The effects of dutasteride, tamsulosin, and the combination on storage and voiding in men with benign prostatic hyperplasia and prostatic enlargement: 2-year results from the Combination of Avodart and Tamsulosin study

Emerging drugs for the treatment of benign prostatic hyperplasia: a 2023 update

INTRODUCTION

Benign prostatic hyperplasia (BPH) is a condition that affects over 50% of men as they enter their fifth decade of life, often leading to lower urinary tract symptoms (LUTS). Primary treatment options include alpha blockers, 5-alpha reductase inhibitors, and phosphodiesterase-5 inhibitors. However, these medications can have some side effects, and there is a noticeable dearth of information addressing the long-term use of these medications. Thus, the exploration of all treatment modalities helps ensure patients receive personalized and effective care. Consequently, the primary objective of this review is to identify potential emerging medications for the treatment of BPH.

AREAS COVERED

We conducted an extensive review of articles discussing pharmacotherapy for BPH spanning the last 15 years. Our information gathering process involved Scopus, PubMed-MEDLINE, Cochrane, Wiley Online Library Google Scholar, ClinicalTrials.gov, and the PharmaProjects database. This approach ensures that readers gain an in-depth knowledge of the existing therapeutic agents as well as promising avenues for managing BPH.

EXPERT OPINION

BPH treatment targets a patient's specific constellation of symptoms. Therefore, a broad knowledge base encompassing various treatment options is paramount in ensuring optimal treatment. Looking forward, the emphasis on personalization promises to reshape the landscape of BPH treatment and improve patient outcomes.

Association between oral frailty and lower urinary tract symptoms among middle-aged and older adults in community-dwelling individuals: a cross-sectional study

PURPOSE

We assessed the association between oral frailty risk and LUTS among middle-aged and older adults in a community-dwelling population.

METHODS

This cross-sectional study was conducted among 586 subjects aged ≥ 40 years who participated in the Iwaki Health Promotion Project in Hirosaki, Japan. We used the International Prostate Symptom Score (IPSS) and the Overactive Bladder Symptom Score (OABSS) to assess LUTS. LUTS was defined as an IPSS score of 8 or higher or meeting diagnostic criteria for OAB. Oral frailty risk was defined as experiencing two or more of the following: decreased chewing ability, decreased biting force, and dry mouth sensation. Physical performance (10-m gait speed and grip strength) was used for analysis. The association between oral frailty risk and LUTS was examined using multivariate logistic regression analyses.

RESULTS

The study included 218 men and 370 women, of whom 140 had LUTS. The mean age of this cohort was 59 years. Significant differences were observed between the LUTS and non-LUTS groups, including age, hypertension, history of CVD, depressive status, sleep disturbance, and 10 m gait speed. The prevalence of oral frailty risk was significantly higher in the LUTS group than in the non-LUTS group (26% vs. 11%, P < 0.001). Multivariate analysis revealed that age, male gender, and oral frailty risk (odds ratio: 2.67, 95% confidence interval: 1.57-4.51, P < 0.001) were independent factors for LUTS. Moreover, oral frailty risk was an independent factor in both participants aged < 65 years and participants aged ≥ 65 years.

CONCLUSIONS

Oral frailty was independently associated with LUTS.

Correlation between Higher Aging Males' Symptoms Scores and a Higher Risk of Lower Urinary Tract Symptoms

BACKGROUND

Late-onset hypogonadism (LOH) is a condition caused by the decline of testosterone levels with aging and is associated with various symptoms, including lower urinary tract symptoms (LUTSs). Although some reports have shown that testosterone replacement treatment for LOH improves LUTSs, no large study has revealed a correlation between LUTSs and LOH. This study investigated the correlation between the severity of LOH and LUTSs in Japanese males >40 years of age using a web-based questionnaire with the Aging Males' Symptoms (AMS) scale.

METHODS

We asked 2000 Japanese males to answer both the AMS and IPSS/QOL questionnaires using a web-based survey. Among these 2000 individuals, 500 individuals were assigned to each age group.

