A multicenter, randomized, double-blind, placebo-controlled study to evaluate the safety and efficacy of terazosin in the treatment of benign prostatic hyperplasia

Safety and efficacy of an α1 -blocker plus mirabegron compared with an α1 -blocker plus antimuscarinic in men with lower urinary tract symptoms secondary to benign prostatic hyperplasia and overactive bladder: A systematic review and network meta-analysis

AIM

Antimuscarinics and the β3-adrenoreceptor agonist, mirabegron, are commonly used for treating patients with overactive bladder (OAB) and α1 -adrenoreceptor antagonists (α1 -blockers) are the main pharmacological agents used for treating lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). As these conditions commonly occur together, the aim of this systematic review was to identify publications that compared the use of an α1 -blocker plus mirabegron with an α1 -blocker plus antimuscarinic in men with LUTS secondary to BPH and OAB. A meta-analysis was subsequently conducted to explore the safety and efficacy of these combinations.

METHODS

Included records had to be from a parallel-group, randomized clinical trial that was ≥8 weeks in duration. Participants were male with LUTS secondary to BPH and OAB. The indirect analyses that were identified compared an α1 -blocker plus OAB agent with an α1 -blocker plus placebo. The PubMed/Medical Literature Analysis and Retrieval System Online, the Excerpta Medica Database, the Cochrane Central Register of Controlled Trials, and the ClinicalTrials.gov registry were searched for relevant records up until March 5, 2020. Safety outcomes included incidences of overall treatment-emergent adverse events (TEAEs) and urinary retention, postvoid residual volume, and maximum urinary flow (Qmax ). Primary efficacy outcomes were micturitions/day, incontinence episodes/day, and urgency episodes/day, and secondary outcomes were Overactive Bladder Symptom Score and International Prostate Symptom Score. A Bayesian network meta-analysis approach was used for the meta-analysis.

RESULTS

Out of a total of 1039 records identified, 24 were eligible for inclusion in the meta-analysis. There were no statistically significant differences between the α1 -blocker plus mirabegron and α1 -blocker plus antimuscarinic groups in terms of the comparisons identified for all the safety and efficacy analyses conducted. Numerically superior results were frequently observed for the α1 -blocker plus mirabegron group compared with the α1 -blocker plus antimuscarinic group for the safety parameters, including TEAEs, urinary retention, and Qmax . For some of the efficacy parameters, most notably micturitions/day, numerically superior results were noted for the α1 -blocker plus antimuscarinic group. Inconsistency in reporting and study variability were noted in the included records, which hindered data interpretation.

CONCLUSION

This systematic review and meta-analysis showed that an α1 -blocker plus mirabegron and an α1 -blocker plus antimuscarinic have similar safety and efficacy profiles in male patients with LUTS secondary to BPH and OAB. Patients may, therefore, benefit from the use of either combination within the clinical setting.

Add-on treatment with mirabegron may improve quality of life in patients with benign prostatic hyperplasia complaining of persistent storage symptoms after tamsulosin monotherapy

Background

The aim of this study was to evaluate the change in lower urinary tract symptoms and quality of life (QoL) after combination therapy of solifenacin and mirabegron in patients with benign prostatic hyperplasia presenting with persistent storage symptoms after treatment with tamsulosin.

Material & Methods

We evaluated the International Prostatic Symptom Score (IPSS), Overactive Bladder Symptom Score (OABSS), prostate-specific antigen, prostate volume, peak flow rate (Qmax), and post-voided residual volume (PVR) before and after treatment. Patients showing baseline OABSS ⩾3 were included and treated with tamsulosin 0.2 mg as an initial drug for 1 month. After 1 month, add-on treatment with solifenacin 5 mg or mirabegron 50 mg was provided to patients who did not show improvement in OABSS with tamsulosin 0.2 mg. After 2 months, we evaluated changes in OABSS, IPSS, Qmax, and PVR.

Results

After combination therapy for 2 months, there were no significant differences between patients receiving add-on treatment with solifenacin and those receiving mirabegron. However, the IPSS QoL score improved in patients treated with mirabegron and tamsulosin more than in those treated with solifenacin and tamsulosin (p < 0.05).

Conclusion

A combination of tamsulosin and mirabegron might improve the QoL of patients presenting with persistent storage symptoms after tamsulosin monotherapy. Better QoL due to mirabegron compared with solifenacin could be associated with fewer adverse effects, such as dry mouth and constipation.

Comparative effectiveness of oral drug therapies for lower urinary tract symptoms due to benign prostatic hyperplasia: a systematic review and network meta-analysis

INTRODUCTION

Lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) are common in elder men and a number of drugs alone or combined are clinically used for this disorder. But available studies investigating the comparative effects of different drug therapies are limited. This study was aimed to compare the efficacy of different drug therapies for LUTS/BPH with network meta-analysis.

