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Which Anticholinergics Should Be Started Along With CISC?

Posted on Fri, 21 Mar 2014

Question: Hello Dr. Sasanka, I visited Dr. XXXXXXX XXXXXXX today and got the urodynamics study done. Dr XXXXXXX suggested to start anticholinergics with CISC and asked to consult you for exact medication. He said we have options for injections & surgery if medicines do not work after reaching highest dosage but ideally it should get resolved with medicines and CISC. Please find the reports in the link below: https://www.dropbox.com/s/yj1lfulp8t0jjgy/urodynamics_sanjay_sinha_0000.zip Few questions: The technician recommended ciplox. Should I change the antibiotic or continue Nitrofurontoin ? There is no bleeding or pain after urodynamics yet. Regarding anticholinergics, which one we should be starting along with CISC ? She did not respond to Terol last time. We continued Terol for 30 days with CISC till the infection was symptomatic and she was admitted in emergency. As we have discussed, the current issue with CISC is continuous leakage. Please guide how we can prevent this. As without resolving this issue CISC is almost useless. As per the urodynamics report the bladder capacity is 60ml, which is very odd. When she was on CISC, it seemed like the capacity is at-least 150-200. What's your suggestion ? The experience at Apollo was bitter again, as expected. People are ignorant, arrogant & careless. If possible I would avoid visiting Apollo again. Do you know any other reliable location where urodynamics can be done in future?

Answered by Dr. V. Sasanka (20 hours later)

Brief Answer: Anti-cholinergics it has to be Detailed Answer: Hi, I had a look at all the reports you have uploaded. It looks like there is no alternative other than CISC. I know you have tried earlier and therefore considering that your wife is sufficiently motivated this will be the best solution. I suggest you continue using Urifast. Ciplox is standard medication they prescribe as part of their protocol. You need not change from one which you already are using and which has helped her. 60 ml bladder capacity is not odd at all considering that she had been on an indwelling catheter for such a long time. Also there could be some'clinic' effect and this might explain why at home the capacity is nearly 150 ml. But I am sure eventually it will go up considerably to over 180 ml. This is the reason why I suggested you clamp her urobag tubing for as long as possible so as to enable bladder 'cycling'. Even a 5 ml increase of capacity a week will eventually get her to hold urine for 2-3 hours which is acceptable. I doubt if we will use the injections straightaway but we will consider them if there is no relief. We will consider surgery only when the bladder pressures are 'unsafe'. As of now, they are OK. I doubt if there are more reliable locations for urodynamics at present in Hyderabad. We might get one in Star Hospitals after March 2015. We have exhausted our budget for this year by investing in high-end lasers. Let me know what is happening. Bye.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. V. Sasanka (2 hours later)

Thanks Dr.Sasanka, We'll start CISC. But Dr. XXXXXXX also mentioned that only CISC without a good anticholinergics (or medication to help bladder storage) would not be helpful and he asked me to check with you for exact medicine name. Do you have a recommendation for anticholinergics ? Last time you recommended vesigard 7.5 mg for few days but after our visit you asked to stop taking it. Please suggest. Thanks for your time.

Answered by Dr. V. Sasanka (5 hours later)

Brief Answer: Vesigard is perfectly fine Detailed Answer: Vesigard or Dariten or Darilong contain anti-cholinergic Darifenacin which should be pretty useful in the clinical condition of your wife. Higher dosage of 15 mg is likely to be more beneficial but I suggest you start with the smaller dose initially of 7.5 mg, and see how is the response and side-effect profile. Do not be discouraged by temporary incontinence which is almost likely to be universal.Things will improve. also keep a regular monitor of her Serum Creatinine levels.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. V. Sasanka (26 hours later)

Thanks Dr.Sasanka. We'll start CISC with Darifenacin. Regarding serum creatinine levels, how frequently should I get it checked ? Also, when should I get back to you next with the status ?

Answered by Dr. V. Sasanka (22 minutes later)

Brief Answer: Once a month initially Detailed Answer: Hi, Initially I think Serum Creatinine evaluation once a month should be adequate and we will be able to pick up any problem soon. Once she gets a hang of the issue and is comfortable, we can gradually make it once every 3 months. You can inform me the reports at the same time. Regards and all the best.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. V. Sasanka (16 hours later)

Many thanks again Dr.Sasanka. I'll get back to you in a month. I appreciate your time and support.

Answered by Dr. V. Sasanka (16 hours later)

Brief Answer: Willpower to maintain CISC must Detailed Answer: You are welcome. I only hope she manages to keep up her willpower and does not revert back to catheter. I am sure the bladder capacity will improve in a few days. Continue using the anti-cholinergic drugs despite the minor side-effects they may have such as dry mouth. We may increase the dose if we find Creatinine gong up.

Above answer was peer-reviewed by : Dr. Raju A.T

Follow up: Dr. V. Sasanka (38 hours later)

Sure Dr.Sasanka, I can bet on her strong willpower. She has come a long way with that trait alone, when almost everyone gave up. Dry mouth is not that much of a problem, but the only major issue so far with CISC is incontinence which impacted the sleep & lifestyle heavily. We hope we'll overcome the roadblock this time. We're more optimistic this time as we've a doctor like you as our guide. Thanks again for your guidance. I'll keep you posted.