RESULTS

The IPSS total score was positively correlated with the severity of AMS (shown as median [mean ± SD]): no/little group, 2 (3.67 ± 5.36); mild group, 6 (7.98 ± 6.91); moderate group, 11 (12.49 ± 8.63); and severe group, 16 (14.83 ± 9.24) (p < 0.0001).

CONCLUSIONS

Individuals with higher AMS values, representing cases with severe LOH symptoms, had a higher risk of experiencing nocturia and LUTSs than those with lower AMS values.

Clinical outcomes of withdrawing one medication from long-term combination therapy comprising α-blocker and 5α-reductase inhibitor for benign prostatic hyperplasia

PURPOSE

To assess adherence to combination therapy comprising α-adrenergic blocker (AB) and 5α-reductase inhibitor (5ARI) for benign prostatic hyperplasia (BPH) in a real-world setting and whether lower urinary tract symptoms (LUTS) will relapse after discontinuing one medication from long-term combination therapy.

METHODS

BPH/LUTS patients receiving initial AB +5ARI combination therapy for at least 1 year between January 2012 and January 2017 were retrospectively analyzed. The patients were classified into DC-AB group (n = 65, AB discontinued) and DC-5ARI group (n = 77, 5ARI discontinued) and followed up. Clinical effects were assessed at baseline and annually using the International Prostatic Symptoms Score (IPSS), quality of life (QoL) index, total prostate volume (TPV), maximal flow rate (Qmax), and prostate-specific antigen (PSA) level.

RESULTS

Of total 1783 patients, 809 (45.4%) patients were identified with more than 1-year combination therapy. After withdrawal of one medication from combination therapy, the TPV progression (27.6% vs. - 10.8%; P < 0.001) and the requirement for prostate surgery (14.3% vs. 6.1%; P = 0.038) were significantly higher in the DC-5ARI group than in the DC-AB group. The rate of resuming combination therapy was significantly higher in the DC-5ARI group than in the DC-AB group (38.9% vs. 23.0%; P = 0.009).

CONCLUSIONS

Adherence to combination BPH therapy is relatively low. Although patients adhered to combination therapy for more than 1 year, a higher risk of requiring prostate surgery or resuming combination therapy was observed in patients who discontinued 5ARI.

The impact of preoperative lower urinary tract symptoms medication on the functional performance of holmium laser enucleation of the prostate

Introduction

Medical treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO) targets prostate size, to prevent disease progression, and prostate smooth muscle tone for rapid relieve of LUTS. Holmium laser enucleation of the prostate (HoLEP) is a size-independent method for surgical treatment of LUTS/BPO in medication-refractory patients and offers durable long-term results with reduced perioperative morbidity. As up to 50% of patients receive medical treatment for LUTS/BPO prior to surgery, we analyzed the impact of alpha-blockers and 5-alpha reductase inhibitors (5-ARI) on outcomes and perioperative morbidity in patients undergoing HoLEP for LUTS.

Material and methods

We retrospectively gathered data of 1,057 patients, who underwent HoLEP for LUTS/BPO from 2013–2018, and divided patients into group 1 (no medication), group 2 (α-blockers), and group 3 (5-ARI and α-blockers). Perioperative parameters, short-term functional outcomes and safety were assessed and statistical analysis was performed using SPSS V26.0 software.

Results

Even though preoperative LUTS profile was significantly different between groups, all patients improved significantly after HoLEP, irrespective of preoperative LUTS medication. Median improvement of IPSS was 9, 8 and 7 points, of Q_max was 10, 12 and 9.5 ml/s, with significant improvement of quality of life (QoL) and reduction of post-void residual volume (PVR) for groups 1–3, respectively, 30 days after surgery. With only 4.0% (42/1,057) of patients experiencing a Clavien-Dindo grade ≥II complication, there was no difference in prevalence of perioperative complications between groups (p = 0.943).

Conclusions

Although preoperative LUTS medication does not impair efficacy of HoLEP with acceptable perioperative morbidity, the time gap between medical therapy and surgical treatment may favor an earlier response.

Questionnaire survey assessing seasonal changes in lower urinary tract symptoms in men with benign prostate hyperplasia

OBJECTIVE

A prospective questionnaire survey was conducted for patients with benign prostatic hyperplasia (BPH) to clarify seasonal changes in the lower urinary tract symptoms (LUTS).

