Currently, there is a range of treatment options available for overactive bladder.  Oral pharmacotherapies include selective and non-selective antimuscarinic drugs and B3-adrenergic receptor agonists.  Intravesical botulinum toxin (botox) injection is reserved for those whose symptoms are refractory to oral medications.  Additionally, surgical treatments also exist ranging from minimally invasive procedures such as sacral modulation and percutaneous tibial nerve stimulation to major open surgeries such as bladder augmentation and urinary diversion.  In light of the myriad of treatment options available, position statements have been released to guide Australian clinicians in adopting an evidence-based approach for its management.  We hereby aim to describe the Australian landscape of overactive bladder treatment. [OAB]

The Australian Government Pharmaceutical Benefits Scheme and Medicare Benefits Schedule reports were queried from January 2009 to December 2019. The Australian Government Pharmaceutical Benefits Scheme (PBS) is a program that improves access to medicine by subsidising its cost herein making them more affordable to the public.  Next, data from the Medicare Benefits Schedule (MBS), were also sought.  This is an online platform which contains a listing of the Medicare services subsidised by the Australian Government.  Both PBS and MBS data do not incorporate claims for treatments received in the pubic hospitals; henceforth not captured in this study.

The two therapies available on PBS were oxybutynin and propantheline. There was a steep uptake from 1996 to 2005 reaching around 175,000 prescriptions a year and its dispensing plateaued thereafter [see Figure 1].  Next, per oral prescriptions oxybutynin was found to be the most widely used anticholinergic for OAB followed by its extended release version.  The bulk of those prescriptions originated from New South Wales, Victoria and Queensland.

 Further, practitioners of the Australian Capital Territory were the second most common prescribers of botox; at odd with being the lowest prescriber of oxybutynin. Moreover, Sacral nerve stimulators item numbers were introduced on the MBS in 2010.  Since then, there was a gradual uptake across states over the past 10 years.  Percutaneous tibial nerve stimulator was approved in 2018.  The following year witnessed a surge of demand for its related procedures surpassing SNS items -See Figure 2. 
Last, bladder augmentation procedures have decreased over the years from 42 in 1995 to 11 in 2019.

Oxybutynin is still a widely used anticholinergic in Australia.  The plateauing of its dispensing after 2005 may be reflective of the introduction of Vesicar (2006) and Betmiga (2014) in the Australian market.  Propantheline, which is an old drug, is still in use across the states although the frequency is falling.

Botulinum Toxin A bladder injections became part of MBS in 2013 for selective users and 2014 for non-selective users.  It was interesting to note that ACT dominated the shares of botox for idiopathic OAB over the last 3 years but yet was amongst the lowest three prescribers of oxybutynin.  To be able to access botox on the PBS one’s condition ought to have been inadequately controlled by therapy involving at least two alternative anticholinergic agents. 

Sacral nerve lead placement rates in Australia remained low with a 6 to 10% variation across all the years captured.  In stark contrast, PTNS use jumped from 118 in 2018 - the year of its introduction - to 7143 the following year, representing a staggering 6000 fold increase.  One of the reasons could be that PTNS does not require a strict trial period as the device is not implanted.  To our knowledge, there are no head to head randomised controlled trials comparing PTNS and SNS.  Overall, it would be intriguing to see how PTNS use evolve in Australia over time.

In practice, there are other agents that are used such as imipramine, tolterodine and darifenacin.  Given that these drugs are unscheduled, it was not possible to retrieve prescribing data which represent an obvious important gap.  The individual companies restrict data of prescription due to internal policies and privacy clause.

Despite the advent of new OAB drugs on the market, oxybutynin use remain high.  However, it is known that adherence may be problematic due to their intolerable side effects and/or inadequate response.  Patients with bothersome symptoms refractory to anticholinergic treatments pose a therapeutic challenge.  There might be a place for subsidised therapy prior considering alternative treatment such as botox and neuromodulation. Further studies in assessing trends in prescription will require prescribing patterns via the responsible companies for non-PBS OAB agents.