MATERIALS AND METHODS

An electronic search of PubMed, Cochrane Library and Embase was performed to identify randomized controlled trials (RCTs) comparing different drug therapies for LUTS/BPH within 24 weeks. Comparative effects were calculated using Aggregate Data Drug Information System. Consistency models of network meta-analysis were created and cumulative probability was used to rank different therapies.

RESULTS

A total 66 RCTs covering seven different therapies with 29384 participants were included. We found that α-blockers (ABs) plus phosphodiesterase 5 inhibitors (PDE5-Is) ranked highest in the test of IPSS total score, storage subscore and voiding subscore. The combination therapy of ABs plus 5α-reductase inhibitors was the best for increasing maximum urinary flow rate (Qmax) with a mean difference (MD) of 1.98 (95% CI, 1.12 to 2.86) as compared to placebo. ABs plus muscarinic receptor antagonists (MRAs) ranked secondly on the reduction of IPSS storage subscore, although monotherapies including MRAs showed no effect on this aspect. Additionally, PDE5-Is alone showed great effectiveness for LUTS/BPH except Qmax.

CONCLUSIONS

Based on our novel findings, combination therapy, especially ABs plus PDE5-Is, is recommended for short-term treatment for LUTS/BPH. There was also evidence that PDE5-Is used alone was efficacious except on Qmax. Additionally, it should be cautious when using MRAs. However, further clinical studies are required for longer duration which considers more treatment outcomes such as disease progression, as well as basic research investigating mechanisms involving PDE5-Is and other pharmacologic agents alleviate the symptoms of LUTS/BPH.

Current role of treatment in men with lower urinary tract symptoms combined with overactive bladder

Lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH) are highly prevalent in older men. The storage subcategory of LUTS is synonymous with overactive bladder (OAB) syndrome, which is an empirical diagnosis. Traditionally, alpha-blockers are widely prescribed to manage the LUTS of BPH, although storage symptoms may persist in many men despite treatment. Therefore, because therapies that target the prostate often fail to alleviate storage symptoms, they may not be the appropriate therapy for OAB. In past years, most physicians appeared to give more weight in elderly men to voiding symptoms than to storage symptoms and to be more concerned with initial treatment with anticholinergics for males with storage symptoms. Considering the recent increase in data on the efficacy and safety of combination treatment with alpha receptor antagonists and antimuscarinic agents, the standard pharmacologic treatment of patients with LUTS combined with OAB should be an alpha receptor antagonist and an antimuscarinic agent. Beta-3 adrenoreceptor agonists may also potentially be useful for the treatment of male LUTS combined with OAB.

WITHDRAWN: Terazosin for benign prostatic hyperplasia

BACKGROUND

Lower urinary tract symptoms associated with benign prostatic obstruction (BPO) occur in up to 70% of men over the age of 60 years. To relieve these bothersome symptoms, treatment options include alpha-antagonists, also know as alpha-blockers.

OBJECTIVES

We conducted a systematic review to evaluate the effectiveness and adverse effects of the alpha-blocker, terazosin, for treatment of urinary symptoms associated with BPO.

SEARCH STRATEGY

Trials were searched in computerized general and specialized databases (MEDLINE, Cochrane Library), by checking bibliographies, and by contacting manufacturers and researchers.

SELECTION CRITERIA

Studies were included if they (1) were randomized trials of at least 1 month duration, and (2) included men with symptomatic BPO and compared terazosin with placebo or active controls.

DATA COLLECTION AND ANALYSIS

Study, patient characteristics and outcomes data were extracted in duplicate onto standardized forms utilizing a prospectively developed protocol. The main outcome measure for comparing the effectiveness of terazosin with placebo or other BPO medications was change in urological symptoms as measured by validated symptom scores. Secondary outcomes included urodynamic measures. The main outcome measure for adverse effects was the number of men reporting side effects. We also evaluated the number of men withdrawing from treatment and the number withdrawing due to adverse effects.

MAIN RESULTS

Seventeen studies involving 5151 subjects met inclusion criteria (placebo-controlled (n = 10); alpha-blockers (n = 7); finasteride alone or in combination with terazosin as well as placebo (1); microwave therapy (TUMT) (1). Study duration ranged from 4 to 52 weeks. Mean age was 65 years and 82% of men were white. Baseline urologic symptom scale scores and flow rates demonstrated that men had moderate BPO. Efficacy outcomes were rarely reported in a fashion that allowed for data pooling but indicated that terazosin improved symptom scores and flow rates more than placebo or finasteride and similarly to other alpha antagonists. The pooled mean percentage improvements for the Boyarsky symptom score was 37% for terazosin versus 15% for placebo (n = 4 studies). The mean percentage improvement for the American Urological Association symptom score (AUA) was 38% compared to 17% and 20% for placebo and finasteride, respectively (n = 2 studies). The pooled mean improvement in the International Prostate Symptom Score (IPSS) (40%) was similar to tamsulosin (43%). Peak urine flow rates improved greater with terazosin (22%), than placebo (11%) and finasteride (15%) but did not differ significantly from the other alpha-blockers. The percentage of men discontinuing terazosin was comparable to men receiving placebo and finasteride but was greater then with other alpha-antagonists. Adverse effects were greater than placebo and included dizziness, asthenia, headache, and postural hypotension.