MATERIAL AND METHODS

Male patients receiving α1-adrenoreceptor antagonists for BPH were enrolled. They answered the International Prostate Symptom Score (IPSS) questionnaire, and an unvalidated questionnaire that consisted of 10 questions assessing variations in the urinary stream (voiding symptoms) and urinary frequency (storage symptoms), depending upon the seasons or the patients' subjective sensations of warm and cold in last one year.

RESULTS

A total of 412 participants answered IPSS and our unvalidated questionnaire. Of the 412 participants, 36.7% and 59.0% realized seasonal variations in urinary stream and frequency, respectively. Among patients perceiving seasonal urinary stream and urinary frequency changes (n=151 and n=243, respectively), significantly more patients realized weaker urinary stream, 59.8% (107/179) in winter compared with 26.2% (47/179) in summer, and increased urinary frequency, 69.8% (199/285) in winter compared with 20.7% (59/285) in summer (p<0.0001 and p<0.0001, respectively). Even in summer, when feeling cold, 34.7% and 56.3% realized a weaker urinary stream and an increased urinary frequency, and even in winter, when feeling warm, 53.4% and 69.4% realized a stronger urinary stream and a decreased urinary frequency. Those with seasonal stream changes showed a significantly higher IPSS total, voiding and post-voiding scores than those without, and those with seasonal frequency changes showed significantly higher IPSS total, storage, voiding, and post-voiding scores.

CONCLUSION

Our results revealed seasonal changes and feeling of hot and cold were associated with subjective changes of LUTS in BPH patients.

Integrated Item Response Theory Modeling of Multiple Patient-Reported Outcomes Assessing Lower Urinary Tract Symptoms Associated with Benign Prostatic Hyperplasia

In clinical trials within lower urinary tract symptoms due to benign prostatic hyperplasia (BPH-LUTS), the International Prostate Symptom Score (IPSS) is commonly the primary efficacy outcome while the Quality of Life (QoL) score and the BPH Impact Index (BII) are common secondary efficacy markers. The current study aimed to characterize BPH-LUTS progression using responses to the IPSS, the QoL, and the BII in an integrated item response theory (IRT) framework and assess the Fisher information of each scale. The power of this approach to detect a drug effect was compared with an IRT approach considering only IPSS responses. A unidimensional and a bidimensional pharmacometric IRT model, based on item-level IPSS responses in a clinical trial with 403 patients, were extended by incorporating patients’ QoL and summary BII scores over the 6-month trial period. In the developed unidimensional integrated model, the QoL score was found to be the most informative, representing 17% of the total Fisher information, while the combined information content of the seven IPSS items represented 70.6%. In the bidimensional model, “storage” and both storage and “voiding” disability drove QoL and summary BII responses, respectively. Sample size reduction of 16% to detect a drug effect at 80% power was obtained with the unidimensional integrated IRT model compared with its counterpart IPSS IRT model. This study shows that utilizing the information content across the IPSS, QoL, and BII scales in an integrated IRT framework results in a modest but meaningful increase in power to detect a drug effect.

The role of adrenal derived androgens in castration resistant prostate cancer

Castration resistant prostate cancer (CRPC) remains androgen dependant despite castrate levels of circulating testosterone following androgen deprivation therapy, the first line of treatment for advanced metstatic prostate cancer. CRPC is characterized by alterations in the expression levels of steroidgenic enzymes that enable the tumour to derive potent androgens from circulating adrenal androgen precursors. Intratumoral androgen biosynthesis leads to the localized production of both canonical androgens such as 5α-dihydrotestosterone (DHT) as well as less well characterized 11-oxygenated androgens, which until recently have been overlooked in the context of CRPC. In this review we discuss the contribution of both canonical and 11-oxygenated androgen precursors to the intratumoral androgen pool in CRPC. We present evidence that CRPC remains androgen dependent and discuss the alterations in steroidogenic enzyme expression and how these affect the various pathways to intratumoral androgen biosynthesis. Finally we summarize the current treatment strategies for targeting adrenal derived androgen biosynthesis.

