A comparative study of terazosin and tamsulosin for symptomatic benign prostatic hyperplasia in Japanese patients

Comparative efficacy and safety of alpha-blockers as monotherapy for benign prostatic hyperplasia: a systematic review and network meta-analysis

Despite the availability of various drugs for benign prostatic hyperplasia (BPH), alpha(α)-blockers are the preferred first-line treatment. However, there remains a scarcity of direct comparisons among various α-blockers. Therefore, this network meta-analysis (NMA) of randomized controlled trials (RCTs) aimed to evaluate the efficacy and safety of α-blockers in the management of BPH. A comprehensive electronic search covered PubMed, Embase, Ovid MEDLINE, and Cochrane Library until August 2023. The primary endpoints comprised international prostate symptom score (IPSS), maximum flow rate (Qmax), quality of life (QoL), and post-void residual volume (PVR), while treatment-emergent adverse events (TEAEs) were considered as secondary endpoints. This NMA synthesized evidence from 22 studies covering 3371 patients with six kinds of α-blockers with 12 dose categories. IPSS has been considerably improved by tamsulosin 0.4 mg, naftopidil 50 mg and silodosin 8 mg as compared to the placebo. Based on the p-score, tamsulosin 0.4 mg had the highest probability of ranking for IPSS, PVR, and Qmax, whereas doxazosin 8 mg had the highest probability of improving QoL. A total of 297 adverse events were reported among all the α-blockers, silodosin has reported a notable number of TEAEs. Current evidence supports α-blockers are effective in IPSS reduction and are considered safer. Larger sample size with long-term studies are needed to refine estimates of IPSS, QoL, PVR, and Qmax outcomes in α-blocker users.

Efficacy of combination terazosin and nifedipine therapy in postoperative treatment of distal ureteral stones after transurethral ureteroscopic lithotripsy

Objective

Methods

Results

Conclusion

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

PURPOSE

Tamsulosin 0.2 mg is used widely in Asian people, but the low dose has been studied less than tamsulosin 0.4 mg or other alpha blockers of standard dose. This study investigated the efficacy and safety of tamsulosin 0.2 mg by a meta-analysis and meta-regression.

MATERIALS AND METHODS

We conducted a meta-analysis of efficacy of tamsulosin 0.2 mg using International Prostate Symptom Score (IPSS), maximal urinary flow rate (Qmax), post-voided residual volume (PVR), and quality of life (QoL). Safety was analyzed using adverse events. Relevant studies were searched using MEDLINE, EMBASE, and Cochrane library from January 1980 to June 2013.

RESULTS

Ten studies were included with a total sample size of 1418 subjects [722 tamsulosin 0.2 mg group and 696 other alpha-blockers (terazosin, doxazosin, naftopidil, silodosin) group]. Study duration ranged from 4 to 24 weeks. The pooled overall standardized mean differences (SMD) in the mean change of IPSS from baseline for the tamsulosin group versus the control group was 0.02 [95% confidence interval (CI); -0.20, 0.25]. The pooled overall SMD in the mean change of QoL from baseline for the tamsulosin group versus the control group was 0.16 (95% CI; -0.16, 0.48). The regression analysis with the continuous variables (number of patients, study duration) revealed no significance in all outcomes as IPSS, QoL, and Qmax.

CONCLUSION

This study clarifies that tamsulosin 0.2 mg has similar efficacy and fewer adverse events compared with other alpha-blockers as an initial treatment strategy for men with lower urinary tract symptoms.

Rate and associated factors of solifenacin add-on after tamsulosin monotherapy in men with voiding and storage lower urinary tract symptoms

AIM

To explore the rate of add-on therapy with solifenacin in men with voiding and storage lower urinary tract symptoms (LUTS) after tamsulosin monotherapy and to explore predictive factors for starting solifenacin add-on therapy.

METHODS

Men aged ≥ 45 years with IPSS ≥ 12 and symptoms of OAB (OAB-V8 ≥ 8, micturition ≥ 8/24 h, urgency ≥ 2/24 h) were enrolled to receive tamsulosin 0.2 mg once daily. After 4 weeks, men with residual symptoms of OAB and reported 'dissatisfied' or 'a little satisfied' were received solifenacin 5 mg in combination with tamsulosin monotherapy. Subjects completed an IPSS, a Quality of life (QoL) index, OAB V8, and an International Consultation of Incontinence Questionnaire (ICIQ)-Male LUTS, and patient perception of bladder condition (PPBC) at baseline and week 4.