AUTHORS' CONCLUSIONS

The available evidence suggests that terazosin improves urinary symptoms and flow measures associated with BPO. Effectiveness is superior to placebo or finasteride, similar to other alpha-blockers but less than TUMT. Adverse effects were generally mild but more frequent than other alpha-blockers and associated with between a two-to-four fold increase in treatment discontinuation.

Outcomes and quality of life issues in the pharmacological management of benign prostatic hyperplasia (BPH)

BACKGROUND

Benign prostatic hyperplasia (BPH) is a common disease of the aging male population. BPH treatment includes a variety of pharmacological and surgical interventions. The goal of this paper is to review the natural history of BPH, outcomes of pharmacological management, effects on quality of life (QoL), future pharmacotherapies, and associated patient-focused perspectives.

MATERIALS AND METHODS

Medline searches for the keywords benign prostatic hyperplasia, BPH, alpha blockers, 5 alpha-reductase, and quality of life were performed. Relevant literature was reviewed and analyzed.

RESULTS

Alpha blockers, 5 alpha-reductase inhibitors, and phytotherapy are the three categories of pharmaceutical interventions currently available for BPH. Various clinical trials have shown that alpha blockers and 5 alpha-reductase inhibitors are safe, efficacious, and improve QoL in patients with BPH. The evidence for phytotherapeutics is not as convincing. The current armamentarium of pharmaceutical interventions are encompassed in these three classes of medications. New pharmacotherapies based on novel mechanisms are on the horizon.

CONCLUSION

There are a variety of safe and efficacious medical therapies available for the management of BPH and it is important for the practicing physician to have an understanding of these pharmacotherapies and their potential impact on the patient. There is not enough evidence to make a recommendation regarding phytotherapy use. New classes of drugs for BPH will likely find their way into routine use.

A meta-analysis of the vascular-related safety profile and efficacy of alpha-adrenergic blockers for symptoms related to benign prostatic hyperplasia

OBJECTIVES

To evaluate the safety profile and efficacy of alpha1-adrenergic receptor blockers (A1Bs) currently prescribed for benign prostatic hyperplasia (BPH).

DATA SOURCES

A systematic literature search of MEDLINE, the Cochrane Database and the Food and Drug Administration Web site through December 2006 identified double-blinded, prospective, placebo-controlled trials, evaluating agents commercially available by prescription for the symptomatic treatment of BPH.

REVIEW METHODS

Data were reviewed by two investigators with the use of a standardised data abstraction form. Studies were evaluated for methodological quality using the Jadad scale. Studies with a score of < 3 were considered of weaker methodology.

RESULTS

Of 2389 potential citations, 25 were usable for evaluation of safety data, 26 for efficacy. A1B use was associated with a statistically significant increase in the odds of developing a vascular-related event [odds ratio (OR) 2.54; 95% confidence interval (CI): 2.00-3.24; p < 0.0001]. The odds of developing a vascular-related adverse event were: alfuzosin, OR 1.66, 95% CI: 1.17-2.36; terazosin, OR 3.71, 95% CI: 2.48-5.53; doxazosin, OR 3.32, 95% CI: 2.10-5.23 and tamsulosin, OR 1.42, 95% CI: 0.99-2.05. A1Bs increased Q(max) by 1.32 ml/min (95% CI: 1.07-1.57) compared with placebo. Difference from placebo in American Urological Association symptom index/International Prostate Symptom Score was -1.92 points (95% CI: -2.71 to -1.14).

CONCLUSIONS

Alfuzosin, terazosin and doxazosin showed a statistically significant increased risk of developing vascular-related events compared with placebo. Tamsulosin showed a numerical increase that was not statistically significant. All agents significantly improved Q(max) and symptom signs compared with placebo.