Emerging drugs for the treatment of benign prostatic hyperplasia

INTRODUCTION

Benign prostatic hyperplasia (BPH) is a common condition affecting over 50% of men as they reach their 5^th decade of life. This leads to a number of sequelae such as lower urinary tract symptoms, urinary retention and a decrease in quality of life. Currently, the available treatments for BPH are alpha blockers and 5-alpha reductase inhibitors. Clinical studies have demonstrated these medical options are effective in alleviating a patient's symptoms, however there are a number of side effects. There is a paucity of information regarding long-term use of these medications. The purpose of this review is to identify potential and emerging medications for the treatment of BPH. Areas covered: Articles used in this review were retrieved from Pubmed, Google and through searching the PharmaProjects database over the last 10 years, giving the reader an in-depth knowledge about the current pharmacological agents available and other potential treatments for BPH. Expert opinion: The new paradigm of BPH treatment depends on addressing a patient's specific constellation of symptoms. This allows to tailor therapy of increasing efficacy and reduce adverse events that our patients have by increasing dosage.

Effects of barbed suture during robot-assisted radical prostatectomy on postoperative tissue damage and longitudinal changes in lower urinary tract outcome

OBJECTIVE

To compare the postoperative tissue damage and longitudinal changes in functional and patient-reported outcomes after vesicourethral anastomosis with barbed suture and nonbarbed suture in robot-assisted laparoscopic radical prostatectomy (RARP).

MATERIALS AND METHODS

This was a prospective cohort study involving 88 consecutive patients who underwent RARP. These patients were categorized into the barbed suture group (n = 50) and the nonbarbed suture group (n = 38). Urethral and periurethral damages determined by magnetic resonance imaging at nine months after RARP were compared using generalized linear models. The International Prostate Symptom Score (IPSS), quality of life (QOL) index, uroflowmetry, and the 1-h pad test were measured at baseline and at 1, 3, 6, 9, and 12 months after RARP. The findings were analyzed using mixed-effects models. Confounding was adjusted for using propensity score covariate adjustment.

RESULTS

The likelihood of having Grade 2/3 urethral and periurethral damages was greater in the barbed suture group than in the nonbarbed suture group (adjusted risk ratios: 2.98 and 3.85, respectively). IPSS, QOL index, and urinary leakage transiently increased at one month after RARP in both groups. QOL index was higher in the barbed suture group than in the nonbarbed suture group at 1, 9, and 12 months (P = 0.023, P = 0.025, and P = 0.011, respectively). The barbed suture group had significantly more cases of urinary incontinence than the nonbarbed suture group at 3 months (P = 0.041). Other outcomes were comparable between the two groups at all time points.

CONCLUSIONS

This cohort study showed that, after RARP, barbed sutures during VUA induced more severe tissue damage as determined by MRI and greater transient aggravation of QOL and continence function than nonbarbed sutures. The present findings suggest that using nonbarbed sutures during VUA may facilitate earlier acquisition of urinary QOL and urinary continence.

Dutasteride add-on therapy reduces detrusor mass in patients with benign prostatic enlargement not satisfied with alpha-adrenergic antagonist monotherapy: A single center prospective study

AIMS

The ultrasound assessment of bladder wall thickness (BWT) and intravesical prostatic protrusion (IPP) have emerged as a non-invasive, inexpensive, time-saving alternatives to pressure-flow studies to assess benign prostatic obstruction (BPO). Aim of our study was to evaluate the effect on detrusor mass of dutasteride add-on therapy in men with lower urinary tract symptoms (LUTS) and benign prostatic enlargement (BPE).

METHODS

A consecutive series of BPE patients with a prostate volume (PV) ≥30 mL and an international prostate symptoms score (IPSS) ≥8 not satisfied with Tamsulosin monotherapy were enrolled. Free maximum flow (Qmax), PV, BWT, and IPP were recorded at baseline and at 24 weeks follow-up.

