Multicentre controlled trial of indoramin in the symptomatic relief of benign prostatic hypertrophy

Recent advances in the identification of a 1- and a 2-adrenoceptor subtypes: therapeutic implications

The cloning of multiple subtypes of both alpha1- and alpha2-adrenoceptors has renewed interest in the therapeutic application of agents interacting with these receptors. Effort has primarily been directed towards the design of uroselective alpha1-adrenoceptor antagonists for the treatment of benign prostatic hyperplasia (BPH). Evidence is accumulating for the involvement of a novel alpha1-adrenoceptor, designated as alpha1L-adrenoceptor, in alpha1-adrenoceptor-mediated smooth muscle contraction in prostatic and other urogenital tissues. While several antagonists showing a high degree of uroselectivity in animal models have been identified, their clinical superiority over the currently available alpha1-adrenoceptor antagonists has not yet been demonstrated. It is possible that the interaction with alpha1-adrenoceptors, as yet uncharacterised subtypes, at non-prostatic sites contributes to the therapeutic activity of this drug class in BPH. The alpha1-adrenoceptor subtypes involved in the control of vascular tone are currently being evaluated, and the profile of interaction with the various alpha1-adrenoceptor subtypes may play a key role in the efficacy of cardiovascular drugs such as carvedilol. Alpha2-adrenoceptor agonists are now being employed for a variety of therapeutic applications, most involving actions on receptors within the central nervous system (CNS). These agents are useful in the treatment of hypertension, glaucoma, opiate withdrawal and attention deficit hyperactivity disorder (ADHD), and as analgesics and adjuncts to general anaesthesia. While subtype selectivity has not yet been applied to the design of new alpha2-adrenoceptor agonists for these applications, recent gene mutation/knock-out experiments have identified the alpha2-subtypes involved in some of these actions, and optimisation of a therapeutic profile may be possible. Furthermore, the design of agents combining affinities for multiple adrenoceptor subtypes, or the combination of a specific adrenoceptor affinity profile with another pharmacological action, may offer advantages over molecules selective for an individual adrenoceptor subtype.

Comparative efficacy of two alpha-adrenoreceptor antagonists, doxazosin and alfuzosin, in patients with lower urinary tract symptoms from benign prostatic enlargement

OBJECTIVES

To compare doxazosin and alfuzosin in patients with moderate to severe lower urinary tract symptoms (LUTS) suggestive of bladder outlet obstruction.

PATIENTS AND METHODS

In all, 210 men with LUTS were randomized to receive doxazosin 1-8 mg once daily or alfuzosin 5-10 mg divided in two or three daily doses in a 14-week, multicentre, double-blind, baseline-controlled, dose-titration study. The International Prostate Symptom Score (IPSS) and maximum urinary flow rate were used to assess the efficacy of the treatment.

RESULTS

At study completion, the mean dose of doxazosin was 6.1 mg/day and alfuzosin 8.8 mg/day. The least squares mean (se) change from baseline in total IPSS was -9.23 (0.6) for doxazosin and -7.45 (0.6) (both P < 0.001) for alfuzosin. The respective mean change from baseline in irritative symptoms was -3.5 (0.2) and -2.8 (0.3) (both P < 0.001). The differences between the treatment groups were statistically significant in favour of doxazosin (total IPSS, P = 0.036; irritative symptoms, P = 0.049). The improvement between groups was also significantly different for postvoid residual urine volume, at -29.19 (8.6) and + 9.59 (8.9) mL for doxazosin and alfuzosin, respectively (P = 0.002). Improvements in mean and maximum urinary flow rates were similar for both treatments, at + 1.5 and + 1.2, and + 2.8 and + 2.5 mL/s, respectively. Doxazosin and alfuzosin were both well tolerated, with most all-cause adverse events reported as mild or moderate.

CONCLUSIONS

The mean doses of doxazosin and alfuzosin used in this study were not equipotent. Doxazosin 6.1 mg/day produced significantly greater improvements than alfuzosin 8.8 mg/day in total and irritative urinary symptom scores and postvoid residual urine volume in men with moderate to severe LUTS. Changes in maximum and mean flow rates were comparable. Doxazosin and alfuzosin were both well tolerated.

Current concepts in the pharmacotherapy of benign prostatic hyperplasia

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

Drug or symptom-induced depression in men treated with alpha 1-blockers for benign prostatic hyperplasia? A nested case-control study

PURPOSE

Regulatory authorities have raised concern that alpha 1-blockers, prescribed predominantly for benign prostatic hyperplasia (BPH), may be associated with an increased risk of depression. The aim was to assess the risk of depression with alpha 1-blockers independently of that associated with symptoms being treated and concurrent illness.

