cholinergic antagonists

A review of the causes, presentations, and management of patients with dental caries with an emphasis on what primary care clinicians can do the help patients until they can see a dentist. James W. Mold, MD, MPH

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Dental caries (tooth decay or cavities) refers to demineralization of teeth, which occurs after bacteria metabolize dietary carbohydrates into acid. More than 90% of US adults experience caries and 26% have untreated caries.

Author/s:

Elizabeth Alpert, Hugh Silk, Lisa Simon

Lower Urinary Tract Symptoms in Men: A Review

Hope Smashey — Tue, 15 Jul 2025 17:34:18 +0000

Date Added:

July 15, 2025

Journal/Publication:

JAMA

Publication Date:

July 14, 2025

URL:

Lower Urinary Tract Symptoms in Men: A Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2025.7045

Keywords

prostate

Lower Urinary Tract Symptoms

PMID (1):

40658396

MeSH

Urinary Bladder

Overactive

Phosphodiesterase 5 Inhibitors

Finasteride

Tadalafil

Transurethral Resection of Prostate

Urinary Retention

cholinergic antagonists

Prostate

Nocturia

Hematuria

Urinary Bladder Calculi

pelvic floor

Lower Urinary Tract Symptoms

Minimally Invasive Surgical Procedures

An evidence-based review of lower urinary symptoms in men. James W. Mold, MD, MPH

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Importance: Up to 40% of men older than 50 years have lower urinary tract symptoms, including urinary urgency, nocturia, and weak urinary stream, due to disorders of the bladder and prostate. These symptoms negatively affect quality of life and may be associated with urinary retention, which can cause kidney insufficiency, bladder calculi, hematuria, and urinary tract infections.

Observations: In men, lower urinary tract symptoms can be caused by bladder outlet obstruction secondary to benign prostatic hyperplasia (BPH), an overactive bladder detrusor (a syndrome of urinary urgency and frequency), or both. Behavioral therapy, including pelvic floor physical therapy, timed voiding (voiding at specific intervals), and fluid restriction, can improve symptoms. Medications including α-blockers (such as tamsulosin), 5α-reductase inhibitors (such as finasteride), and phosphodiesterase 5 inhibitors (such as tadalafil) improve lower urinary tract symptoms (mean improvement, 3-10 points on the International Prostate Symptom Score [IPSS], which ranges from 0-35, with higher scores indicating greater severity) and can prevent symptom worsening measured by increased IPSS greater than or equal to 4 points or development of secondary sequelae, such as urinary retention. Combination therapies are more effective than monotherapy. For example, α-blockade (eg, tamsulosin) combined with 5α-reductase inhibition (eg, finasteride) lowers progression risk to less than 10% compared with 10% to 15% with monotherapy. Treatment for overactive bladder detrusor, including anticholinergics (eg, trospium) and β3 agonists (eg, mirabegron), reduces voiding frequency by 2 to 4 times per day and reduces episodes of urinary incontinence by 10 to 20 times per week. Surgery (eg, transurethral resection of the prostate, holmium laser enucleation of the prostate) and minimally invasive surgery are highly effective for refractory or complicated cases of BPH, defined as persistent symptoms despite behavioral and pharmacologic therapy, and these therapies can improve IPSS by 10 to 15 points. Minimally invasive procedures, such as water vapor therapy (endoscopic injection of steam into BPH tissue) and prostatic urethral lift (endoscopic insertion of nonabsorbable suture implants that mechanically open the urethra), have lower complication rates of incontinence (0%-8%), erectile dysfunction (0%-3%), and retrograde ejaculation (0%-3%) but are associated with increased need for surgical retreatment (3.4%-21%) compared with transurethral resection of the prostate (5%) and holmium laser enucleation of the prostate (3.3%).

Conclusions and relevance: Lower urinary tract symptoms, defined as urinary urgency, nocturia, or weak stream, are common among men and are usually caused by BPH, overactive bladder detrusor, or both. First-line therapy consists of behavioral intervention, such as pelvic floor physical therapy and timed voiding, as well as pharmacologic therapy, including α-adrenergic blockers (tamsulosin), 5α-reductase inhibitors (finasteride), phosphodiesterase inhibitors (tadalafil), anticholinergics (trospium), and β3 agonists (mirabegron).