RESULTS

Overall, 27 men were enrolled. Dutasteride significantly improved LUTS (-46.7%; P = 0.001) and Qmax (+18.7%; P = 0.001) and reduced PV (-13%; P = 0.002), BWT (-40.3%; P = 0.001), and IPP (-14.9%; P = 0.015). At baseline, based on BWT ≥5 mm and an IPP >10 mm, 13/27 (48%) and 15/27 (55%) patients were defined at risk for BPO, respectively; while after 24 weeks of treatment they were 3/27 (11.1%) and 11/27 (40%), respectively.

CONCLUSIONS

Dutasteride add-on therapy significantly reduced IPP and detrusor mass and was effective in improving LUTS in patients with BPE not satisfied with αBs monotherapy. The possible role of BWT and IPP as proxies of medical treatment outcomes should be confirmed by further studies.

Decreased urinary nerve growth factor reflects prostatic volume reduction and relief of outlet obstruction in patients with benign prostatic enlargement treated with dutasteride

OBJECTIVES

To examine urinary nerve growth factor before and after dutasteride treatment, and to analyze correlations between clinical parameters and change of urinary nerve growth factor in patients with benign prostatic enlargement.

METHODS

We prospectively studied 30 patients with benign prostatic enlargement who had not been satisfied with α-adrenergic antagonist monotherapy for more than 3 months. Before and 24 weeks after dutasteride add-on treatment, we assessed International Prostate Symptom Score, prostatic volume, filling cystometry and pressure-flow study. Urinary nerve growth factor was measured by enzyme-linked immunosorbent assay, and normalized to the urinary creatinine (nerve growth factor/creatinine) before and 24 weeks after dutasteride add-on treatment.

RESULTS

In baseline characteristics before dutasteride, there was no significant correlation between urinary nerve growth factor/creatinine and any clinical parameters including age, International Prostate Symptom Score, prostatic volume, presence of detrusor overactivity, detrusor pressure at maximum flow rate, bladder outlet obstruction index or bladder contractility index. Dutasteride significantly reduced prostatic volume (from 68 ± 31 mL to 49 ± 28 mL) and improved International Prostate Symptom Score (from 17.2 ± 8.7 to 13.1 ± 6.8), storage (from 8.0 ± 4.3 to 6.0 ± 2.9) and voiding symptom subscore of International Prostate Symptom Score (from 9.3 ± 5.7 to 7.1 ± 4.5). In urodynamic study, detrusor pressure at maximum flow rate (from 77 ± 32 cmH2 O to 59 ± 24 cmH2 O) and bladder outlet obstruction index (from 62 ± 32 to 42 ± 27) were significantly decreased after dutasteride treatment. Urinary nerve growth factor/creatinine was significantly decreased after dutasteride from 2.61 ± 2.50 to 1.64 ± 1.68. The change of urinary nerve growth factor/creatinine significantly correlated only with the change of prostatic volume (r = 0.38) and bladder outlet obstruction index (r = 0.36).

CONCLUSIONS

Urinary nerve growth factor decreases in association with reduction of prostatic volume and relief of bladder outlet obstruction. Urinary nerve growth factor might be useful as a biomarker to monitor the improvement of bladder outlet obstruction in patients with benign prostatic enlargement.

Early symptom improvement and discontinuation of 5-α-reductase inhibitor (5ARI) therapy in patients with benign prostatic hyperplasia (BPH)

BACKGROUND

Pharmacological treatment options for benign prostatic hyperplasia (BPH) commonly include α-blocker (AB) and 5-α-reductase inhibitor (5ARI) agents, which have separate but important attributes that carry clinical implications in terms of improvement of lower-urinary tract symptoms (LUTS) and clinical disease progression.

OBJECTIVES

This study hypothesized that administering AB therapy concomitantly with newly started 5ARI treatment would reduce the likelihood of 5ARI discontinuation through early symptom improvement.

METHODS

This retrospective analysis of the PharMetrics Integrated Medical and Pharmaceutical Database included men aged ≥50 years with ≥1 medical claim of BPH diagnosis and ≥1 prescription claim of a 5ARI with or without an AB. Patients initiating 5ARI monotherapy were propensity score matched with patients initiating combination AB + 5ARI therapy (1:1), with 5ARI time to discontinuation (30-day gap in treatment) compared between groups utilizing survival analysis techniques. The percentage of patients adherent to 5ARI therapy based on medication possession ratio (MPR) was assessed.

