Dear Dr. Roach: For approximately a decade, I have been taking trospium for incontinence. I would like to know if long-term usage of it could have an effect on dementia. I’ve heard about it often. Also, a 20-mg dose daily doesn’t seem to work as well as it used to. I tried taking it twice a day, but it gives me severe cramps in my feet and toes. So, I went back down to 20 mg, though, I am having more accidents than before.
Should I try another brand? Does trospium have other possible long-term side effects? Finally, is there an existing surgery for chronic incontinence, and if so, is it effective?
B.
Trospium is a commonly used medicine of the class called anti-muscarinics, a subtype of anticholinergic drugs. It is most useful in people with urge incontinence, which is also called overactive bladder. This particular agent is thought to have fewer side effects than other anti-muscarinic drugs, but dry mouth, dry eyes, constipation and vision changes are commonly reported.
Not everybody needs medicine. Pelvic floor exercises are effective. Treatment of coexisting vulvovaginal atrophy can also be very helpful and isn’t often looked for by generalists. Non-medication therapy is always worth trying, since there remains concern that drugs with anticholinergic properties may increase the risk of dementia.
There are several trials suggesting that long-term use of anticholinergics does increase dementia risk. Many of the drugs used for Alzheimer’s dementia are cholinergic drugs (the opposite of anticholinergics), so there is reason to suspect that anticholinergics may be a problem. Trospium is thought to be at a lower risk because it does not reach the brain, but I still tend to avoid these drugs when there is a concern for dementia.
A newer class of drugs, the beta-3 agonists, are about as effective as anti-muscarinics, with a lesser risk of side effects and no concern for dementia reported. Unfortunately, many of my patients cannot get coverage for these new and expensive drugs, or the insurance company demands that I try the anti- muscarinics first.
Although surgical options are available, whenever I refer my patients with an overactive bladder to a specialist (if drugs have not been effective), they find other options, including Botox injections and nerve stimulation devices. A urogynecologist is the ideal consultant in women with persistent symptoms.
Dear Dr. Roach: I have a bottle of 500-mg Tylenol tablets that are too big for me to swallow. I do have a pill splitter, but I wonder if I can just dissolve one in water. If it dissolves in your stomach, shouldn’t it be safe to dissolve in water?
J.S.B.
Acetaminophen or paracetamol (Tylenol and many other brand names) is not particularly soluble. If you mixed it in water, it would fall apart into small pieces and be more of a slurry than a solution. It is perfectly safe to take it that way, as long as you are sure to get all the medicine in the glass.
Unfortunately, it’s unpleasantly bitter. The manufacturer makes liquid formulations and dissolvable packs with flavorings to get around the taste. You can also use a mortar and pestle (or pill crusher) and mix it in with a thick liquid, like applesauce or yogurt, if you want to finish the bottle you have. Note that crushing any extended-release formulation will cause all the medicine to be released at once.
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