Is Tamsulosin 0.2 mg Effective and Safe as a First-Line Treatment Compared with Other Alpha Blockers?: A Meta-Analysis and a Moderator Focused Study

Association of silodosin, tamsulosin, and naftopidil with delirium: analysis of the pharmacovigilance database in Japan

BACKGROUND

An association between adrenergic alpha-1 receptor antagonists and delirium has been suggested, but the details are unclear.

AIM

This study investigated the association between adrenergic alpha-1 receptor antagonists and delirium in patients with benign prostatic hyperplasia using the Japanese Adverse Drug Event Report database.

METHOD

First, disproportionality analysis compared the frequency of delirium in the adrenergic alpha-1 receptor antagonists silodosin, tamsulosin, and naftopidil. Next, multivariate logistic analysis was performed to examine the association between delirium and adrenergic alpha-1 receptor antagonists where disproportionality was detected.

RESULTS

A disproportionality in delirium was observed in patients receiving tamsulosin (reporting odds ratio [ROR] 1.85, 95% confidence interval [CI] 1.38-2.44, P < 0.01) compared with those who did not, and also in patients receiving naftopidil (ROR 2.23, 95% CI 1.45-3.28, P < 0.01) compared with those who did not. Multivariate logistic analysis revealed that in addition to previously reported risk factors for delirium, delirium in patients receiving tamsulosin was significantly increased with concomitant use of anticholinergics (odds ratio 2.73, 95% CI 1.41-5.29, P < 0.01) and delirium in patients receiving naftopidil was significantly increased with concomitant use of beta3-adrenergic receptor agonists (odds ratio 4.19, 95% CI 1.66-10.6, P < 0.01).

CONCLUSION

Anticholinergics or beta3-adrenergic receptor agonists to treat overactive bladder in patients receiving tamsulosin and naftopidil was strongly associated with delirium. Confirming the medical history and concomitant medications of patients receiving tamsulosin or naftopidil may contribute to preventing delirium in patients with benign prostatic hyperplasia and to improving their outcomes.

Cardiovascular safety of mirabegron add-on therapy to tamsulosin for the treatment of overactive bladder in men with lower urinary tract symptoms: A post hoc analysis from the MATCH study

Objectives

To investigate the cardiovascular safety of mirabegron add‐on treatment to tamsulosin in male patients with residual overactive bladder symptoms.

Methods

This was a post hoc analysis of MATCH, the first double‐blind, placebo‐controlled study comparing mirabegron and placebo as add‐on therapy to tamsulosin for treatment of overactive bladder in men with lower urinary tract symptoms. The analysis focused on treatment‐emergent adverse events relating to the cardiovascular system or blood pressure, and changes in vital signs during 12 weeks of follow‐up.

Results

Cardiovascular‐related treatment‐emergent adverse events were reported by 6/566 patients, although only one serious treatment‐emergent adverse event was related to treatment (unstable angina in the tamsulosin + placebo group). Hypertension (two patients) and increased blood pressure (one patient) were reported in the tamsulosin + placebo group, but there were no blood pressure‐related treatment‐emergent adverse events among tamsulosin + mirabegron patients. There were no clinically meaningful changes from baseline in blood pressure, and changes in pulse rate were small (+1.2 bpm in the tamsulosin + mirabegron group). Increased pulse rate was more frequent with tamsulosin + mirabegron than with tamsulosin + placebo in older patients, although within the normal range.

Conclusions

Cardiovascular‐related adverse events were uncommon in both treatment groups. Mirabegron is a well‐tolerated add‐on therapy to tamsulosin in Japanese and Korean males with residual overactive bladder symptoms.

Alpha-1 Adrenergic Receptor Blockers for the Treatment of Lower Urinary Tract Symptoms in Women: A Systematic Review and Meta-Analysis

PURPOSE

To assess the effectiveness of alpha-1 adrenergic receptor blockers (α1-blockers) in the treatment of female lower urinary tract symptoms (LUTS).

METHODS

A literature search was conducted using the PubMed/MEDLINE, Embase, and Cochrane Library databases. Fourteen studies with 1,319 patients were ultimately included. The study comprised 2 analyses: a comparison of urinary symptom scores, maximal flow rate (Qmax), and postvoid residual (PVR) urine volume before and after α1-blocker administration in 8 prospective, open-label studies and 5 randomized clinical trials (RCTs); and an evaluation of the same variables in α1-blocker and placebo groups in 4 RCTs.

