Exercise caution in prescribing medications for lower urinary tract symptoms in the elderly

In Sri Lanka, the only alpha-1A blockers available are tamsulosin and terazosin with a few patients retired from the gulf states still continuing on alfuzosin and doxazosin brought from abroad. Silodosin exhibits the highest selectivity for the alpha-1A adrenoceptor blockage. This most uro-selective agent is yet to be introduced in Sri Lanka. 5-alpha reductase inhibitors finesteride and dutasteride are both available in Sri Lanka.


DMH Fernando, SAS Goonawardena
Benign prostatic obstruction (BPO) commonly manifests with a predominantly voiding type of lower urinary tract symptoms (LUTS), difficulty in initiating flow (hesitancy), poor urinary stream, intermittent flow, straining to facilitate voiding and terminal dribbling with a variable degree of storage LUTS.
The mainstay of treatment for moderate and severe LUTS are alpha-1A adrenoceptor antagonists with or without 5-alpha reductase inhibitors.
Detrusor over-activity (DO) is not an uncommon condition, more commonly seen in females with urgency as the prominent symptom. In storage LUTS, increased day time frequency, nocturia, urgency with or without urgency urinary incontinence are the main features of overactive bladder. The mainstay of treatment is antimuscarinics and beta-3 adrenoceptor agonists.
In Sri Lanka, the only alpha-1A blockers available are tamsulosin and terazosin with a few patients retired from the gulf states still continuing on alfuzosin and doxazosin brought from abroad. Silodosin exhibits the highest selectivity for the alpha-1A adrenoceptor blockage. This most uro-selective agent is yet to be introduced in Sri Lanka. 5-alpha reductase inhibitors finesteride and dutasteride are both available in Sri Lanka.
Antimuscarinics available in this country are immediate-release oxybutinin (standard dose), tolterodine and solifenacin. Trospium, propiverine, darifenacin, fesoterodine and extended release oxybutinin, currently used in the West are not yet available in Sri Lanka. Beta-3 adrenoceptor agonist mirabegron too is unavailable.
The FORTA ( fit FOR The Aged ) classification was introduced in 2008 with the aim of guiding physicians in their screening process for inappropriate or harmful medications and drug omissions in older patients (over 65 years) in an everyday clinical setting (1,2). In brief the FORTA classification labels, depending on the state of evidence for safety, efficacy and overall age appropriateness are assigned for individual drugs as follows: • Class A (absolutely): indispensable drug, clear cut benefit in terms of efficacy / safety ratio proven for a given indication in older people.
• Class B (beneficial): drugs with proven or obvious efficacy in older people, but limited extent of efficacy or safety concerns.
• Class C (careful) : drugs with questionable efficacy and safety profiles in older people, to be avoided or omitted in the presence of too many other drugs, lack of benefit or emerging side effects; review/find alternatives.
• Class D (don't) : avoid in older people. Omit first, review/find alternatives.
A recent systematic review found that no drug was rated at the FORTA A level (indispensable), only three drugs were assigned to FORTA B (beneficial): 5-alpha reductase inhibitors finasteride and dutasteride and the antimuscarinic fesoterodine [3]. The majority of drugs were rated FORTA C (Questionable): beta-3 agonist mirabegron, antimuscarinics tolterodine, solifenacin, trospium, darifenacin, extended-release oxybutinin and alpha-1A blocker silodosin. FORTA D (avoid ) was assigned to alpha-1A blockers terozosin, alfuzosin and doxazosin and antimuscarinics drugs immediate-release oxybutinin and propiverine.
Oxybutinin can cause cognitive impairment in the elderly [4].

Correspondence
We would urge the general practitioners and medical specialists to refrain from prescribing the alpha-1A blocker, terazosin to the elderly males and similarly immediate-release oxybutinin for urgency and urgency urinary incontinence in the elderly patients as these are potentially inappropriate medication.

Conflicts of interest
Authors declare that there are no conflicts of interest