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UPJ INSIGHT Who Progresses to Third-Line Therapies for Overactive Bladder? Trends From the AQUA Registry

By: Dora Jericevic, MD, New York University Langone, New York; Katherine Shapiro, MD, New York University Langone, New York; Max Bowman, MD, University of California, San Francisco; Camille A. Vélez, BArch, Universidad Central del Caribe, School of Medicine, Bayamon, Puerto Rico; Rachel Mbassa, MS, American Urological Association, Linthicum, Maryland; Raymond Fang, MSC, MASc, American Urological Association, Linthicum, Maryland; Michelle Van Kuiken, MD,* University of California, San Francisco; Benjamin M. Brucker, MD* New York University Langone, New York *Co-first authors. | Posted on: 18 Mar 2024

Jericevic D, Shapiro K, Bowman M, et al. Who progresses to third-line therapies for overactive bladder? Trends from the AQUA Registry. Urol Pract. 2024;11(2):394-401.

Study Need and Importance

Overactive bladder (OAB) patients who do not reach treatment goals after second-line OAB treatments should be offered third-line therapies (percutaneous tibial nerve stimulation, sacral neuromodulation, bladder onabotulinumtoxinA). However, many patients who may be appropriate for third-line therapies may not ultimately receive them. Using the AUA Quality (AQUA) Registry, we evaluated factors that impact progression from second-to third-line OAB therapy, median time for progression to third-line therapy, and third-line therapy utilization across patient subgroups.

What We Found

Only 2.9% of OAB patients progressed to third-line therapies over the 7-year study period. Women, White race, age 65 to 79, prior dual anticholinergic and β٣ agonist therapy, government insurance, metropolitan setting, and single specialty practice were associated with the greatest odds of treatment with third-line therapy. Time to progression from second- to third-line therapies was > 1 year. Patients < 50 years and women progressed fastest through the OAB pathway. Black and Asian race, male gender, and rural setting all had lower odds of progressing to third-line therapy. Bladder onabotulinumtoxinA was the most common initial third-line therapy overall (40%), followed by sacral neuromodulation (32%) and percutaneous tibial nerve stimulation (28%). The Figure demonstrates the choice of initial third-line therapy across subgroups.

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Figure. Choice of initial third-line therapy across subgroups. BTX-A indicates bladder onabotulinumtoxinA; PTNS, percutaneous tibial nerve stimulation; SNS, sacral neuromodulation.

Limitations

The AQUA Registry does not provide information on OAB severity or capture any patient-reported outcomes. The AQUA Registry data may not be generalizable across all practices. Despite the limitations, our study reveals novel information about time to progression through the OAB treatment pathway and highlights certain subgroups that may be undertreated.

Interpretation for Patient Care

Very few patients received third-line therapies, and the average time to progression from second- to third-line therapies was > 1 year. Further investigation into these findings is warranted to better understand the barriers to third-line therapy.

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