Author/s:

John T Wei, Casey A Dauw, Casey N Brodsky

Drug interactions with cannabinoids

John Bayhi — Mon, 02 Mar 2020 18:41:14 +0000

Date Added:

March 2, 2020

Journal/Publication:

CMAJ: Canadian Medical Association Journal = journal de l'Association medicale canadienne

Publisher:

Joule Inc.

Publication Date:

March 2, 2020

Issue:

Volume:

192

Pages:

E206

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

Keywords

MeSH

Cytochrome P-450 CYP1A2

cannabinoids

Cytochrome P-450 CYP3A Inhibitors

Cytochrome P-450 CYP3A

Tacrolimus

Trimethoprim

Sulfamethoxazole Drug Combination

Cytochrome P-450 CYP2C9

Cytochrome P-450 CYP2C9 Inhibitors

CYP2C19 protein

Cytochrome P-450 CYP2C19

Benzodiazepines

International Normalized Ratio

Marijuana Use

cholinergic antagonists

A nice one-page review of drug interactions with cannabinoids. James W. Mold, MD, MPH

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No abstract available

Author/s:

Antoniou, T, Bodkin, J, Ho, JMW

Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-Control Study

Brian Desmarais — Thu, 27 Jun 2019 13:04:17 +0000

Date Added:

June 27, 2019

Journal/Publication:

Journal of the American Medical Association Internal Medicine

Publication Date:

June 24, 2019

URL:

Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-Control Study

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jamainternmed.2019.0677.

Keywords

MeSH

Muscarinic Antagonists

antipsychotic agents

Middle Aged

Anticonvulsants

Confounding Factors (Epidemiology)

Urinary Bladder

cholinergic antagonists

antidepressive agents

I am only posting this article because your patients may ask about it. The research design isn’t very strong, and the association strengths aren’t terribly impressive. The dementia diagnoses weren’t confirmed, and I can’t tell whether patients were still taking the meds, which we know can cause acute cognitive impairment.. James W. Mold, MD, MPH

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IMPORTANCE:

Anticholinergic medicines have short-term cognitive adverse effects, but it is uncertain whether long-term use of these drugs is associated with an increased risk of dementia.

OBJECTIVE:

To assess associations between anticholinergic drug treatments and risk of dementia in persons 55 years or older.

DESIGN, SETTING, AND PARTICIPANTS:

This nested case-control study took place in general practices in England that contributed to the QResearch primary care database. The study evaluated whether exposure to anticholinergic drugs was associated with dementia risk in 58 769 patients with a diagnosis of dementia and 225 574 controls 55 years or older matched by age, sex, general practice, and calendar time. Information on prescriptions for 56 drugs with strong anticholinergic properties was used to calculate measures of cumulative anticholinergic drug exposure. Data were analyzed from May 2016 to June 2018.

EXPOSURES:

The primary exposure was the total standardized daily doses (TSDDs) of anticholinergic drugs prescribed in the 1 to 11 years prior to the date of diagnosis of dementia or equivalent date in matched controls (index date).

MAIN OUTCOMES AND MEASURES:

Odds ratios (ORs) for dementia associated with cumulative exposure to anticholinergic drugs, adjusted for confounding variables.

RESULTS:

Of the entire study population (284 343 case patients and matched controls), 179 365 (63.1%) were women, and the mean (SD) age of the entire population was 82.2 (6.8) years. The adjusted OR for dementia increased from 1.06 (95% CI, 1.03-1.09) in the lowest overall anticholinergic exposure category (total exposure of 1-90 TSDDs) to 1.49 (95% CI, 1.44-1.54) in the highest category (>1095 TSDDs), compared with no anticholinergic drug prescriptions in the 1 to 11 years before the index date. There were significant increases in dementiarisk for the anticholinergic antidepressants (adjusted OR [AOR], 1.29; 95% CI, 1.24-1.34), antiparkinson drugs (AOR, 1.52; 95% CI, 1.16-2.00), antipsychotics (AOR, 1.70; 95% CI, 1.53-1.90), bladder antimuscarinic drugs (AOR, 1.65; 95% CI, 1.56-1.75), and antiepileptic drugs (AOR, 1.39; 95% CI, 1.22-1.57) all for more than 1095 TSDDs. Results were similar when exposures were restricted to exposure windows of 3 to 13 years (AOR, 1.46; 95% CI, 1.41-1.52) and 5 to 20 years (AOR, 1.44; 95% CI, 1.32-1.57) before the index date for more than 1095 TSDDs. Associations were stronger in cases diagnosed before the age of 80 years. The population-attributable fraction associated with total anticholinergic drug exposure during the 1 to 11 years before diagnosis was 10.3%.