RESULTS

Of a total of 305 patients, 254 patients completed 4 weeks of tamsulosin treatment. For 176 patients, solifenacin was added (69.3%). Significant predictive factors of solifenacin add-on therapy included long LUTS duration, high IPSS, number of micturitions per 24 h, more urgency episodes, high urgency severity score in a voiding diary and high OAB V8 score. Based on multivariable analysis, potential predictive factors of solifenacin add-on therapy included long LUTS duration (OR = 1.008, 95% CI: 1.001-1.014), high serum PSA (OR = 1.543, 95% CI: 1.136-2.095) and small prostate size (OR = 0.970, 95% CI: 0.947-0.994) (p < 0.05). IPSS, daytime micturitions and urgency episodes, OAB V8 scores, ICIQ and PPBC were improved after tamsulosin monotherapy.

CONCLUSIONS

Two thirds of men with voiding and storage LUTS needed to add anticholinergics after 4 weeks of tamsulosin monotherapy. Patients with longer lasting symptoms and storage symptoms with small prostate volume may require the anticholinergic add-on.

General effect of low-dose tamsulosin (0.2 mg) as a first-line treatment for lower urinary tract symptoms associated with benign prostatic hyperplasia: a systematic review and meta-analysis

PURPOSE

In Asian countries, low-dose tamsulosin (0.2 mg) is used widely but this dose has been less popular than 0.4 mg tamsulosin or other types of alpha blockers. The aim of this study was to investigate the efficacy and safety of low-dose tamsulosin by systematic review and meta-analysis.

METHODS

We conducted a meta-analysis of improvements of lower urinary tract symptoms using International Prostate Symptom Score (IPSS), maximal urinary flow rate (Qmax), post-voided residual volume (PVR), and quality of life (QOL). Relevant studies were found using MEDLINE, Embase, and the Cochrane library. Final inclusion was determined by randomized controlled trials (RCT) and performance of IPSS.

RESULTS

A total of fourteen studies were included, with a total sample size of 2147 subjects (1044 experimental and 1103 controls). Study durations ranged from 4 to 52 weeks. The mean change of IPSS improvement from baseline for tamsulosin was -7.18 (95% CI: -7.83, -6.54). The mean change of QOL improvement from baseline was -1.34 (95% CI: -1.46, -1.22). The overall Qmax improvement from baseline was 2.32 ml/sec (95% CI: 1.95, 2.70). The mean change of PVR improvement from baseline was -11.12 ml (95% CI: -17.61, -4.64). Regarding safety, four studies did not report any adverse events while others reported that adverse events were all tolerated.

CONCLUSIONS

Although this study did not consider placebo effect and has high IPSS baseline scores, this study clarifies that low-dose tamsulosin has generally positive effect and safety in treatment of LUTS and could be a suitable option as an initial treatment, especially for patients with low body mass index, as is typical of Asian people.

Persistence with solifenacin add-on therapy in men with benign prostate obstruction and residual symptoms of overactive bladder after tamsulosin monotherapy

AIMS

In spite of the reported efficacy and safety of antimuscarinics in men with OAB (overactive bladder) and BPO (benign prostatic obstruction), many patients do not persist with the treatment. We aimed to evaluate persistence and the reasons for the discontinuation of solifenacin add-on therapy in men with residual symptoms of OAB after tamsulosin monotherapy for BPO in a real clinical environment.

METHODS

Men aged ≥ 45 years with IPSS ≥ 12 and symptoms of OAB (OAB-V8 ≥ 8, micturition ≥ 8/24 h, urgency ≥ 2/24 h) were prescribed tamsulosin 0.2 mg. After 4 weeks, men who had residual symptoms of OAB (OAB-V8 ≥ 8, micturition ≥ 8/24 h, urgency ≥ 1/24 h) and reported that they were 'dissatisfied' or 'a little satisfied' with the therapy were enrolled and prescribed solifenacin 5 mg in combination with tamsulosin. After 52 weeks, persistence and the reasons for the discontinuation of solifenacin were evaluated. Factors related to persistence were analysed.

RESULTS

Of the 305 men who had been treated with tamsulosin, 176 were prescribed solifenacin. After 52 weeks, 44 (25%) remained on solifenacin therapy. Of the 132 who discontinued solifenacin, 85 were evaluated on the reason for discontinuation. The three most common reasons for discontinuation were adverse events (AEs) (35%), lack of efficacy (33%), and improvement in symptoms (16%). The aggravation of voiding symptoms was the most common AE leading to discontinuation. Retention was observed in 11 men. None of the demographical or clinical characteristics were significantly related to persistence.

CONCLUSIONS

Only 25% men with OAB and BPO remained on antimuscarinic add-on therapy after 1 year, mostly because of AEs and lack of efficacy. Realistic data should be added to what is already known about antimuscarinic treatment in men by including patients who were excluded or who dropped out of well-designed clinical trials.

WITHDRAWN: Tamsulosin for benign prostatic hyperplasia

BACKGROUND

Benign prostatic hyperplasia (BPH) is a nonmalignant enlargement of the prostate which can result in bothersome lower urinary tract symptoms. The treatment goal for men with BPH is to relieve these bothersome symptoms.

OBJECTIVES

This systematic review assessed the effects of tamsulosin in the treatment of lower urinary tract symptoms (LUTS) compatible with BPH.