RESULTS

After 180 days of follow-up, 61.7% of the combination therapy arm versus 59.2% of the monotherapy arm remained on therapy. Combination therapy patients were 10% less likely to discontinue 5ARI treatment (hazard ratio = 0.904; P = .006) and were more likely to be adherent when adherence was defined as MPR ≥70% and ≥75%.

CONCLUSIONS

Based on an assessment of claims data, initiating AB with 5ARI therapy is associated with a lower rate of 5ARI discontinuation compared with 5ARI monotherapy. Early symptom relief from AB therapy may contribute to a lower discontinuation rate for concomitant 5ARI therapy.

Efficacy of Additional Dutasteride on Lower Urinary Tract Symptoms in Patients with Alpha-1 Blocker-Resistant Benign Prostatic Hyperplasia

OBJECTIVE

We investigated the effects of dutasteride on urination and quality of life (QOL) in patients diagnosed with benign prostatic hyperplasia (BPH) who showed poor improvement in lower urinary tract symptoms (LUTS) with alpha-1 blockers.

METHODS

We retrospectively analyzed 108 patients with BPH who took dutasteride for more than 3 months from October 2009 to October 2011. The patients showed poor improvement in LUTS despite administration of alpha-1 blockers for more than 3 months; all had an International Prostate Symptom Score (IPSS) of eight or greater. We investigated changes in prostate-specific antigen and prostate volume and performed uroflowmetry and medical interviews to assess IPSS-QOL score and BPH impact index (BII).

RESULTS

Mean prostate volume was 52.8 ± 22.2 mL, and the mean period of dutasteride administration was 284 ± 118 days. Prostate volume decreased 24.1% from baseline to 6 months after administration. Voiding symptoms and storage symptoms showed improvements with longer administration periods, but only nocturia showed no clear improvement. There was a 0.9-point decrease in BII after 6 months. There was no statistically significant association between the rate of prostate volume reduction and improvement in voiding and storage symptoms.

CONCLUSION

Additional administration of dutasteride to patients with alpha-1 blocker-resistant BPH led to improvements in all voiding and storage symptoms except nocturia, and showed no correlation between the prostate volume reduction rates and improvement in LUTS.

Systematic review of combination drug therapy for non-neurogenic male lower urinary tract symptoms

BACKGROUND

Several drugs are approved for the treatment of lower urinary tract symptoms (LUTS) in men, but these are mostly used by clinicians as monotherapies. The combination of different compounds, each of which targets a different aspect of LUTS, seems appealing. However, only few clinical trials have evaluated the effects of combination therapies.

OBJECTIVE

This systematic review analyzes the efficacy and adverse events of combination therapies for male LUTS.

EVIDENCE ACQUISITION

PubMed and Cochrane databases were used to identify clinical trials and meta-analyses on male LUTS combination therapy. The search was restricted to studies of level of evidence ≥ 1b. A total of 49 papers published between January 1988 and March 2012 were identified.

EVIDENCE SYNTHESIS

The α1-adrenoceptor antagonist (α1-blocker)/5α-reductase inhibitor (5-ARI) combination provides the most data. This combination seems to be more efficacious in terms of several outcome variables in patients whose prostate volume is between 30 ml and 40 ml when treatment is maintained for >1 yr; when given for <1 yr, α1-blockers alone are just as effective. The combination of α1-blocker/5-ARI shows a slightly increased rate of adverse events. It remains unknown whether its safety and superiority over either drug as monotherapy are sustained after >6 yr. The α1-blocker/muscarinic receptor antagonist (antimuscarinic) combination was most frequently assessed as an add-on therapy to already existing α1-blocker therapy. Inconsistent data derive from heterogeneous study populations and different study designs. Currently, the α1-blocker/antimuscarinic combination appears to be a second-line add-on for patients with insufficient symptom relief after monotherapy. The combination seems to be safe in men with postvoid residual <200 ml. However, there are no trials >4 mo concerning safety and efficacy of this combination. The α1-blocker/phosphodiesterase type 5 inhibitor combination is a new treatment option with only preliminary reports. More studies are needed before definitive conclusions can be drawn.

