Antimuscarinics in the Treatment of OAB: Is there a First-Line and a Second-Line Choice?

Antimuscarinics are currently the mainstay of pharmacotherapy of the overactive bladder (OAB) syndrome. Several meta-analyses have confirmed their efficacy in comparison with placebo, although the clinical significance of differences in parameters recorded in clinical trials has been questioned. Trials examining the effect of antimuscarinics on outcomes which matter to the patients, such as subjective cure/improvement rates, quality of life parameters and cost-effectiveness are relatively limited. Also, comparative studies between the various available drugs have been designed to support the registration requirements and rarely provide information critical for a physician who needs to assess the best first-line choice for the specific patient, or even a second-line management. Data which might be useful for clinicians who would embark on tailoring the management of OAB for the individual patient could be found in systematic reviews/meta-analyses, cost-effectiveness studies and studies investigating the patients' adherence to treatment and persistence with pharmacotherapy for OAB. In addition, patient co-morbidities and concurrent treatments should be taken into consideration in conjunction with the safety profile of each antimuscarinic. Available evidence suggests that the use of ER formulations of antimuscarinics is favoured over the IR formulations when concerning best balance between efficacy and adverse events, cost-effectiveness, adherence and persistence with treatment.