SEARCH STRATEGY

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

SELECTION CRITERIA

Trials were eligible if they (1) randomized men with BPH to receive tamsulosin in comparison with placebo, other BPH medications or surgical interventions and (2) included clinical outcomes such as urologic symptom scales, symptoms, or urodynamic measurements, and (3) had a treatment duration of 30 days or longer. Eligibility was assessed by at least two independent observers.

DATA COLLECTION AND ANALYSIS

Information on patients, interventions, and outcomes were extracted by at least two independent reviewers using a standard form. The main outcome measure for comparing the effectiveness of tamsulosin with placebo, medical or surgical interventions was the change in urologic symptom scale scores. Secondary outcomes included changes in urinary flow measures (peak urine flow rate). The main outcome measure for adverse effects was the number of men reporting adverse effects.

MAIN RESULTS

Fourteen studies involving 4122 subjects met inclusion criteria. Study duration ranged from 4 to 26 weeks, and no placebo-controlled study lasted longer than 13 weeks. The mean age of subjects was 64 years. Baseline symptom scores and urine flow rates demonstrated that men had moderate LUTS. Tamsulosin improved symptoms and peak urine flow relative to placebo. The weighted mean differences (WMD) for mean change from baseline for the Boyarsky symptom score for 0.4 mg and 0.8 mg doses of tamsulosin relative to placebo were -1.1 points (95% CI = -1.49 to -0.72; 12% improvement) and -1.6 points (95% CI = -2.3 to -1.0; 16% improvement), respectively. The WMD for mean change from baseline in peak urine flow were 1.1 mL/sec (95% CI = 0.59 to 1.51) and 1.1 mL/sec (95% CI= 0.65 to 1.48) for 0.4 mg and 0.8 mg, respectively. Tamsulosin (0.2 mg to 0.4 mg) was as effective as other alpha antagonists and the phytotherapeutic agent Permixon® in improving symptoms and flow rates though the doses of all alpha-antagonists studied may not have been optimal. Discontinuations from treatment for any reason and discontinuations "due to adverse events" were similar in the low dose tamsulosin (0.2 mg) and placebo groups but increased to 16% in trials utilizing a 0.8 mg dose of tamsulosin. Low dose tamsulosin was generally well tolerated although not all the trials reported specific adverse events. The most frequently reported adverse events that were significantly greater than placebo included dizziness, rhinitis and abnormal ejaculation. Adverse effects increased markedly as tamsulosin dosing increased, and were reported in 75% of men receiving the 0.8 mg dose. Men receiving a 0.2 mg dose tamsulosin were less likely to discontinue treatment compared to men receiving terazosin.

AUTHORS' CONCLUSIONS

Tamsulosin provided a small to moderate improvement in urinary symptoms and flow compared to men receiving placebo in men with BPH. Effectiveness was similar to other alpha antagonists and increased only slightly with higher doses. Long term effectiveness and ability to reduce complications due to BPH progression could not be determined. Adverse effects were generally mild but their frequency, including withdrawals, increased substantially with the higher doses that are generally available for treatment.

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.

Efficacy of combination therapy with tamsulosin and zolpidem on nocturia in patients with benign prostatic hyperplasia

Introduction

We examined the efficacy of combination therapy with α1-blocker tamsulosin and hypnotic zolpidem in patients who had suffered from sleep disturbance associated with nocturia.

Material and methods

A total of 35 patients diagnosed with nocturia with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) were studied. After treatment with tamsulosin for 4 weeks, 16 patients dissatisfied with nocturia (nocturiaquality of life index ≥4) and suspected to have sleep disturbance (Athens Insomnia Scale ≥6) received additional treatment with tamsulosin and zolpidem for 2 weeks. Outcomes were evaluated by the International Prostate Symptom Score (IPSS) and quality of life index (QOL), Athens Insomnia Scale (AIS) and nocturia-quality of life index (nocturia-QOL).

Results

After monotherapy with tamsulosin, significant reductions in IPSS (18.9 ±3.8 to 9.9 ±3.0, p <0.001), QOL (4.5 ±0.9 to 3.2 ±0.9, p <0.001) and nocturia episodes (3.4 ±0.7 to 2.6 ±1.0, p <0.001) were observed. However 20 patients were dissatisfied with nocturia (nocturia- QOL ≥4). Among 20 patients, 16 patients were suspected to have sleep disturbances (AIS ≥6). In these patients, additional therapy with tamsulosin and zolpidem significantly reduced nocturia episodes (3.3 ±0.8 to 1.9 ±0.7, p <0.001), AIS (10.6 ±2.9 to 6.8 ±25, p <0.001) and nocturia – QOL (5.6 ±0.5 to 3.6 ±1.1, p <0.001) compared with patients after treatment with tamsulosin only.

Conclusions

Combination therapy with tamsulosin and zolpidem may be useful for patients with BPH dissatisfied with nocturia and suspected to have sleep disturbance.