CONCLUSIONS AND RELEVANCE:

Exposure to several types of strong anticholinergic drugs is associated with an increased risk ofdementia. These findings highlight the importance of reducing exposure to anticholinergic drugs in middle-aged and older people.

Author/s:

Coupland, C.A.C., Hill, T., Dening, T., Morriss, R., Moore M., Hippisley-Cox J.

Pharmacologic and Nonpharmacologic Treatments for Urinary Incontinence in Women: A Systematic Review and Network Meta-analysis of Clinical Outcomes

Jeffrey Wilson — Tue, 19 Mar 2019 19:29:38 +0000

Date Added:

March 19, 2019

Journal/Publication:

Annals of Internal Medicine

Publisher:

American College of Physicians

Publication Date:

March 19, 2019

URL:

Pharmacologic and Nonpharmacologic Treatments for Urinary Incontinence in Women: A Systematic Review and Network Meta-analysis of Clinical Outcomes

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.7326/M18-3227

Keywords

behavioral interventions

incontinence

PMID (1):

30884526

MeSH

urinary incontinence

behavior therapy

cholinergic antagonists

Another large systematic review showing that behavioral interventions are more effective than drugs for both stress and urge incontinence in women. Primary care clinicians can learn to prescribe behavioral interventions if incontinence therapists are unavailable. I only used drugs while patients were mastering the behavioral techniques. James Mold, MD, MPH

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BACKGROUND:

Urinary incontinence (UI), a common malady in women, most often is classified as stress, urgency, or mixed.

PURPOSE:

To compare the effectiveness of pharmacologic and nonpharmacologic interventions to improve or cure stress, urgency, or mixed UI in nonpregnant women.

DATA SOURCES:

MEDLINE, Cochrane Central Register of Controlled Trials (Wiley), Cochrane Database of Systematic Reviews (Wiley), EMBASE (Elsevier), CINAHL (EBSCO), and PsycINFO (American Psychological Association) from inception through 10 August 2018.

STUDY SELECTION:

84 randomized trials that evaluated 14 categories of interventions and reported categorical cure or improvement outcomes.

DATA EXTRACTION:

1 researcher extracted study characteristics, results, and study-level risk of bias, with verification by another independent researcher. The research team collaborated to assess strength of evidence (SoE) across studies.

DATA SYNTHESIS:

84 studies reported cure or improvement outcomes (32 in stress UI, 16 in urgency UI, 4 in mixed UI, and 32 in any or unspecified UI type). The most commonly evaluated active intervention types included behavioral therapies, anticholinergics, and neuromodulation. Network meta-analysis showed that all interventions, except hormones and periurethral bulking agents (variable SoE), were more effective than no treatment in achieving at least 1 favorable UI outcome. Among treatments used specifically for stress UI, behavioral therapy was more effective than either α-agonists or hormones in achieving cure or improvement (moderate SoE); α-agonists were more effective than hormones in achieving improvement (moderate SoE); and neuromodulation was more effective than no treatment for cure, improvement, and satisfaction (high SoE). Among treatments used specifically for urgency UI, behavioral therapy was statistically significantly more effective than anticholinergics in achieving cure or improvement (high SoE), both neuromodulation and onabotulinum toxin A (BTX) were more effective than no treatment (high SoE), and BTX may have been more effective than neuromodulation in achieving cure (low SoE).

LIMITATION:

Scarce direct (head-to-head trial) evidence and population heterogeneity based on UI type, UI severity, and history of prior treatment.

CONCLUSION:

Most nonpharmacologic and pharmacologic interventions are more likely than no treatment to improve UI outcomes. Behavioral therapy, alone or in combination with other interventions, is generally more effective than pharmacologic therapies alone in treating both stress and urgency UI.

Author/s:

Balk, E.M., Rofebero, V.N., Adam, G.P., Kimmel, H.J., Trikalinos, T.A., Jeppson, P.C.