Management of Benign Prostate Hyperplasia: An Overview of α-Adrenergic Antagonist

Benign prostate hyperplasia (BPH) is common among above 50 years age group, interfere with normal activities of lower urinary tract function and reduce the sense of well being. It can also be progressive, with a lost of urinary retention, bladder infection, bladder calculus and renal failure. Although many men with mild to moderate symptoms to well without therapy, others have gradually increasing symptoms and require medical therapy or surgery. BPH is the non-malignant, uncontrolled growth of cells in the prostate gland. This cell growth usually occurs in the tissue that surrounds the urethra as it passes through the prostate gland to the bladder. As BPH progresses, the gland constricts the urethra and obstructs the urine outflow. The bladder no longer empties completely, creating an environment in which infections, bladder stones, and chronic prostatities may develop. If left untreated, chronic obstruction can lead to the back up of urine into the ureters and compromise kidney function. In hyperplastic prostate tissue, the prostate capsule, and the bladder neck are blocked, by using alpha-adrenergic antagonist drugs; the smooth muscle tone of these structures is decreased. As a result, resistance to urinary flow through the bladder neck and the prostatic urethra decreases and urinary flow increases. A variety of alpha-adrenergic antagonists with distinct properties have been investigated as possible treatments for benign prostate hyperplasia.

Comparison of tamsulosin and naftopidil for efficacy and safety in the treatment of benign prostatic hyperplasia: a randomized controlled trial

OBJECTIVES

To compare the efficacy and safety of two alpha1a/alpha1d adrenoceptor (AR) antagonists with different affinity for the alpha1AR subtypes, tamsulosin and naftopidil, in the treatment of benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

Patients with BPH were randomized to receive either tamsulosin or naftopidil. The primary efficacy variables were the changes in the total International Prostate Symptom Score (IPSS), maximum flow rate on free uroflowmetry, and residual urine volume. The secondary efficacy variables were average flow rate, changes in the IPSS storage score, IPSS voiding score, and quality-of-life (QoL) Index score, from baseline to endpoint (12 weeks). Data on all randomized patients were included in the safety analyses for adverse effects and changes in blood pressure.

RESULTS

Of the 185 patients enrolled data for 144 who were eligible for inclusion in the efficacy analysis were analysed (75 from the tamsulosin and 69 from the naftopidil group). There was no significant difference in any variable at baseline between the groups. There were statistically significant improvements for all primary and secondary variables in both groups, except for residual urine in the tamsulosin group. However, there was no significant intergroup difference in the improvement of any efficacy variable between the groups. The adverse effects were comparable, with no significant differences in systolic and diastolic blood pressure after treatment in both groups.

CONCLUSIONS

This study suggests that naftopidil is as effective and safe as tamsulosin. Both drugs were effective in improving storage and voiding symptoms. However, there was no difference in clinical efficacy or adverse effects between the alpha1 AR antagonists with different affinity to alpha1 subtypes, alpha1a and alpha1d.

Lower urinary tract symptoms suggestive of benign prostatic hyperplasia: latest update on alpha-adrenoceptor antagonists

An update of a systematic review of alpha1-adrenoceptor (AR) antagonists in the treatment of lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) showed that these agents have comparable efficacy. The total symptom score is improved by 30-45% and maximum urinary flow rate by 15-30% vs baseline. alpha1-AR antagonists that can be started at their therapeutic dose have a more rapid onset of action than alpha1-AR antagonists that have to be titrated. alpha1-AR antagonists can be differentiated according to their tolerability. Alfuzosin (especially the 10 mg once daily dose) and tamsulosin (especially the 0.4 mg once daily dose) are better tolerated than doxazosin and terazosin. However, alfuzosin might induce more cardiovascular adverse events (AEs) in the elderly and/or patients with cardiovascular comorbidity and/or comedication. Tamsulosin tends to interfere less with blood pressure regulation and induce less vasodilatory AEs than alfuzosin, especially in the elderly, and is well tolerated in patients with cardiovascular comorbidity and/or comedication. Cardiovascular AEs might lead to potentially serious complications such as falls, fractures and institutionalization. Abnormal ejaculation has mainly been reported in placebo-controlled trials with tamsulosin but in direct comparative trials its rate with tamsulosin 0.4 mg was similar to, or only slightly higher than, the rate with alfuzosin. In addition, abnormal ejaculation is not reported as bothersome by the patient or associated with serious complications. It can be concluded that an alpha1-AR antagonist with a low potential to interfere with blood pressure regulation and to induce cardiovascular AEs, also in patients with cardiovascular comorbidity and/or comedication, can be considered a first-choice treatment option in LUTS/BPH.

Effect of terazosin on clinical benign prostatic hyperplasia in older adults

PURPOSE

The objective of this meta-analysis of randomized controlled trials (RCTs) of terazosin versus placebo in men with benign prostatic hyperplasia (BPH) was to evaluate the effect of terazosin on lower urinary tract symptoms.