Tamsulosin versus terazosin for benign prostatic hyperplasia: a systematic review

The effectiveness and safety of tamsulosin and terazosin for patients with benign prostatic hyperplasia (BPH) was evaluated by literature review. PubMed, Embase, the Cochrane Library, Chinese biomedicine literature database (CBM), reference lists of reports, and reviews were searched for randomized controlled trials (RCTs), or quasi-RCTs of tamsulosin versus terazosin in BPH. Twelve studies involving 2,816 men were included. Outcomes included international prostate symptom score (IPSS), quality of life (QOL), maximum urinary flow rate (Q(max)), average urinary flow rate (Q(ave)), residual volume, prostate volume, and adverse effect (dizziness, severe hypotension, dry mouth). Relative risk was calculated for dichotomous data. Sensitivity analyses assessed the influence of baseline symptom severity. We found that tamsulosin is better than terazosin when assessed by IPSS (weighted mean difference (WMD)=-1.24 95% CI [- 1.98, -0.51], there was no significant difference between the two groups in QOL (WMD=0.04 95% CI [-0.16, 0.24]), Qmax (WMD=-0.38 95% CI [-1.18, 0.41]), Q(ave) (WMD=-0.39 95% CI [- 0.84, 0.06]), residual volume (WMD=-4.32 95% CI [-10.96, 2.33]), and prostate volume (WMD=-0.28 95% CI [- 3.37, 2.81]). Fewer patients receiving tamsulosin experienced dizziness (relative risk (RR) -0.38 95% CI [0.30, 0.48]), severe hypotension (RR=0.16 95% CI [0.04, 0.68]), and dry mouth (RR=0.14 95% CI [0.03, 0.77]), compared with patients receiving terazosin. Many of the high quality RCTs showed beneficial effects of tamsulosin in terms of improving IPSS. However, whether tamsulosin proves more efficacious than terazosin in long term therapy requires confirmation by additional large sample, high quality trials.

The effect of alpha-blocker therapy on erectile functions in patients with lower urinary tract symptoms due to benign prostate hyperplasia

In this study we aimed to evaluate the impact of doxazosin treatment on erectile functions in patients with lower urinary tract symptoms (LUTS) and having erectile dysfunction (ED) at baseline. Fifty-three patients with LUTS (IPSS score > 7) whose maximum flow rate (Q(max)) < 15 mL s(-1) and PSA < 4 ng dL(-1) were enrolled in the study. Patients received doxazosin 4 mg once daily for 6 weeks. Subjective efficacy was assessed by IPSS, IPSS-Quality of Life (IPSS-QoL) for LUTS and efficacy was assessed by International Index of Erectile Function (IIEF) for erectile functions at baseline and sixth weeks. The objective efficacy was assessed by Q(max). The patients were classified according to their self reported erectile status: group I had ED and group II did not have ED. At the endpoint, doxazosin significantly improved the total IPSS score (-7.7 +/- 6.1, P = 0.006), IPSS-QoL score (-1.5 +/- 1.5, P = 0.024) and Q(max) (3.2 +/- 4.6 mL s(-1), P = 0.002) over baseline. Mean decrease in IPSS and IPSS-QoL scores after the treatment period were 6.9 +/- 6.4 (P < 0.001) and 0.95 +/- 1.80 (P < 0.05) in group I, whereas 8.2 +/- 5.8 (P < 0.001) and 1.9 +/- 1.1 in group II (P < 0.001), respectively. Mean changes of Q(max) values were 2.3 +/- 3.3 mL s(-1) in group I (P < 0.05) and 3.7 +/- 5.3 mL s(-1) in group II (P < 0.001). The improvement of IIEF-EF scores after the treatment period was only significant for group I. The efficacy of alpha-blocker therapy for LUTS was better by means of symptomatic relief for patients who did not have ED when compared with patients who had ED at baseline. However, slight improvement in erectile functions with alpha-blocker therapy was only seen in LUTS patients with ED.

Effects of tamsulosin on bladder blood flow and bladder function in rats with bladder outlet obstruction

OBJECTIVES

To investigate the mechanism underlying the ameliorating effect of tamsulosin, an alpha(1)-adrenoceptor antagonist, on storage symptoms associated with benign prostatic hyperplasia, the effects of tamsulosin on bladder blood flow (BBF) and bladder function was evaluated in rats with bladder outlet obstruction (BOO).

METHODS

BOO was produced by partial ligature of the proximal urethra, which was maintained for 2 weeks. Tamsulosin was subcutaneously administered via an osmotic pump for 2 weeks immediately after the BOO surgery. The BBF in the sham-operated rats, the control BOO rats, and the tamsulosin-treated BOO rats was measured using the fluoromicrosphere method. Each rat was kept in a metabolic cage for observation of micturition behavior. Expression of the alpha(1)-adrenoceptor subtype mRNA in the vesical artery was measured by reverse transcriptase-polymerase chain reaction.

