Editing AUA: Overactive Bladder (2019) (section)

==== Failure of medical therapy ====
*'''<span style="color:#ff0000">If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one anti-muscarinic medication, then a dose modification or a different anti-muscarinic medication or a β3-adrenoceptor agonist may be tried.</span>'''
**Patients who had prior unsatisfactory symptom control and/or unacceptable adverse events with older medications (tolterodine or oxybutynin) reported better efficacy and/or more acceptable adverse event profiles with new medications (fesoterodine, solifenacin or darifenacin).
**Non-responders to anti-muscarinics should be tried on at least one other anti-muscarinic or mirabegron and/or dose modification attempted to determine if a better balance between efficacy and adverse events occurs. 
***Failure and/or the experience of adverse events with one medication should usually be addressed by trying at least one other medication before third-line therapies are considered.
**If adverse events are severe enough to compromise patient QOL, then strategies to manage specific adverse events, such as ameliorating constipation with appropriate bowel management, should be implemented before abandoning anti-muscarinic treatment.
*'''<span style="color:#ff0000">Clinicians may consider combination therapy with an anti-muscarinic and β3-adrenoceptor agonist for patients refractory to monotherapy with either anti-muscarinics or β3-adrenoceptor agonists.</span>'''
**Studies have demonstrated improved efficacy with combination therapy without any significant effect on the safety profile when compared to monotherapy
**Combination therapeutic approaches should be assembled methodically, beginning with the establishment of confidence in the partial efficacy of one therapy, continuing with an adequate trial of any additional therapies one at a time until the patient experiences adequate symptom control in the context of tolerable adverse events.
*'''Patients who are refractory to behavioral''' '''and medical therapy should be evaluated''' '''by an appropriate specialist if they desire additional'''
**The refractory patient as the patient who has failed a trial of symptom-appropriate behavioral therapy of sufficient length to evaluate potential efficacy and who has failed a trial of at least one anti-muscarinic medication administered for 4 to 8 weeks. Failure of an anti-muscarinic medication may include lack of efficacy and/or inability to tolerate adverse drug effects.