METHODS

Using a study population registered on the UK General Practice Research Database, and taking a prescription for an antidepressant as a proxy for clinical depression, we performed: (a) cohort analyses comparing the incidence of depression in current users of alpha 1-blockers versus non-users, and in men with BPH versus those without. (b) A nested case-control analysis looking at the association between depression and alpha 1-blocker exposure, accounting for the presence of BPH and other illness.

RESULTS

In the cohort analyses, risk of depression was significantly higher in men with BPH compared to those without (IRR 2.17, 2.12-2.22), but was not significantly different for men exposed to alpha 1-blockers versus those unexposed when adjusted for the presence of BPH. Cases of depression were more likely to have pre-existing BPH (crude OR 2.09, 2.02-2.15) than controls. After adjusting for concurrent illness (using number of GP visits as a proxy) and the presence of BPH (adjusted OR 1.38, 1.33-1.43), there was no association with depression for exposure to any alpha 1-blocker (adjusted OR 1.03, 0.90-1.18).

CONCLUSIONS

This study did not suggest that the prescribing of alpha 1-blockers increases the risk of being depressed. The association highlighted by spontaneous reporting systems appears to be explained by confounding by concurrent disease.

Alpha-1 adrenoceptor blockade: potential new treatment for anal fissures

PURPOSE

Patients with chronic anal fissures are known to have high resting anal pressures that return to normal after successful surgical treatment. Internal anal sphincter activity is increased by sympathetic excitatory innervation via alpha adrenoceptors. The objective of this study was to determine the effect of alpha-1 adrenoceptor blockade on anal sphincter pressure in patients with and without chronic anal fissures.

METHODS

The effect on the anal canal pressure profile of a single oral 20 mg dose of indoramin, an alpha-1 adrenoceptor antagonist, on seven patients with chronic anal fissure and six healthy patients without a fissure was investigated.

RESULTS

Indoramin reduced anal resting pressures in those with anal fissure by a mean of 35.8 percent, from 106.9 +/- 22.15 cm H2O to 68.6 +/- 20.35 cm H2O, and in those without anal fissure by a mean of 39.9 percent, from 84.17 +/- 27.46 cm H2O to 52.17 +/- 24.78 cm H2O, after one hour. This pressure reduction persisted at three hours, and its magnitude is comparable to that obtained after internal sphincterotomy. The pressure reduction occurred over the whole length of the anal canal.

CONCLUSION

It is proposed that alpha-1 adrenoceptor antagonists could be a suitable treatment for chronic anal fissure and other painful conditions where reduction in anal pressure is warranted.

[Prostatic benign hypertrophy: review of effectiveness, tolerance, and impact on quality of life of prolonged treatment with alfuzosin]

OBJECTIVES

To evaluate the effectiveness of Alfuzosin in terms of long term effect in BHP patients. To analyze the effectiveness according to the observer, the treatment compliance and the tolerance of alfuzosin, and specifically, cardiovascular and sexually adverse events. Also, to define the clinical profile of the BPH patients that spontaneously seek medical treatment in Spain.

DESIGN OF THE STUDY

Observational, descriptive, multicentric and 6-month retrospective study. DATA SOURCES AND COLLECTION: From the patient reports of BPH patients treated with alfuzosin during more than 6 months, data gathered were, along with usually anamnesic data and physical exploration (age, symptoms, blood pressure, e.g.), those related to treatment response, effectiveness, compliance and tolerance of Alfuzosin in the first and second quarter. Data of the 1635 patients initially recruited were considered to define the clinical profile of this population. Effectiveness and tolerance analysis were undertaken with the 911 patients who followed the treatment during the 6-month study.

RESULTS

After 6 months of treatment an improvement of the mean intensity of each of the urinary symptoms were statistically significant (p < 0.005). Also, the mean score of each of the analyzed variables and of the I-PSS global score were reduced significantly (p < 0.005). After 6 months of treatment the effectiveness evaluated by the observer was good or very good for the 88.5% of the patients. Treatment compliance was very good; from the 911 patients finishing the study, 96.4% continued with the initially prescribed treatment. Just 16 patients (3%) developed adverse events; measures undertaken were to modify the dosage or to interrupt the treatment (2 cases). The specific study of cardiovascular adverse events showed a mild reduction in the systolic (142 mmHg versus 137.86 mmHg) and diastolic blood pressure (83.53 mmHg) versus 80.72 mmHg), and the heart rate (76.80 l/m versus 76.04 l/m). The mean score of sexual life showed an improvement in all the items studied, although very slight.

CONCLUSIONS

The usefulness, effectiveness and tolerance of a long term treatment with alfuzosin in HPB patients was confirmed. Alfuzosin is considered a first choice treatment in patients with the clinical profile described.