RESULTS

The first meta-analysis showed that, following treatment, patients exhibited statistically significant symptom relief (mean difference [MD], -5.85; 95% confidence interval [CI], -7.71 to -3.99; P<0.00001), increased Qmax (MD, 3.67 mL/sec; 95% CI, 2.76-4.59 mL/sec; P<0.00001), and decreased PVR volume (MD, -28.46 mL; 95% CI, -34.99 to -21.93 mL; P<0.00001). In the second meta-analysis, α1-blockers demonstrated significant symptom relief relative to placebo (MD, -1.60; 95% CI, -2.68 to -0.51; P=0.004). However, no significant differences were observed in Qmax (MD, 0.05 mL/sec; 95% CI, -0.74 to 0.83 mL/sec, P=0.91) and PVR (MD, -8.10 mL; 95% CI, -32.32 to 16.12 mL, P=0.51) between the α1-blocker and placebo groups.

CONCLUSION

These analyses suggest that α1-blockers are effective in the treatment of female LUTS patients. However, the effect of α1-blockers on female LUTS should be assessed according to the underlying cause, and the role of α1-blockers in combination therapy with other drugs should also be investigated.

Efficacy and safety of tamsulosin 0.4 mg single pills for treatment of Asian patients with symptomatic benign prostatic hyperplasia with lower urinary tract symptoms: a randomized, double-blind, phase 3 trial

OBJECTIVE

To verify the efficacy and safety of tamsulosin 0.4 mg and tamsulosin 0.2 mg compared with those of placebo in patients with lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH).

METHODS

A total of 494 patients from multiple centers participated in this double-blind, randomized, phase 3 trial. Eligible patients were randomly assigned to the tamsulosin 0.4 mg group, tamsulosin 0.2 mg group or placebo group. The International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), post-void residual (PVR) urine volume, blood pressure, heart rate and adverse events were compared among the three groups at 4, 8 and 12 weeks.

RESULTS

A total of 494 BPH patients were analyzed. There were no differences in the baseline characteristics among the three groups. After 12 weeks of treatment, total IPSS was improved in the 0.2 mg and 0.4 mg tamsulosin groups; however, the extent of improvement was greater in the 0.4 mg group than in the 0.2 mg group (0.4 mg: -9.59 vs. 0.2 mg: -5.61; least-squares mean difference [95% confidence interval]: -3.95 [-5.01, -2.89], p < .0001). In addition, in the patients with severe symptoms (IPSS ≥20), total IPSS was improved the most in the 0.4 mg group (-11.27 ± 5.00, p < .0001). Qmax and PVR were improved in the 0.4 mg and 0.2 mg groups; however, the differences were not statistically significant between treatment groups. No patients experienced any serious adverse effects in any of the three groups.

CONCLUSIONS

Tamsulosin 0.4 mg and 0.2 mg appear to be superior to placebo treatment, and tamsulosin 0.4 mg is more effective than 0.2 mg in terms of total IPSS improvement. Tamsulosin 0.4 mg has favorable efficacy and tolerability in Asian men with symptomatic BPH. ClinicalTrials.gov Identifier: NCT02390882.

Alpha-blockers with or without phosphodiesterase type 5 inhibitor for treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia: a systematic review and meta-analysis

PURPOSE

Recently, several randomized controlled trials (RCTs) explored the effects of α-blockers with or without phosphodiesterase type 5 inhibitors (PDE5-Is) for lower urinary tract symptoms secondary to benign prostatic hyperplasia (LUTS/BPH). However, the results were inconsistent. We performed this meta-analysis to evaluate the role of combination therapy (α-blockers and PDE5-Is) in patients with LUTS/BPH.

MATERIALS AND METHODS

Databases including PubMed, Cochrane library, Web of Science, and Embase were searched for qualified RCTs. Pooled mean differences (MDs) and odds ratios (ORs) were calculated to measure the effects and adverse events in combination therapy. Moreover, subgroup analyses of ethnicity, dosage of PDE5-Is, treatment duration, and severity of LUTS/BPH were performed. In addition, trial sequential analyses (TSAs) were used to assess whether the evidence for the results was sufficient.

RESULTS

Overall, this study identified 11 eligible RCTs, including 855 LUTS/BPH patients. Patients receiving combination therapy had better improvement in international prostate symptom score (IPSS: MD: 1.66, 95% CI - 3.03 to - 0.29), maximum urinary flow rate (Q_max: MD: 0.94, 95% CI 0.24-1.64), and international index of erectile function (IIEF: MD: 4.73, 95% CI 2.95-6.51), comparing those without PDE5-Is. Besides, subgroup analyses indicated that the effects of combination treatment were associated with ethnicity, treatment duration, and severity of LUTS/BPH. By TSA, the findings in the current study were based on sufficient evidence.

CONCLUSIONS

Our results indicated that combination therapy can significantly improve IPSS, Q_max, and IIEF in patients with LUTS/BPH. Combination therapy might be more suitable for these patients.