RESULTS

BBF was significantly reduced in BOO rats compared with sham-operated rats, and tamsulosin significantly increased the BBF in BOO rats. Tamsulosin ameliorated the decrease in mean voided volume in BOO rats with bladder masses < 500 mg. Expression of the alpha(1)-adrenoceptor subtype in the vesical artery was alpha(1a)- > alpha(1d)-adrenoceptors; almost no expression was observed of alpha(1b)-adrenoceptors in either sham-operated or BOO rats.

CONCLUSIONS

Tamsulosin increased BBF in BOO rats via an antagonistic effect, presumably on the alpha(1A)- and/or alpha(1D)-adrenoceptor in the vesical artery mainly, and improved the decrease in mean voided volume. Therefore, the results of this study suggest that tamsulosin improves bladder overactivity via improvement of BBF.

Effects of dietary flaxseed lignan extract on symptoms of benign prostatic hyperplasia

A flaxseed lignan extract containing 33% secoisolariciresinol diglucoside (SDG) was evaluated for its ability to alleviate lower urinary tract symptoms (LUTS) in 87 subjects with benign prostatic hyperplasia (BPH). A randomized, double-blind, placebo-controlled clinical trial with repeated measurements was conducted over a 4-month period using treatment dosages of 0 (placebo), 300, or 600 mg/day SDG. After 4 months of treatment, 78 of the 87 subjects completed the study. For the 0, 300, and 600 mg/day SDG groups, respectively, the International Prostate Symptom Score (IPSS) decreased -3.67 +/- 1.56, -7.33 +/- 1.18, and -6.88 +/- 1.43 (mean +/- SE, P = .100, < .001, and < .001 compared to baseline), the Quality of Life score (QOL score) improved by -0.71 +/- 0.23, -1.48 +/- 0.24, and -1.75 +/- 0.25 (mean +/- SE, P = .163 and .012 compared to placebo and P = .103, < .001, and < .001 compared to baseline), and the number of subjects whose LUTS grade changed from "moderate/severe" to "mild" increased by three, six, and 10 (P = .188, .032, and .012 compared to baseline). Maximum urinary flows insignificantly increased 0.43 +/- 1.57, 1.86 +/- 1.08, and 2.7 +/- 1.93 mL/second (mean +/- SE, no statistical significance reached), and postvoiding urine volume decreased insignificantly by -29.4 +/- 20.46, -19.2 +/- 16.91, and -55.62 +/- 36.45 mL (mean +/- SE, no statistical significance reached). Plasma concentrations of secoisolariciresinol (SECO), enterodiol (ED), and enterolactone (EL) were significantly raised after the supplementation. The observed decreases in IPSS and QOL score were correlated with the concentrations of plasma total lignans, SECO, ED, and EL. In conclusion, dietary flaxseed lignan extract appreciably improves LUTS in BPH subjects, and the therapeutic efficacy appeared comparable to that of commonly used intervention agents of alpha1A-adrenoceptor blockers and 5alpha-reductase inhibitors.

High-dose terazosin therapy (5mg) in Korean patients with lower urinary tract symptoms with or without concomitant hypertension: a prospective, open-label study

PURPOSE

We determined the efficacy and safety of a relatively high dose of terazosin (5mg) in Korean patients with lower urinary tract symptoms (LUTS), with or without concomitant hypertension.

MATERIALS AND METHODS

From July to December 2006, 200 men who consecutively presented with LUTS were prospectively studied. Eight weeks after treatment, blood pressure (BP), uroflowmetry, and International Prostate Symptom Score (I-PSS) were assessed. For analysis purposes, patients were stratified according to concomitant hypertension. Of the 200 patients, 173 completed the scheduled eight-week treatment period.

RESULTS

At baseline, no differences were evident in the two groups in terms of I-PSS, Qmax, PVR and BP. After eight weeks of treatment-although I-PSS and uroflowmetry parameters were not significantly different in the two groups-systolic and diastolic BP in the non-hypertensive control group were higher than in the hypertensive group (p= 0.001 and p=0.0100, respectively). Changes in I-PSS, uroflowmetry parameters, and BPs measured at week eight post- treatment commencement did not significantly differ between the two groups. Moreover, the addition of 5mg of terazosin to antihypertensives did not cause a significant reduction in either systolic or diastolic BP in either group.

CONCLUSION

Adding terazosin to existing antihypertensive regimens did not seem to increase the incidence of adverse events. Our findings suggest that 5mg terazosin is effective and that it has an acceptable safety profile as an add-on therapy for patients with LUTS and concomitant hypertension.

Zolpidem pharmacotherapy combined with alpha-blocker therapy for nocturia unresponsive to alpha-blocker monotherapy in men with lower urinary tract symptoms: a preliminary study

AIM

The aim of the present study was to determine whether administration of zolpidem, a nonbenzodiazepine sedative-hypnotic agent, at night would improve the frequency of nocturia unresponsive to alpha-blocker monotherapy in men with lower urinary tract symptoms (LUTS).