CONCLUSIONS

An α1-blocker/5-ARI combination is beneficial for patients whose prostate volume is between 30 ml and 40 ml when medical treatment is intended for >1 yr. Based on short-term follow-up studies, add-on of antimuscarinics to α1-blockers is an option when postvoid residual is <200 ml.

Latest treatment for lower urinary tract dysfunction: therapeutic agents and mechanism of action

Recent studies suggest that antimuscarinics might suppress bladder afferent activity by blocking muscarinic receptors in the urothelium, myofibroblasts and detrusor, thereby improving overactive bladder symptoms. β(3)-Adrenoceptors are predominantly expressed in the human bladder and mediate relaxation of detrusor muscle. β(3)-Adrenoceptor agonists increase bladder capacity and prolong micturition interval. It is assumed that β(3)-adrenoceptor agonists could exert an inhibitory effect on bladder afferent through β(3)-adrenoceptors in the urothelium and detrusor, which eventually improve the symptom of urgency. Mirabegron is a potent and selective β(3)-adrenoceptor agonist. A Japanese phase 3 study showed that mirabegron has excellent efficacy and safety for treating overactive bladder. α(1)-Adrenoceptor antagonists (α(1)-blockers) have become a mainstay of male lower urinary tract symptoms treatment. The α(1)(A) subtype is known to mediate functional obstruction as a result of benign prostatic enlargement. Recent studies have suggested that α(1)(A)-adrenoceptors are additionally involved in the generation of storage symptoms. The α(1)(D) subtype is thought to play a role in the facilitation of voiding reflex; that is; storage symptoms. α(1)-Blockers often fail to alleviate overactive bladder symptoms. In this context, combination therapy with α(1)-blockers and antimuscarinics has been recommended. Treatment with 5α-reductase inhibitor for 1 year improves urinary symptoms and flow rate by reducing prostatic volume in men with benign prostatic enlargement. A pooled analysis showed that the long-term (2 or 4 years) treatment with 5α-reductase inhibitor reduced the rate of progression to acute urinary retention and surgery. Combination therapy with 5α-reductase inhibitor and α(1)-blocker was shown to provide a rapid improvement in lower urinary tract symptoms, and reduce the relative risk of acute urinary retention and benign prostatic hyperplasia-related surgery. Phosphodiesterase inhibitors might target a nitric oxide-cyclic guanosine monophosphate pathway in the prostate, urethra and bladder. Phosphodiesterase-5 inhibitors (sildenafil or tadalafil) were shown to provide clinically relevant improvements in both male lower urinary tract symptoms and erectile dysfunction.

Effect of Discontinuation of Tamsulosin in Korean Men with Benign Prostatic Hyperplasia Taking Tamsulosin and Dutasteride: An Open-Label, Prospective, Randomized Pilot Study

OBJECTIVE

This study was conducted to examine the effect of discontinuing tamsulosin in patients with benign prostatic hyperplasia who had been receiving combination therapy with tamsulosin and dutasteride.

METHODS

The study sample consisted of 108 men with benign prostatic hyperplasia and lower urinary tract symptoms who visited our urology clinics between April 2008 and December 2010. All were assessed using the International Prostate Symptom Score (IPSS). The patients had IPSS of 8-19 and prostate volumes ≥25 mL by transrectal ultrasonography. They were put on tamsulosin and dutasteride, and the efficacy of this regimen was assessed every 12 weeks. After 48 weeks, patients were divided at random into a group continuing to take the same drug combination (group 1) and a group taking only dutasteride 0.5 mg (group 2).

RESULTS

Sixty-nine of the original 108 patients completed the study, 36 (52%) in group 1 and 33 (48%) in group 2. The mean age of all patients was 67.96 ± 7.88 years and mean prostatic volume was 40.45 ± 12.81 mL. Mean prostate-specific antigen was 3.31 (0.4-9.9) ng/mL at the outset. The IPSS scores of the two groups at first visit, 48 and 72 weeks were, respectively, 14.69 versus 15.85 (P = 0.322), 12.08 versus 12.85 (P = 0.582) and 10.89 versus 11.06 (P = 0.897.) There was a statistically significant difference between the baseline and 72-week IPSS scores in both groups (group 1: P < 0.001, group 2: P < 0.001).