BACKGROUND

BPH is common in older men; more than 90% of men aged 70 and older suffer from BPH. (1,2) BPH has substantial negative effect on quality of life, with symptoms that interfere with activities of daily living. (3) The symptoms of BPH are primarily due to bladder outlet obstruction and are caused by dynamic prostatic smooth muscle tone and static prostatic obstruction. (4,5) The smooth muscle tone is dependent on the degree of the alpha-1 adrenergic receptors present in the bladder neck, prostrate capsule, and prostrate gland. The blockade of alpha-1 receptors with drugs such as terazosin reduces bladder outlet obstruction by reducing the smooth muscle tone. STUDY SELECTION AND DATA SOURCES: Selected studies were all RCTs of terazosin with two primary end points, namely, changes in the peak urinary flow rates and urinary symptom scores from baseline. Nine studies were selected using a Medline search, the details of which were not provided. The studies were conducted in North America and Europe between 1992 and 1996. Two of the studies included unpublished data that were obtained from Abbott Laboratories, which is the manufacturer of terazosin (Hytrin). The company also provided data on the other seven studies.

DATA EXTRACTION

The meta-analysis did not provide details of the data abstraction process. Urinary symptom score was measured using two different tools: the Boyarsky Symptom Index (BSI) and American Urology Association Symptom Index (AUA-SI). The BSI was used in seven studies and AUA-SI in two studies. The authors calculated a common symptom score, based on the common items from both questionnaires, that had all but one item used in the AUA-SI. Questions from AUA-SI are scored on a 0 to 5 scale and those on BSI on a 0 to 3 scale. To adjust for this difference, the authors performed a nonlinear rescaling of the AUA-SI to adjust for these scoring differences.

MAIN RESULTS

The ages of the patients (N = 3,948) ranged from 62 to 66. The duration of the studies varied from 8 to 52 weeks. Four of the studies used fixed dosages, and the rest used titration-to-response doses. The effect of terazosin versus placebo on peak urinary flow rate was similar in all the studies. The estimated mean increase in peak urinary flow rate was 1.39 mL/s greater in men receiving terazosin than in those receiving placebo, and the improvements were observed within 8 weeks of therapy. However, the changes in the symptom scores varied across the studies. Patients treated with terazosin had an estimated 1.9-point reduction (95% confidence interval (CI) = 1.6-2.3) in BSI and 3.5-point reduction (95% confidence interval (CI) = 2.8-4.1) in AUA-SI score from baseline. Improvements in scores were greater in studies that were conducted for longer duration.

CONCLUSIONS

The authors concluded that treatment with terazosin was associated with greater peak urinary flow rate and lower symptom score than treatment with placebo. There was no variability of efficacy of terazosin as a result of prostrate volume, and measurement of prostrate volume was not essential before initiation of therapy.

Long-term treatment with finasteride in men with symptomatic benign prostatic hyperplasia: 10-year follow-up

OBJECTIVES

To evaluate the safety and efficacy of finasteride 5 mg during a 10-year period in men with enlarged prostates from a single center who participated in the double-blind and extension phases of the multicenter, Phase III, North American benign prostatic hyperplasia (BPH) trial. It is important that the long-term safety and efficacy of drugs intended for chronic administration in men with BPH be well understood.

METHODS

The Phase III North American BPH trial involved a 1-year, placebo-controlled, double-blind study, followed by a 5-year open extension with finasteride 5 mg/day. The trial enrolled men with symptomatic BPH, an enlarged prostate on digital rectal examination, and no evidence of prostate cancer. Of the 46 patients originally enrolled from our institution, 43 were randomized to receive finasteride or placebo, of whom 41 (95%) completed the double-blind study and entered the 5-year extension. Thirty (73%) of these 41 patients completed the 5-year extension. Patients continued to be followed up by their physicians for an additional 5 years, for a total follow-up of at least 10 years.

RESULTS

Twenty-four (56%) of the original 43 patients randomized to finasteride or placebo were judged as successfully treated during the 10-year finasteride follow-up (17 patients taking finasteride alone at 10 years and 7 patients who were taking finasteride alone when they discontinued during the 10-year follow-up for reasons not related to finasteride treatment). Altogether, 22 (51%) of the original 43 randomized patients continued finasteride treatment at 10 years (17 taking finasteride alone, 4 taking finasteride plus an alpha-blocker, and 1 taking finasteride for treatment of hematuria). Finasteride was well tolerated, with no new adverse experiences occurring with increasing duration of exposure to the drug.

CONCLUSIONS

This long-term follow-up study has demonstrated that appropriately selected patients with symptomatic BPH and enlarged prostates are likely to have a long-term response to taking finasteride 5 mg daily.

Current concepts in the pharmacotherapy of benign prostatic hyperplasia

Benign prostatic hyperplasia is a major men's health issue, with approximately 80% of all men developing this condition within their lifetime. A variety of oral treatments is available, including alpha-adrenoceptor antagonists (alpha-blockers), 5alpha reductase inhibitors, aromatase inhibitors and phytotherapy. A large number of alpha-blockers can be administered, but no single agent has demonstrated a clear superiority over the other drugs. 5alpha Reductase inhibitors have demonstrated similar efficacy in larger volume prostates but most evidence suggests that there is no benefit in combining them with alpha-blockers. The use of phytotherapy is not entirely novel but requires further long-term evaluation before it can be endorsed for clinical use in benign prostatic hyperplasia.