Sexual dysfunction in patients with benign prostatic hyperplasia

Two of the most common problems presenting to urologists are benign prostatic hyperplasia and sexual dysfunction, with an increasing number of patients presenting for treatment as a result of the proliferation of less invasive therapies. How such therapies for lower urinary tract symptoms affect sexual function in men is important to both urologists and their patients, and is the focus of this review.

Long-term treatment of benign prostatic hyperplasia with alfuzosin: a 24-30 month survey. BPHALF Group

OBJECTIVE

To address the long-term results of alfuzosin, an alpha 1-antagonist, in patients with benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

A 6-month, placebo-controlled study involving 518 patients was followed by two successive one-year, open extensions. Only centres who wished to continue the trial participated in the extensions; 131 patients entered the first extension, with 50 continuing into the second year extension. The results of the second year follow-up are presented here.

RESULTS

Depending on their initial randomization to either the placebo or alfuzosin arm, patients were treated with alfuzosin for 24 (n = 50) or 30 months (n = 22). The data collected on those 50 patients in comparison to baseline confirmed that the clinical efficacy observed in short/medium-term studies was maintained. A clinically significant improvement in urinary symptoms was observed; the Boyarsky score decreased from 8.7 (+/- 0.3) at baseline to 5.2 (+/- 0.3) at 24 months, with no deterioration in the objective parameters. In patients treated for 30 months (n = 22), symptomatic assessment and urodynamic parameters remained stable, indicating the sustained effectiveness of therapy. No serious or unexpected side-effect related to long-term exposure to alfuzosin was observed. No complications associated with BPH occurred. Two patients (4%) reported dizziness, neither of whom withdrew from the study. In this population, where 40% of patients were receiving concomitant cardiovascular therapy, no clinically significant change in standing systolic blood pressure, diastolic blood pressure or heart rate was apparent between baseline data and those at 24 months.

CONCLUSION

These data demonstrate the usefulness of long-term treatment with alfuzosin in patients with uncomplicated, moderate BPH.

A three month double-blind study of doxazosin as treatment for benign prostatic bladder outlet obstruction

OBJECTIVE

To evaluate the efficacy and tolerability of doxazosin in the treatment of bladder outflow obstruction resulting from benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

One-hundred and thirty-five patients with symptomatic urodynamically confirmed obstructive BPH were treated for 12 weeks with either doxazosin (67 patients) or placebo (68 patients) after an initial 2 week baseline evaluation. The main outcome measures were urodynamic and symptomatic evaluation for efficacy. Blood pressure and adverse events were monitored.

RESULTS

Data were obtained in 122 patients (60 doxazosin, 62 placebo). Doxazosin produced increases in both mean and maximum urinary flow rates of 1.01 ml/s and 3.2 ml/s respectively, compared with 0.21 ml/s and 2.2 ml/s on placebo. The increase in mean flow rate was statistically significant (P = 0.04), while that for maximum flow rate approached significance (P = 0.09). The maximum subtracted voiding pressure was substantially reduced (P = 0.007) and 19 of 53 (36%) patients had an increase in maximum flow rate of 50% or more compared with 9 of 54 (17%) on placebo (P = 0.024). Twelve weeks' therapy with doxazosin resulted in significant improvements (compared with placebo) in: hesitancy (doxazosin 26 of 46, placebo 11 of 43; P = 0.003), impaired urinary stream (doxazosin 31 of 55, placebo 16 of 48; P = 0.019) nocturia (doxazosin 22 of 56, placebo 10 of 54; P = 0.017) and urgency (doxazosin 27 of 45, placebo 16 of 42; P = 0.041). Frequency improved with doxazosin therapy (doxazosin 26 of 59, placebo 15 of 55; P = 0.062). Adverse events, most frequently dizziness and headache, were usually mild and transient and led to a discontinuation of doxazosin therapy in one patient. No clinically significant changes in sexual function or blood pressure were seen.

CONCLUSION

Doxazosin was well-tolerated and produced both urodynamic and symptomatic improvement in men with BPH, thereby providing a satisfactory alternative to existing drugs with the additional benefit of once daily dosage.

Long-term treatment of benign prostatic hyperplasia with alfuzosin: a 12-18 month assessment. BPHALF Group

In order to assess the efficacy and safety of alfuzosin, an alpha-1 blocker, in symptomatic patients with benign prostatic hyperplasia (BPH), 131 patients who had completed a 6-month placebo-controlled trial conducted on parallel groups entered a 12-month open study; 122 patients were treated with alfuzosin for 12 months and 56 patients for 18 months. After 12 months, all obstructive and irritative symptoms assessed according to the Boyarsky scale were significantly improved, as were peak flow rates in obstructed patients and mean flow rates and residual urine in the whole population. Voiding symptoms showed sustained improvement after treatment for 12 to 18 months. Only 5.3% of patients experienced vasodilatory side effects, none of which led to withdrawal from the study. No side effect related to long-term administration was reported. Alfuzosin has a beneficial effect on voiding symptoms in patients with BPH and can be safely used in long-term administration.

