EURURO Vol. 72 No. 3

400 476

Platinum Priority – Editorial
Referring to the article published on pp. 389–399 of this issue
Better Persistence Rates with Mirabegron: Questions Raised
Alan J. Wein
Division of Urology, Perelman School of Medicine, University of Pennsylvania Health System, Perelman Center for Advanced Medicine, Philadelphia,
PA 19104, USA
In this issue of European Urology, Chapple et al report on
persistence rates and median time to discontinuation for a
number of drugs routinely prescribed for overactive bladder
(OAB). The report raises some important questions. (1) How
bad are these rates, how do they compare with agents in
other fields, and what factors influence these rates? (2) Is
mirabegron really superior to the other OAB agents in these
categories and, if so, why?
Persistence data are disappointing in general, and worse
for agents prescribed for OAB. Yeaw et al summarized 6-
mo persistence and adherence rates for drug therapy for six
chronic conditions: prostaglandin analogs (eye drops),
47%; statins, 56%; bisphosphonates, 56%,;oral diabetic
medications, 66%; angiotension receptor blockers, 63%;
and OAB medications (all antimuscarinics at that time),
28%. At 1 yr, these rates decreased to 32%, 43%, 41%, 54%,
50%, and 18%, respectively. The spread between persistence
rates became evident after 90 d of therapy, after which
relative rates were stable and declined consistently to the
study end. Interestingly, patients taking prostaglandin eye
drops for glaucoma and those taking OAB medications
showed the earliest rapid declines. Eye drops are in a
special category because of the potential difficulty and
nuisance in administering them, but other factors cited for
nonadherence seemed to be common to all groups and
include poor patient-physician communication, poor
patient education, lack of efficacy, adverse events, and
costs. Specifically related to the treatment of OAB with
antimuscarinics, the most important patient reasons for
discontinuing medications are consistently reported as
unrealistic expectations regarding efficacy and side effects
. Other reasons include patients learning to get by
without medication, improved or ‘‘cured’’ symptoms, and
patients switching medications, most likely because of
minimal satisfaction.
Similar poor persistence rates for antimuscarinics have
been reported by others , with risk factors for
discontinuation identified as younger age, male gender,
immediate release (IR) versus extended release (ER)
formulation, more than once daily dosage, unmet treatment
expectations, adverse effects, and prior use of oxybutynin.
Is mirabegron superior to the antimuscarinics in terms of
persistence and adherence? If so, why? Persistence, although
a secondary outcome measure, is the easiest metric to
understand, relates directly to clinical practice, and is easy to
use for comparison. The 12-mo persistence reported by
Chapple et al for mirabegron was 38% ; the rate was 25%
for solifenacin, 24% for fesoterodine, 21% for propiverine, 21%
for tolterodine IR, 20% for tolterodine ER, 19% for trospium,
17% for oxybutynin ER, 16% for darifenacin, and 8.3% for
flavoxate. The median time to discontinuation was 169 d for
mirabegron, followed by 78 d for fesoterodine and 67 d for
solifenacin. Consistent with the report by Yeaw et al , the
spread between persistence rates was evident after 90–100
d of therapy, following which the relative rates declined
consistently with a stable spread. Similar superiority of
mirabegron over tolterodine ER in terms of persistence at
6 mo (34.7% vs 18.5%) was reported by Nitti et al
Treatment-experienced patients persisted for longer
than treatment-naı¨ve individuals, and men persisted for
slightly longer than women did. Similar superiority for
mirabegron over antimuscarinics was also reported byWagg
et al . All studies that included mirabegron revealed a
higher persistence rate, except for that by Kinjo et al , who
reported a rate of 12.2% for mirabegron at 12 mo compared
to 21.1% for solifenacin. In their series, discontinuation
available at
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DOI of original article: .
* Division of Urology, Perelman School of Medicine, University of Pennsylvania Health System, Perelman Center for Advanced Medicine, West Pavilion,
3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
E-mail address: .
0302-2838/# 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.