MATERIALS AND METHODS

The study inclusion criteria were: age >/=50 years, nocturia twice or more per night (International Prostate Symptom Score [IPSS] question 7) after taking alpha-blockers for more than eight weeks, and incomplete frequency-flow chart (FVC). A total of 18 patients met the criteria and constituted the study cohort. Three patients were given 0.2 mg tamsulosin once daily and others were given 4 mg terazosin once daily. All patients were additionally administered 10 mg zolpidem once at night for the eight weeks.

RESULTS

There were no serious side-effects in any patient. Nocturia decreased from a baseline median (25-75th percentiles) of 3 (3-5) to 3 (3-4.5) episodes after taking alpha-blockers (p = 0.129) and to 2 (1-3) episodes after taking zolpidem and alpha-blockers (p = 0.001) on the IPSS. After treatment, the scores of uroflowmetry values did not significantly changed. However, at eight weeks, voiding symptoms (p = 0.041) and total IPSS scores (p = 0.028) significantly decreased compared with those at baseline. Median (25-75th percentiles) quality-of-life (QoL) index changed from 5 (4-5) at baseline to 3 (3-3) after eight weeks of treatment (p = 0.005).

CONCLUSION

Our results indicate that zolpidem resulted in a subjective reduction in nocturia episodes when given to some men with LUTS.

Efficacy and safety of tamsulosin hydrochloride compared to doxazosin in the treatment of Indonesian patients with lower urinary tract symptoms due to benign prostatic hyperplasia

AIM

The objective of the study was to compare the efficacy and safety of tamsulosin hydrochloride and doxazosin in patients with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH).

METHODS

The safety and efficacy of tamsulosin (0.2 mg) and doxazosin (2 mg) was determined after once daily administration for 6 weeks in an open-label, randomized, multicenter study of 101 men with BPH. The International Prostatic Symptom Score (IPSS), maximal urinary flow rates (Qmax), average urinary flow rates (Qave) and residual urine were determined at baseline and again at 6 weeks as efficacy parameters. The primary parameters used for safety evaluation were vital signs (blood pressure and heart rate) and adverse events. The number of patients with a clinically significant response to treatment with tamsulosin or doxazosin was determined and defined as those with >20% improvement from the baseline Qmax or >20% decrease in total IPSS.

RESULTS

The total IPSS decreased significantly in both the tamsulosin and doxazosin groups compared to baseline. There was a significant difference in the decrease in total IPSS between two groups. Qmax, Qave and residual urine significantly improved only in the tamsulosin group. There were no significant differences in systolic blood pressure, diastolic blood pressure or heart rate profile in the tamsulosin group; however, doxazosin resulted in a significant difference in systolic and diastolic blood pressure. Tamsulosin was well tolerated; only three patients (6%) in the tamsulosin group reported an adverse event (dizziness) while 11 patients (22%) in the doxazosin group reported an adverse event (dizziness), one of whom withdrew from the study.

CONCLUSIONS

Tamsulosin was shown to be more effective than doxazosin in the treatment of LUTS due to BPH.

alpha-blocker monotherapy in the treatment of nocturia in men with lower urinary tract symptoms: a prospective study of response prediction

OBJECTIVE

To determine the efficacy of an alpha-adrenoceptor antagonist, terazosin, in reducing nocturia in men with lower urinary tract symptoms (LUTS), and to identify the factors predicting treatment outcome.

PATIENTS AND METHODS

In all, 100 patients were treated with 2 mg of terazosin once daily for the first 7 days, and continued to receive 4 mg of terazosin once daily for the following 3 weeks. The men were assessed at baseline and at the end of treatment using uroflowmetry, the International Prostate Symptom Score (IPSS), and the degree of nocturia estimated from a frequency-volume chart (FVC) and objectively.

RESULTS

On the FVC, 27 patients reported that the terazosin treatment reduced their nocturia by more than half, and 14 reported a reduction of 25-49%. On the IPSS, 31 patients reported that the treatment reduced their nocturia by more than half and 27 reported a reduction of 25-49%. On multivariate regression analysis, only the actual number of nightly voids on the FVC was associated with a 2.1-fold chance of an improvement of >25% in objective nocturia (P = 0.016). Using a comparable model, a greater nocturia score on the IPSS was associated with a higher likelihood of improvement in subjective nocturia (odds ratio, 1.653; 95% confidence interval, 1.079-2.533; P = 0.021).

CONCLUSION

Treatment with terazosin can reduce patients' episodes of nocturia both subjectively and objectively in some men with LUTS. Our results suggest that both subjective and objective numbers of nocturia episodes are associated with improvements in subjective and objective nocturnal frequencies, respectively.

