a threshold HbA1c value with the greatest difference in complication rates.
The authors concluded that women with an HbA1c level ≥ 8% showed the greatest increase of perioperative complications. Patients with an HbA1c ≥ 8%, compared with those who had an HbA1c < 8%, had a statistically significantly increased rate of overall (58% vs 42%, P = .002) and severe (27% vs 13%, P< .001) perioperative complications.
After multivariate logistic regression, the risk of overall complications remained elevated, with a 1.9-times higher risk of perioperative complications for women with an HbA1c ≥ 8%.
Women should be medically optimized before undergoing surgery and, while this study was restricted to urogynecologic surgery patients, it seems reasonable to assume that a similar HbA1c threshold would be beneficial for women undergoing other gynecologic procedures. Appropriately screening patients and referring them for early intervention with their primary care clinician or endocrinologist may improve surgical outcomes, especially in women with an HbA1c level > 8%.
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