CONCLUSION

In patients with moderate IPSS, discontinuing tamsulosin after 48 weeks of combined tamsulosin and dutasteride therapy has no significant effect on outcome.

Effect of 5-alpha Reductase Inhibitor on Storage Symptoms in Patients with Benign Prostatic Hyperplasia

Purpose

Many patients with benign prostatic hyperplasia (BPH) have storage symptoms. The aim of this study was to evaluate the effects of treatment with a 5-alpha reductase inhibitor (5ARI) on storage symptoms in patients with BPH.

Methods

This study was conducted in 738 patients with lower urinary tract symptoms secondary to BPH. Patients with a prostate volume of higher than 30 mL on the transrectal ultrasound were classified into two groups: group A, in which an alpha blocker was solely administered for at least 12 months, and group B, in which a combination treatment regimen of an alpha blocker plus 5ARI was used. This was followed by an analysis of the changes in parameters such as the total International Prostate Symptom Score (IPSS), voiding symptom subscore, and storage symptom subscore between the two groups. In addition, we examined whether there was a significant difference between the two groups in the degree of change in storage symptoms between before and after the pharmacological treatment.

Results

Of the 738 men, 331 had a prostate volume ≥30 mL, including 150 patients in group A and 181 patients in group B. Total IPSS, the voiding symptom subscore, and the storage symptom subscore were significantly lower after treatment than before treatment in both groups (P<0.05). A comparison of the degree of change between before and after treatment, however, showed no significant differences in the storage symptom subscore between the two groups (P>0.05).

Conclusions

Alpha blocker and 5ARI combination treatment is effective for patients with BPH including storage symptoms. However, 5ARI does not exert a significant effect on storage symptoms in BPH patients.

5-α reductase inhibitors and prostate cancer prevention: where do we turn now?

With the lifetime risk of being diagnosed with prostate cancer so great, an effective chemopreventive agent could have a profound impact on the lives of men. Despite decades of searching for such an agent, physicians still do not have an approved drug to offer their patients. In this article, we outline current strategies for preventing prostate cancer in general, with a focus on the 5-α-reductase inhibitors (5-ARIs) finasteride and dutasteride. We discuss the two landmark randomized, controlled trials of finasteride and dutasteride, highlighting the controversies stemming from the results, and address the issue of 5-ARI use, including reasons why providers may be hesitant to use these agents for chemoprevention. We further discuss the recent US Food and Drug Administration ruling against the proposed new indication for dutasteride and the change to the labeling of finasteride, both of which were intended to permit physicians to use the drugs for chemoprevention. Finally, we discuss future directions for 5-ARI research.

Annual drug update: 2010 in review

In 2010, the FDA approved several new drugs and new indications for use in primary care. From new therapies for adults with rheumatoid arthritis to a combination drug for benign prostatic hyperplasia, NPs need to be aware of the latest medications now available.

Effect of combination treatment on patient-related outcome measures in benign prostatic hyperplasia: clinical utility of dutasteride and tamsulosin

BACKGROUND

Benign prostatic hyperplasia, the fourth most commonly diagnosed medical condition in the elderly, is a major underlying cause of lower urinary tract symptoms in men. Medical therapy is usually the first therapeutic option. Combination therapy is increasingly used for better symptom relief and outcome.

METHODS

We searched the literature using the MEDLINE database for the efficacy of combination therapy in men with benign prostatic hyperplasia in terms of symptom improvement and impact on quality of life.

RESULTS

Combination therapy with dutasteride and tamsulosin not only provides better symptom improvement and improved urinary flow rate, but is also associated with a more favorable impact on quality of life and patient satisfaction with treatment than monotherapy. Combination therapy also reduces the risk of events related to disease progression, such as acute urinary retention and benign prostatic hyperplasia-related surgery.

CONCLUSION

Combination therapy with dutasteride and tamsulosin is highly efficacious as medical therapy for benign prostatic hyperplasia in patients with moderate-to-severe lower urinary tract symptoms.