Slow recruitment and small observed effect size

The proposed study is a randomized, double blind placebo controlled multicenter study to determine the effectiveness of mirabegron in the treatment of neurogenic bladder dysfunction. Patients will be randomized into one of two trial arms: mirabegron 25mg for two weeks, with escalation to 50mg for the remaining 8 weeks, or matched placebo capsule for two weeks, with placebo escalation for the remaining 8 weeks. Each of these trial arms will be stratified based on whether the patient is already taking an anticholinergic medication or not. The study will treat a total of 144 patients (72 with placebo, 72 with mirabegron). The study hypothesis is that mirabegron will result in a statistically superior (increased) urodynamic bladder capacity.

The study duration is 12 weeks, with a 1-4 week run in period where no active or placebo treatment will be administered. The primary outcome measure will be based on an increase in urodynamic bladder capacity. Secondary outcome measures will be additional urodynamic parameters, urinary symptom scales, urinary quality of life indices, and voiding diary results.

Patients who are over 18 years of age with a diagnosis of multiple sclerosis (MS) or spinal cord injury (SCI) will be eligible to participate. All eligible patients will have urodynamic studies performed within 4 weeks of trial enrollment, and at the end of study (week 9-10). Adverse events and study outcomes will be assessed at predefined study time points.

Inclusion criteria:

• Diagnosis of traumatic or nontraumatic suprasacral spinal cord injury (SCI) or multiple sclerosis (MS, based on a neurologist assessment and/or the McDonald criteria)(28)
• Age >18 years
• Stable method of bladder management for >3months (either spontaneous or provoked voiding, or intermittent catheterization).
• Bothersome urinary symptoms (urinary frequency, urgency, or urgency incontinence based on standard ICS definitions(29)) and completed 3 day voiding diary demonstrating at least 1 episode of non-stress based urinary incontinence over the 72hr period (this may be urgency based incontinence or unaware incontinence).
• Patient is able to read and speak English

Exclusion criteria:

Based on Screening visit history:

• Participation in another drug or device study in the 60 days prior to the screening visit.

• Previous urologic surgery: Transurethral prostatectomy, bladder augmentation, sphincterotomy, bladder neck sling, artificial urinary sphincter, catheterizable channel, implantable electrostimulator/neuromodulator

• Current use of suprapubic catheter/foley catheter

• Unstable cardiac disease (uncontrolled hypertension, myocardial infarction, unstable angina, severe congestive heart failure (NYHA 3 or 4), ventricular arrhythmia (such as torsades de pointes), or stroke within the last 6 months)

• Clinically significant abnormal ECG

• The investigator believes the patient has an increased risk of QT prolongation (based on review of the screening ECG and patients concurrent medications)

• History of significant renal dysfunction within 1 year, or serum creatinine >150umol/L at screening visit (visit 1).

• History of significant liver disease within 1 year, or serum AST/ALT >2 times upper limit of normal, GGT >3 times upper limit of normal, total bilirubin >2 times upper limit of normal at screening visit (visit 1).

• History of pelvic radiation

• History of bladder cancer

• History of a concurrent malignancy or cancer (except noninvasive skin cancer) within the last 5 years. Subjects with a history of cancer are considered eligible if the subject has undergone potentially curative therapy and the subject has been considered disease free for at least 5 years (with the exception of basal cell or squamous cell carcinoma of the skin).

• Patient has a history of interstitial cystitis/pelvic pain syndrome

• Patient has a history of acute or chronic urinary retention within the last 3 months, and is currently not using intermittent catheters

• Patient has a history of a tachyarrhythmia

• Patient has a history of glaucoma

• Patient has a medical condition that may cause noncompliance with the study protocol

• In the opinion of the Investigator the patient has a history of significant stress urinary incontinence

• Patient has signs and symptoms of an active urinary tract infection (symptoms of dysuria, foul smelling urine, cloudy urine, increased spasticity, increased autonomic dysreflexia, self reported fever, increased incontinence, back/suprapubic pain).

  o Patient will submit urine for culture and sensitivity, undergo treatment, and will be eligible for rescreening after treatment.

• Female patient who is pregnant or breastfeeding, or plans to become pregnant.

• Male patient who is planning on fathering a child during the study or for 28 days after the last dose of study drug, or who is planning to donate sperm

• Patient refuses to provide written consent

• Patient will be unable or unwilling to complete the questionnaires and study visits

• In the opinion of the study investigator, it is not in the patient's best interest to be enrolled in this study.

Based on medication and allergy review

• The new addition of an anticholinergic medication, or a change to anticholinergic dose, within the last 30 days, (bladder specific anticholinergics include oxybutynin, tolterodine, fesoterodine, solifenacin, darifenacin, trospium, hyoscine, oxybutynin gel or patch, atropine, benzatropine). If previously used and discontinued, these medications must have been stopped for >2 weeks
• Newly added bladder active medication (or dose change) within the last 2 months (Tamsulosin, Silodosin, Terazosin, Baclofen, Diazepam, amitriptyline, Finasteride, Dutasteride, DDAVP/desmopressin)
• Use of flecainide, propafenone, donepezil, thioridazine, tramadol, aripiprazole, desipramine, imipramine, venlafaxine or digoxin
• Intravesical onabotulinum toxin use within the last 1 year
• Intravesical oxybutynin within the last 3 months
• Patient has a previous history of treatment with mirabegron
• Patient has a known allergy to mirabegron or a previous adverse reaction to a beta 3 agonist.

Based on physical exam

• Patient has a postvoid residual > 250mL at study enrollment after repeated tested (1 attempt to re-void to ensure complete emptying of the bladder) and is not using intermittent catheters
• Patient has a resting BP >180 mmHg systolic and/or >110 mmHg diastolic after 2 minutes of sitting quietly
• Patient has a resting heart rate >100bpm after 2 minutes of sitting quietly
• In the opinion of the study investigator, it is not in the patient's best interest to be enrolled in this study based on a clinically significant abnormality on physical exam.

10 Weeks