Factors affecting the efficacy and safety of phosphodiesterase 5 inhibitor and placebo in treatment for lower urinary tract symptoms: meta-analysis and meta-regression

PURPOSE

We aimed to investigate the real benefit and safety of phosphodiesterase 5 inhibitor (PDE 5I) for benign prostatic hyperplasia/lower urinary tract symptoms (BPH/LUTS) by determining the affecting factors and to overcome the previous meta-analysis studies.

METHODS

We conducted a systematic review of improvements in LUTS using International Prostate Symptom Score (IPSS), voiding subscore of IPSS (voiding IPSS), storage subscore of IPSS (storage IPSS), quality of life (QoL), maximal urinary flow rate (Qmax), and post-voided residual volume (PVR), and also investigated adverse events and relevant withdrawal rate.

RESULTS

Final included studies were 28 studies with 19,820 subjects (9800 treatment group and 10,020 control group). The overall weighted mean differences of total IPSS, voiding IPSS, storage IPSS, and QoL showed significant improvement. Single placebo group showed significant improvement in all outcomes except PVR. The weighted prevalence of overall withdrawal rate and adverse event-specific withdrawal rate was 10 and 3%, respectively. Meta-regression showed that baseline IPSS, dosage of PDE 5I, and country affect clinical improvement compared with placebo.

CONCLUSIONS

This study clarifies the efficacy of PDE 5I on treatment of BPH/LUTS as an initial treatment strategy. However, baseline IPSS, dosage of PDE 5I and country affected the clinical improvement. Moreover, adverse event-specific withdrawal rate was not as high as suspected based on the overall withdrawal rate.

Correlation Between Residual Volume of Male Patients After Uroflowmetry and Random Residual Volume

OBJECTIVES

Our aim was to examine correlation between Post-void residual urine (PVR) after uroflowmetry and random PVR.

METHODS

Male patients reporting to the Urology outpatient clinic with LUTS were selected. Patients' age, prostate volume, bladder capacity, voided volume, maximum flow rate, average flow rate, random PVR and PVR after uroflowmetry were recorded. We evaluated the correlations between these parameters. Also we assessed if there was a difference between random PVR and PVR after uroflowmetry. We divided PVR after uroflowmetry and random PVR into three groups: Group 1: 0-50 mL, Group 2: 51-100 mL and Group 3: >100 mL. Also we divided the patients into two groups according to bladder capacity as Group 1: ≤400 mL and Group 2: >400 mL. We compared these groups to determine whether a significant difference.

RESULTS

Seventy-seven patients applying to the urology outpatient clinic were assessed between 2013 and 2014. PVR after uroflowmetry was significantly higher than random PVR (P < 0.001). When we divided PVR after uroflowmetry and random PVR into three groups there was a significant difference between the groups (P = 0.02). When we divided the patients into two groups according to bladder capacity as Group 1: ≤400 mL and Group 2: >400 mL, PVR after uroflowmetry was different, but random PVR was similar (P < 0.001, P = 0.72).

CONCLUSIONS

PVR after uroflowmetry seems to be incorrectly high in patients whose bladder capacity is above 400 mL.

Evidence Is Enough?: A Systematic Review and Network Meta-Analysis of the Efficacy of Tamsulosin 0.2 mg and Tamsulosin 0.4 mg as an Initial Therapeutic Dose in Asian Benign Prostatic Hyperplasia Patients

Purpose

We compared the efficacy of tamsulosin between 0.2 mg and 0.4 mg in Asian prostatic hyperplasia (BPH) patients using network meta-analysis due to lack of studies with direct comparison.

Methods

The literature search was conducted using the MEDLINE, Embase, and Cochrane Library. Keywords used were “BPH,” “tamsulosin,” “placebo.” Experimental groups were defined as tamsulosin 0.2 mg (Tam 0.2) and 0.4 mg (Tam 0.4) and common control group was defined as placebo for indirect treatment comparison. Mixed treatment comparison was performed including one direct comparison study.

Results

Seven studies met the eligible criteria. Indirect treatment comparison revealed that total International Prostate Symptoms Score (IPSS) and quality of life score of IPSS were not significantly different in Tam 0.2 and Tam 0.4 (P>0.05). There was no significant difference of maximal flow rate and postvoid residual urine volume in Tam 0.2 and Tam 0.4 (P>0.05). Mixed treatment comparison including one direct comparison study showed inconsistency (P<0.001). Therefore, analysis using direct treatment comparison effect sizes of Tam 0.2 vs. placebo and Tam 0.4 vs. placebo was done and there was no significant difference.

Conclusions

Network meta-analysis showed no difference of efficacy between tamsulosin 0.2 mg and 0.4 mg and the evidence of tamsulosin 0.4 mg as initial dose for Asian BPH patient seems to be insufficient. Therefore, initial dose of tamsulosin for Asian BPH patient should be 0.2 mg.