Terazosin for benign prostatic hyperplasia

BACKGROUND

Lower urinary tract symptoms associated with benign prostatic obstruction (BPO) occur in up to 70% of men over the age of 60 years. To relieve these bothersome symptoms, treatment options include alpha-antagonists, also know as alpha-blockers.

OBJECTIVES

We conducted a systematic review to evaluate the effectiveness and adverse effects of the alpha-blocker, terazosin, for treatment of urinary symptoms associated with BPO.

SEARCH STRATEGY

Trials were searched in computerized general and specialized databases (MEDLINE, Cochrane Library), by checking bibliographies, and by contacting manufacturers and researchers.

SELECTION CRITERIA

Studies were included if they (1) were randomized trials of at least 1 month duration, and (2) included men with symptomatic BPO and compared terazosin with placebo or active controls.

DATA COLLECTION AND ANALYSIS

Study, patient characteristics and outcomes data were extracted in duplicate onto standardized forms utilizing a prospectively developed protocol. The main outcome measure for comparing the effectiveness of terazosin with placebo or other BPO medications was change in urological symptoms as measured by validated symptom scores. Secondary outcomes included urodynamic measures. The main outcome measure for adverse effects was the number of men reporting side effects. We also evaluated the number of men withdrawing from treatment and the number withdrawing due to adverse effects.

MAIN RESULTS

17 studies involving 5,151 subjects met inclusion criteria (placebo-controlled (10); alpha-blockers (7); finasteride alone or in combination with terazosin as well as placebo (1); microwave therapy (TUMT) (1). Study duration ranged from 4-52 weeks. Mean age was 65 years and 82% of men were white. Baseline urologic symptom scale scores and flow rates demonstrated that men had moderate BPO. Efficacy outcomes were rarely reported in a fashion that allowed for data pooling but indicated that terazosin improved symptom scores and flow rates more than placebo or finasteride and similarly to other alpha antagonists. The pooled mean percentage improvements for the Boyarsky symptom score was 37% for terazosin versus 15% for placebo (n=4 studies). The mean percentage improvement for the American Urological Association symptom score (AUA) was 38% compared to 17% and 20% for placebo and finasteride, respectively (n = 2 studies). The pooled mean improvement in the International Prostate Symptom Score (IPSS) (40%) was similar to tamsulosin (43%). Peak urine flow rates improved greater with terazosin (22%), than placebo (11%) and finasteride (15%) but did not differ significantly from the other alpha-blockers. The percentage of men discontinuing terazosin was comparable to men receiving placebo and finasteride but was greater then with other alpha-antagonists. Adverse effects were greater than placebo and included dizziness, asthenia, headache and postural hypotension.

REVIEWER'S CONCLUSIONS

The available evidence suggests that terazosin improves urinary symptoms and flow measures associated with BPO. Effectiveness is superior to placebo or finasteride, similar to other alpha-blockers but less than TUMT. Adverse effects were generally mild but more frequent than other alpha-blockers and associated with between a two-four fold increase in treatment discontinuation.

Recruitment for a clinical trial of drug treatment for benign prostatic hyperplasia

OBJECTIVES

To evaluate the effectiveness of various recruitment strategies for a 6-year multicenter clinical trial of medical therapy for benign prostatic hyperplasia, the Medical Therapy of Prostatic Symptoms Trial.

METHODS

How participants learned about the trial was obtained during initial contact with clinical centers and at the first screening visit. The yield of randomized participants from the initial contact and first screening visit was calculated for each of the recruitment techniques.

RESULTS

During a period of 28 months, 16,723 potential trial participants made an initial contact with the 17 clinical centers, and 2931 men were randomized. An average of four initial contacts were required for each first screen visit and six per randomized participant. Newspaper (29.9%) and mail (26.7%) were the two leading sources of randomized participants. Medical sources (9.6%), radio (8.8%), and newsletters (8.4%) were also important sources. All clinical centers achieved or exceeded their recruitment goals.

CONCLUSIONS

Mass mail and newspaper were the most effective recruitment techniques to enlist the interest of men with urinary symptoms for a long-term trial of drug therapy for benign prostatic hyperplasia.

Meta-analysis of randomized trials of terazosin in the treatment of benign prostatic hyperplasia

OBJECTIVES

To determine the effectiveness of the long-acting alpha(1)-adrenergic receptor blocking agent terazosin compared with placebo on lower urinary tract symptoms and peak urinary flow rate in men with clinical benign prostatic hyperplasia.