Combination of a cholinergic drug and an alpha-blocker is more effective than monotherapy for the treatment of voiding difficulty in patients with underactive detrusor

AIM

The aim of the present study was to compare the effectiveness of a cholinergic drug, an alpha-blocker and combinations of the two for the treatment of underactive detrusor.

METHODS

One hundred and nineteen patients with underactive bladder were assigned to three groups: the cholinergic group, consisting of 40 patients taking bethanechol chloride (60 mg/day) or distigmine bromide (15 mg/day); the alpha-blocker group, consisting of 38 patients taking urapidil (60 mg/day); and the combination group, consisting of 41 patients taking both a cholinergic drug and an alpha-blocker. The effectiveness of each therapy was assessed 4 weeks after initialization of the therapy.

RESULTS

Total urinary symptom scores (International Prostate Symptom Score, IPSS) remained unchanged after the cholinergic therapy, but were significantly lower after the alpha-blocker treatment (P = 0.0001) and the combination therapy (P = 0.0001). With regard to the total IPSS, there were significant differences between the cholinergic and the alpha-blocker groups (P = 0.0008), and also between the cholinergic and combination groups (P = 0.0033), in favor of the latter. The average and maximum flow rates did not increase significantly after monotherapy with either the cholinergic drug or the alpha-blocker, but they significantly increased after combination therapy compared to baseline values (P = 0.0033 and P= 0.0004, respectively). Postvoid residual volume did not decrease significantly after the cholinergic drug therapy, but decreased significantly after the alpha-blocker (P = 0.0043) and the combination therapies (P = 0.0008). The percentage of residual urine decreased significantly after therapy in all groups (P = 0.0005, P= 0.0176 and P= 0.0001, respectively).

CONCLUSION

Combination therapy with a cholinergic drug and an alpha-blocker appears to be more useful than monotherapy for the treatment of underactive detrusor.

Alpha-blocker test: Alternative to pressure-flow study of bladder outlet obstruction and detrusor contractility in patients without an enlarged prostate

OBJECTIVES

We investigated whether the cause of urinary disturbance in men with a prostate volume < or =20 mL can be determined by analyzing the efficacy of alpha1-adrenoceptor antagonist (alpha-blocker) treatment.

METHODS

Thirty-five men who were >50 years of age, with an International Prostate Symptom Score (IPSS) > or =8 points, a quality of life (QOL) index > or =2 points and a prostate volume </=20 mL were enrolled in the non-enlarged prostate group. Twenty-six men who met the above conditions but who had a prostate volume >20 mL served as controls. The alpha1-adrenoceptor antagonist tamsulosin was administered at a dose of 0.2 mg/day for 4 weeks. Results for the IPSS, QOL index, free flowmetry and pressure-flow studies were obtained before and after tamsulosin administration.

RESULTS

In both groups, tamsulosin improved the IPSS and QOL index and the bladder outlet obstruction index (BOOI) was lowered without reducing the bladder contractility index (BCI). No parameter showed a significant difference in treatment efficacy between the two groups. In the non-enlarged prostate group, both the pretreatment BOOI and BCI correlated with the efficacy of treatment in improving maximum flow rate (Qmax). In the enlarged prostate group, BOOI and BCI did not correlate with Qmax. When Qmax was improved by > or =3.5 mL/s, the positive predictive value for both pretreatment BOOI >40 and BCI >100 was 100% in the non-enlarged prostate group.

CONCLUSIONS

The alpha-blocker test is one method to assess the presence of bladder outlet obstruction and the state of detrusor contractility in men without an enlarged prostate.

Tamsulosin for benign prostatic hyperplasia

BACKGROUND

Benign prostatic hyperplasia (BPH) is a nonmalignant enlargement of the prostate which can result in bothersome lower urinary tract symptoms. The treatment goal for men with BPH is to relieve these bothersome symptoms.

OBJECTIVES

This systematic review assessed the effects of tamsulosin in the treatment of lower urinary tract symptoms (LUTS) compatible with BPH.

SEARCH STRATEGY

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

SELECTION CRITERIA

Trials were eligible if they (1) randomized men with BPH to receive tamsulosin in comparison with placebo, other BPH medications or surgical interventions and (2) included clinical outcomes such as urologic symptom scales, symptoms, or urodynamic measurements, and (3) had a treatment duration of 30 days or longer. Eligibility was assessed by at least two independent observers.

DATA COLLECTION AND ANALYSIS

Information on patients, interventions, and outcomes were extracted by at least two independent reviewers using a standard form. The main outcome measure for comparing the effectiveness of tamsulosin with placebo, medical or surgical interventions was the change in urologic symptom scale scores. Secondary outcomes included changes in urinary flow measures (peak urine flow rate). The main outcome measure for adverse effects was the number of men reporting adverse effects.

