Chronic obstructive pulmonary disease is a progressive respiratory disorder in which inflammation or blockage in the lungs makes breathing difficult. According to background information in the article, it affects 10 percent of people age 40 years and older. Inhaled anticholinergic medications (IACs) help the airway's muscles relax and reduce obstructions in airflow. However, the authors note, "there is uncertainty about whether IACs cause clinically important systemic anticholinergic effects."
In previous clinical trials of these medications, a connection was noticed with acute urinary retention (AUR), an inability to urinate which is considered a medical emergency. The authors note that AUR can lead to serious complications. "Understanding the risk of AUR associated with IAC therapy would help to identify those at risk for this complication," they explain.
Anne Stephenson, M.D., Ph.D., from St. Michael's Hospital, Toronto, Canada, and colleagues conducted a study using data from Ontario's universal health insurance program. They selected individuals ages 66 years or older with COPD and searched the data for treatment with IACs and development of AUR between April 2003 and March 2009. Researchers further segmented the data by patients' IAC regimens.
Among the original cohort of 565,073 patients with COPD, a total of 9,432 men and 1,806 women developed AUR. "This relationship was not statistically significant in women," the researchers write, but was significant in men. Among IAC users, the odds of AUR were about 40 percent higher in men who had been using IACs for one month or less and about 80 percent higher in men with an enlarged prostate gland. Simultaneous use of both short-acting and long-acting IACs significantly elevated men's odds of AUR.
"Physicians should highlight for patients the possible connection between urinary symptoms and inhaled respiratory medication use to ensure that changes in urinary flow (ie, incomplete voiding, urinary incontinence, and decreased urinary flow) are reported to the physician prescribing the IAC," explain the authors. They add that the odds of AUR may be reduced by taking the lowest effective dose of IACs and avoiding combinations that raise a patient's risk. "Physicians and the public need to be aware of the potential for this significant adverse event," they conclude, "so that preventive measures and potential therapy can be considered."
(Arch Intern Med. 2011;171:914-920. Available pre-embargo to the media at www.jamamedia.org
Editor's Note: The study was funded by a grant from the Canadian Institutes of Health Research and was conducted at the Institute for Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario Ministry of Health and Long-term Care. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
Commentary: Deciding Whether, and When, to Treat COPD with IACs
In a commentary accompanying the article, Sonal Singh, M.D., M.P.H., from The Johns Hopkins University in Baltimore and Curt D. Furberg, M.D., Ph.D., from Wake Forest University, Winston-Salem, N.C., note that IACs do not completely stall the progress of COPD or keep patients alive longer. "Therefore, information on serious adverse effects associated with IACs can potentially alter their benefit-harm assessment," they observe. Besides the urological complications found by Stephenson and colleagues, previous studies have connected this category of drugs with cardiovascular events and mortality. An alternate therapy, corticosteroids, has been associated with an increased risk of serious pneumonia. Ultimately, write Singh and Furberg, "Physicians should inform patients with COPD about the risk of AUR associated with IACs and determine the optimal choice of therapy for their patients after eliciting patient preferences for various patient-oriented outcomes in a shared decision-making context."
(Arch Intern Med. 2011;171:920-922. Available pre-embargo to the media at www.jamamedia.org
Editor's Note: Dr. Singh receives support from the National Cen ter for Research Resources, a component of the National Institutes of Health, and from the NIH Roadmap for Medical Research.