METHODS

A formal meta-analysis of all nine randomized trials of terazosin using both an Empirical Bayes and a fully Bayesian approach was conducted. A pooled analysis was conducted on those studies in which patients had a baseline assessment of prostate volume by transrectal ultrasonography.

RESULTS

No evidence of heterogeneity was found in the estimated effects of terazosin on the change in peak flow rates in the studies. Terazosin treatment was associated with an increase in the peak flow rate of 1.4 mL/s (95% confidence interval [1.0, 1.7]) compared with placebo. Terazosin resulted in an average reduction of 2.2 points over placebo (95% confidence interval [1.6, 3.0]) regarding the common symptom score (range 0 to 36 points). A mild heterogeneity was found across the studies, with the decrease in symptom score slightly greater with longer treatment duration. No evidence was found that the baseline prostate volume influenced the effect of terazosin.

CONCLUSIONS

Terazosin was effective and superior to placebo in reducing symptoms and increasing the peak urinary flow rate. The effect of terazosin on the peak urinary flow rate was apparent in studies as short as 8 weeks. Most importantly, the effect of terazosin on symptoms and peak urinary flow rate was independent of the baseline prostate size for the range of prostate volumes reported.

The short-term effects of terazosin in Japanese men with benign prostatic hyperplasia

We evaluated the short-term efficacy of terazosin for treating symptomatic benign prostatic hyperplasia (BPH). Thirty men, aged 52 to 83 years (mean: 69.2 years) complaining of obstructive urinary symptoms due to BPH who had not received any prior treatment for their symptoms were orally administered 2 mg/day of terazosin. Symptoms (the total IPSS and the obstructive and irritative symptom scores) and objective parameters (peak flow rate [Qmax] and prostatic volume) were evaluated before treatment and after 1, 2, and 4 weeks of treatment. The mean total IPSS and the mean symptom scores for weak stream and nocturia were significantly decreased after only 1 week of treatment, while the mean scores for emptying, frequency, and urgency were significantly decreased after 2 weeks of treatment. However, the mean scores for intermittency and hesitancy did not decrease significantly at any time during treatment. Regarding objective parameters, the mean Qmax was significantly improved after 1 week of treatment, but the mean prostatic volume remained almost unchanged after 4 weeks. In conclusion, short-term terazosin therapy not only improved Qmax but also alleviated symptoms including irritative symptoms.

Minimally invasive procedures as an alternative to medical management for lower urinary tract symptoms of benign prostatic hyperplasia

Data are reviewed relating to the safety and efficacy of minimally invasive transurethral microwave thermotherapy and medical management in patients with lower urinary tract symptoms of benign prostatic hyperplasia. Recent evidence is summarized indicating more pronounced long-term beneficial effects of microwave treatment. alpha-Blockade, however, offers the advantage of more rapid action than microwave treatment. Neoadjuvant and adjuvant alpha-blocker therapy can accelerate symptom and flow rate improvement in patients receiving microwave treatment. Compared with medical management, microwave treatment possesses greater versatility, allowing patients with severe baseline symptoms and small prostate sizes to be treated with a high probability of success.

Transurethral microwave thermotherapy: an alternative to medical management in patients with benign prostatic hyperplasia?

Transurethral microwave thermotherapy (TUMT) is being increasingly considered as an alternative to medical management with alpha-blockers or finasteride in patients with lower urinary tract symptoms (LUTS) of benign prostate hyperplasia (BPH). Enduring clinical benefits have been demonstrated after a single 1-hour microwave treatment session under topical anesthesia, and the associated morbidity is low. Optimal results are obtained with the delivery of high thermal doses and accurate targeting of microwave energy. Extensive evidence from randomized clinical trials supports the safety and efficacy of both microwave treatment and medical management, but randomized trial data have only recently become available directly comparing these two approaches to BPH treatment. These data indicate that greater long-term improvements in symptoms, peak urinary flow rates, and quality of life are attained with microwave treatment than with alpha-blockade. Furthermore, the actuarial rate of treatment failure is markedly lower in patients undergoing microwave v alpha-blocker treatment. However, the onset of action of alpha-blocker treatment is more rapid. The principal limitations of alpha-blockade are side effects and lack of efficacy leading to treatment failure in some patients. The maximal effects of finasteride are modest and require a period of months to be manifested, although the side effect profile and tolerability of this agent are favorable. Neoadjuvant and adjuvant alpha-blocker therapy can accelerate symptom and flow rate improvement after TUMT. In contrast to medical management, microwave treatment is highly versatile, allowing patients over a broad range of baseline symptom severities and prostate sizes to be treated with a high probability of success.

