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Urinary tract disorders
Published in Henry J. Woodford, Essential Geriatrics, 2022
Duloxetine, a combined serotonin and norepinephrine reuptake inhibitor, has been proposed for stress incontinence. The theory is that serotonergic neurons may suppress bladder parasympathetic actions. A meta-analysis of studies (four trials; n = 1,913; mean age 52) compared duloxetine to placebo for stress UI. Duloxetine had a small significant reduction of around 0.4 fewer incontinent episodes per day.129 However, this came at the cost of adverse effects. People receiving duloxetine were more than five times more likely to discontinue treatment. Reported adverse events include anxiety, nausea, dry mouth, constipation, fatigue, insomnia, dizziness, increased sweating, vomiting, somnolence and tremor. It is hard to justify the use of duloxetine on the current evidence of such a small beneficial effect, particularly in older people who are more likely to have adverse reactions. Duloxetine is not recommended as a first-line treatment for stress UI and is only considered for women who do not want, or are unsuitable for, surgery.87
Answers
Published in Andrew Schofield, Paul Schofield, The Complete SAQ Study Guide, 2019
Andrew Schofield, Paul Schofield
Incontinence is considered one of the ‘geriatric giants’. Stress incontinence is a common problem in older women, and it often causes the patient significant distress and embarrassment. Weakness of the pelvic floor is responsible for stress incontinence, and is commonly caused by the weight of the uterus during pregnancy and stretching of the muscles during pregnancy. Increasing the tone of pelvic floor muscles should be encouraged, and numerous programmes explaining how to do this, how often and for how long are advised by physiotherapists. Conservative management also includes addressing exacerbating factors, such as obesity, smoking and drinking large volumes of caffeine. Duloxetine is given to some patients. The internal urethral sphincter is under autononomic control, and increasing the NA at the synapse increases sympathetic activity and increases its tone. Surgical options include referral to a urogynaecologist for consideration of tension-free vaginal tapes/sling procedures.
Common/useful drugs
Published in Jonathan P Rogers, Cheryl CY Leung, Timothy RJ Nicholson, Pocket Prescriber Psychiatry, 2019
Jonathan P Rogers, Cheryl CY Leung, Timothy RJ Nicholson
Interactions: as morphine but ☠ ↑risk of hyperpyrexia/CNS toxicity with MAOIs☠. Ritonavir ⇒ ↓levels and ↑s toxic metabolites. May ↑serotonergic effects of duloxetine. No known interaction with gabapentin or baclofen.
Efficacy of pelvic floor muscle exercise or therapy with or without duloxetine: a systematic review and network Meta-analysis
Published in The Aging Male, 2022
Jae Joon Park, Allison Kwon, Tae Il Noh, Yong Nam Gwon, Sung Ryul Shim, Jae Heon Kim
Treatment of PPUI starts with PFME and PFMT, and in patients’ refractory to such intervention, pharmacotherapy options are limited, warranting surgical treatment such as sling and artificial urethral sphincter [30]. Duloxetine is one of the limited drug therapy options available [31]. In patients undergoing PPUI, urine leakage occurs when the abdominal pressure induced by physical activity exceeds the urethral resistance due to contraction of the urethral sphincter [32]. The contraction of the urethral sphincter results from activation of the pudendal nerve induced by serotoninergic and noradrenergic neurotransmitters in the Onuf’s nucleus [11,33]. Accordingly, duloxetine, a selective serotonin (5-HT)-norepinephrine (NE) reuptake inhibitor, induces contraction of the urethral sphincter and alleviates PPUI symptoms [33,34].
Emerging injectable therapies for osteoarthritis
Published in Expert Opinion on Emerging Drugs, 2022
Topical NSAIDs are recommended in most guidelines, and a recent meta-analysis supports this [25]. Only three sets of guidelines [7,8,12] address the use of topical capsaicin, which has variable but overall weaker recommendations. Oral acetaminophen/paracetamol perhaps has the most variable recommendations between guidelines. In general, older sets of guidelines strongly support its use whereas more recent guidelines provide a weaker endorsement or even recommend against its use. This is in part due to the publication of a 2019 meta-analysis which demonstrated that acetaminophen/paracetamol provides only minimal improvements in pain and function in hip or knee OA compared to placebo, and its effect is not dose-dependent [26]. Oral NSAIDs are generally supported across all guidelines, however many stipulate that this drug class should only be used for a short duration and warn of the potential for serious side-effects. While oral opioids are generally not recommended, tramadol (which exhibits opioid-like characteristics but structurally is not an opiate [27]) is recommended in two sets of guidelines [8,15]. Duloxetine, an antidepressant, is supported by weak recommendations, particularly in patients with concomitant depression or widespread pain.
Postoperative pain: a review of emerging therapeutic options
Published in Expert Review of Neurotherapeutics, 2021
Abhishek K Gupta, Shayla Mena, Zhaosheng Jin, Tong J Gan, Sergio Bergese
A systematic meta-analysis found that use of duloxetine decreased post-operative pain up to 48 hours post-operatively, in addition to decreasing opioid consumption [99]. However, the authors of this meta-analysis found the effect sizes to be below the level of clinical significance. Interestingly, Koh et al conducted a trial in total knee arthroplasty patients with central sensitization secondary to chronic osteoarthritic pain. When compared against placebo, duloxetine 30 mg was found to improve pain metrics in the two to twelve-week post-operative period and led to superior recovery two weeks post-operatively [100]. In select patients, duloxetine may be more efficacious beyond the immediate postoperative period. While SNRIs could play a role in multimodal analgesia, further research will help delineate their exact clinical significance. If they are used for prolonged periods, the risk of serotonin syndrome must be considered.