MAIN RESULTS

Fourteen studies involving 4,122 subjects met inclusion criteria. Study duration ranged from 4-26 weeks, and no placebo-controlled study lasted longer than 13 weeks. The mean age of subjects was 64 years. Baseline symptom scores and urine flow rates demonstrated that men had moderate LUTS. Tamsulosin improved symptoms and peak urine flow relative to placebo. The weighted mean differences (WMD) for mean change from baseline for the Boyarsky symptom score for 0.4 mg and 0.8 mg doses of tamsulosin relative to placebo were -1.1 points (95% CI = -1.49, -0.72; 12% improvement) and -1.6 points (95% CI = -2.3, -1.0; 16% improvement), respectively. The WMD for mean change from baseline in peak urine flow were 1.1 mL/sec (95% CI = 0.59, 1.51) and 1.1 mL/sec (95% CI= 0.65, 1.48) for 0.4 mg and 0.8 mg, respectively. Tamsulosin (0.2 mg-0.4 mg) was as effective as other alpha antagonists and the phytotherapeutic agent Permixon in improving symptoms and flow rates though the doses of all alpha-antagonists studied may not have been optimal. Discontinuations from treatment for any reason and discontinuations "due to adverse events" were similar in the low dose tamsulosin (0.2 mg) and placebo groups but increased to 16% in trials utilizing a 0.8 mg dose of tamsulosin. Low dose tamsulosin was generally well tolerated although not all the trials reported specific adverse events. The most frequently reported adverse events that were significantly greater than placebo included dizziness, rhinitis and abnormal ejaculation. Adverse effects increased markedly as tamsulosin dosing increased, and were reported in 75% of men receiving the 0.8 mg dose. Men receiving a 0.2 mg dose tamsulosin were less likely to discontinue treatment compared to men receiving terazosin.

REVIEWER'S CONCLUSIONS

Tamsulosin provided a small to moderate improvement in urinary symptoms and flow compared to men receiving placebo in men with BPH. Effectiveness was similar to other alpha antagonists and increased only slightly with higher doses. Long term effectiveness and ability to reduce complications due to BPH progression could not be determined. Adverse effects were generally mild but their frequency, including withdrawals, increased substantially with the higher doses that are generally available for treatment.

Evidence-based meta-analysis of pharmacotherapy for benign prostatic hypertrophy

Evidence-based diagnosis and treatment have been proposed recently in various medical fields. Evidence-based diagnostic and therapeutic guidelines for benign prostatic hypertrophy (BPH), one of the most common urological diseases, have been proposed in foreign countries. This paper examines common therapeutic drugs for BPH in Japan from the viewpoint of evidence-based medicine (EBM). The term 'BPH' and drugs indicated for BPH were used as key words to search related articles in the PubMed website. A total of 813 articles extracted as of October 2001 were examined. The articles were ranked in levels ranging from I-V, where Level I indicated a large randomized controlled trial and Level V indicated a non-controlled case accumulation study. Among the 813 articles extracted, 132 clinical articles were suitable for evaluation. There were many reliable articles on the effectiveness of alpha-blockers. However, it seemed necessary to examine further how to choose the optimum alpha-blocker for each clinical case and the combination of antiandrogen drugs with alpha-blockers. It was also considered necessary to evaluate the effectiveness of drugs, such as eviprostat and hachimi-jio-gan, that are available only in Japan. The present study evaluated the effectiveness of commonly available therapeutic drugs for BPH in Japan from a viewpoint of EBM.

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.

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.

Changing therapeutic regimens in benign prostatic hyperplasia. Clinical and economic considerations

About one-quarter of men aged 50 years and older experience voiding problems due to benign prostatic hyperplasia (BPH). Until about 10 years ago, surgery (particularly transurethral resection of the prostate) was the only effective treatment for symptomatic BPH. Over the last decade, several new treatments have been introduced. These include different types of medication (alpha-blockers and finasteride), thermotherapy, laser prostatectomy, needle ablation and vaporisation methods. The diffusion of these less invasive treatment modalities has resulted not only in a decrease in the age-adjusted surgery rates, but also in an increase of the total number of men treated for BPH. A large number of studies on clinical benefits and risks reveal that the conventional types of surgery remain the most effective treatments, whereas new interventional therapies require a shorter hospital stay and result in fewer short term complications. The efficacy of medication is lower than that of interventional treatments. Adverse effects include dizziness and orthostatic hypotension (alpha-blockers) and decreased sexual function (finasteride), but are generally mild. There is some evidence that medication and minimally invasive treatments may preclude eventual surgical treatment, but the precise effect is difficult to estimate because of differences in the study populations and the relatively short study periods. As a result of the dynamic nature of BPH treatment and the lack of long term data, the cost effects of the introduction of the various new treatments are also difficult to assess. Given the aging of the population and the growing percentage of patients with BPH for whom any type of treatment can be considered, a considerable increase of total costs can be expected. Long term prospective studies are necessary to gain insight into the most cost-effective treatment for different patient groups.