Alpha-adrenergic blocking drugs in the management of benign prostatic hyperplasia: interactions with antihypertensive therapy

Management of benign prostatic hyperplasia (BPH) is often complicated by concomitant hypertension, a life-threatening condition that must be managed optimally. Many of the alpha blockers used to treat BPH also decrease blood pressure, and terazosin and doxazosin have been shown to have significant cardiovascular side effects, such as asthenia/fatigue, postural hypotension, and dizziness when used to treat BPH patients. Furthermore, these drugs are not first-line therapies for hypertension, and the majority of hypertensive BPH patients will be receiving other antihypertensive agents. Therefore, it is possible that the introduction of these drugs will affect blood pressure control, at least temporarily, with possible adverse effects. In contrast, the selective alpha1A blocker tamsulosin does not appear to have significant cardiovascular side effects and produces minimal blood pressure reductions. Therefore, urologists can choose either to use alpha blockers to treat both hypertension and BPH or to treat BPH using alpha blockers that do not interact with antihypertensive therapy. This review focuses on the alpha blockers currently being used to treat BPH, their effects on the cardiovascular system, and their interaction with antihypertensive drugs.

Use of meta-analytic results to facilitate shared decision making

OBJECTIVES

Describe and evaluate an Internet-based approach to patient decision support using mathematical models that predict the probability of successful treatment on the basis of meta-analytic summaries of the mean and standard deviation of symptom response.

DESIGN

An Internet-based decision support tool was developed to help patients with benign prostatic hypertrophy (BPH) determine whether they wanted to use alpha blockers. The Internet site incorporates a meta-analytic model of the results of randomized trials of the alpha blocker terazosin. The site describes alternative treatments for BPH and potential adverse effects of alpha blockers. The site then measures patients' current symptoms and desired level of symptom reduction. In response, the site computes and displays the probability of a patient's achieving his objective by means of terazosin or placebo treatment.

SETTING

Self-identified BPH patients accessing the site over the Internet.

MAIN OUTCOME MEASURES

Patients' perceptions of the usefulness of information.

RESULTS

Over a three-month period, 191 patients who were over 50 years of age and who reported that they have BPH used the decision support tool. Respondents had a mean American Urological Association (AUA) score of 18.8 and a desired drop in symptoms of 10.1 AUA points. Patients had a 40 percent chance of achieving treatment goals with terazosin and a 20 percent chance with placebo. Patients found the information useful (93 percent), and most (71 percent) believed this type of information should be discussed before prescribing medications.

CONCLUSIONS

Interactive meta-analytic summary models of the effects of pharmacologic treatments can help patients determine whether a treatment offers sufficient benefits to offset its risks.

Transurethral microwave thermotherapy: what role should it play versus medical management in the treatment of benign prostatic hyperplasia?

Both transurethral microwave thermotherapy (TUMT) and medical management by alpha-blockade or 5-alpha-reductase inhibition are increasingly being considered as alternatives to surgery for treatment of patients with benign prostatic hyperplasia (BPH). We review current evidence supporting the effectiveness and safety of TUMT and medical management. Factors for consideration in appropriately selecting patients for TUMT versus medical management are suggested. Available data indicate that TUMT confers greater long-term benefits than medical management as judged by symptom score and peak urinary flow rate improvements. TUMT-associated morbidity is comparatively low. Alpha-blockade affords more rapid relief than TUMT for patients with BPH; however, other strategies such as the use of temporary intraurethral endoprostheses during the acute post-TUMT recovery period may diminish or abolish the differences in time-course of symptom and flow rate improvement between TUMT and alpha-blockade. 5-Alpha-reductase inhibition with finasteride offers a favorable side-effect profile, although the magnitude of symptom and flow rate improvements is modest, and maximal effects of finasteride do not become manifest until after several months of treatment. As TUMT continues to evolve, increasing attention is being accorded the delivery of high thermal doses and precise targeting of the thermal energy delivered. The development of alpha-blockers with a more favorable side-effect profile continues to be a major focus of investigation. The potential clinical utility of combination therapy with TUMT and alpha-blockade is currently under investigation.

Conservative non-instrumental treatment of benign prostatic hyperplasia

This paper critically reviews the clinical effects in benign prostatic hyperplasia (BPH) patients that can be achieved with the presently available medical treatment options. The classes of drugs that are reviewed include: 5-alpha-reductase inhibitors, alpha-blockers, cholesterol-lowering agents and phytotherapeutic drugs. Only double-blind placebo-controlled studies with a duration of at least 3 months that have reported symptomatic changes and changes in flow rate in a quantitative fashion have been included. Studies that exclusively included selected groups of patients such as hypertensives or non-hypertensives have been excluded. The results of the clinical trials that are reviewed in this paper often show improvements in symptom score and maximum flow rate in the patients taking the active drug. These improvements are often statistically significantly better than the improvements seen in the placebo groups. However, taking into account that the symptomatic and the flow rate improvements achieved are below the level of perception in most of these trials, there seems to be no convincing evidence that medical treatment of BPH with the presently available drugs is also clinically more effective than placebo.