Is indoramin an effective alternative to prostatectomy?

Alpha-1-adrenergic antagonists are recommended for symptomatic treatment of patients awaiting prostatic surgery. Their efficacy has been confirmed in placebo controlled clinical trials, but to date no comparison of their effects with the results of subsequent prostatectomy has been made. Fifty-five patients awaiting prostatectomy were assessed (by symptom scores and peak urinary flow rates) prior to treatment, on indoramin 20 mg bd, and 2 months following prostatectomy. Side effects while taking indoramin were experienced by 36% of patients. Despite an overall improvement in mean symptom scores, 26% of patients with obstructive and 30% of those with irritative symptoms who were assessed while taking indoramin failed to experience any improvement. Of the 31 patients assessed while on indoramin and again following surgery, prostatectomy produced a greater symptomatic relief than indoramin. The increase in peak flow rate following prostatectomy was 11.7 ml/s compared with 3.2 ml/s on indoramin. However, 5 patients preferred to continue taking indoramin rather than proceeding to surgery. Indoramin is no substitute for prostatectomy. Although some patients might benefit from treatment while awaiting surgery, significant side effects may severely restrict its use for this purpose. The response to indoramin cannot be used as an accurate predictor of response to prostatectomy.

A 12-week placebo-controlled double-blind study of prazosin in the treatment of prostatic obstruction due to benign prostatic hyperplasia

A series of 93 normotensive patients with benign prostatic hyperplasia and maximum urinary flow rates < 15 ml/s, treated at 2 hospital centres using an identical protocol, was randomly assigned to receive a 12-week course of treatment with prazosin or placebo in a double-blind parallel group trial. A total of 75 patients completed the study and were suitable for the final analysis. Prazosin was administered orally in doses of 0.5 mg and then 1 mg twice daily for 4 days and 2 mg twice daily for the remainder of the trial. Patients on treatment with prazosin exhibited a significantly increased maximum urinary flow rate as compared with placebo, with a significant reduction in maximum voiding detrusor pressure. Prazosin therapy did not produce a significant effect on either frequency or standard parameters of detrusor instability. A double-blind overall assessment of drug efficacy and tolerance significantly favoured prazosin therapy. A total of 30 patients receiving prazosin and 28 receiving placebo reported varied adverse effects. Eighteen patients were excluded from the final analysis, 10 being withdrawn because of adverse effects, 7 on treatment with prazosin and 3 in the placebo group. In long-term usage oral prazosin was well tolerated and appeared to improve obstructed voiding in patients with benign prostatic hyperplasia.

Alfuzosin for treatment of benign prostatic hypertrophy. The BPH-ALF Group

To assess the long-term efficacy and safety of alfuzosin, a selective alpha 1-adrenergic antagonist, 518 symptomatic patients with benign prostatic hypertrophy (BPH) were randomised to received either alfuzosin (daily dose 7.5-10 mg) or placebo for 6 months. Obstructive and irritative symptoms, assessed according to the Boyarsky scale, significantly improved in the alfuzosin group compared with the placebo group (p = 0.0004). Fewer patients in the alfuzosin group than in the placebo group dropped out due to lack of efficacy (6.8% vs 14.6%, p = 0.004) and the prevalence of spontaneous acute urine retention was lower in the alfuzosin group (0.4% vs 2.6%, p = 0.04). By 6 months, mean urinary flow rates had increased (p less than 0.05) and residual volume had decreased (p = 0.017) in the alfuzosin group, although the two groups were broadly similar with respect to increase in peak flow rate. The overall incidence of adverse events was similar in the two groups, which led to the withdrawal of 10.8% and 9.0% of patients, respectively. The findings emphasise the magnitude of the placebo response in symptomatic patients with BPH and show that treatment with alpha 1 adrenergic antagonist drugs provides long-lasting improvement in such patients.

Indoramin in the treatment of prostatic bladder outflow obstruction

A series of 40 patients took part in a double-blind, placebo-controlled trial of indoramin in prostatic bladder outflow obstruction. Patients were assessed clinically and urodynamically before and after 4 weeks' treatment. Significant improvement was seen in nocturia, volume voided, flow rates and residual urine. The drug was well tolerated, although 7 patients on treatment and 7 on placebo noted side effects. These results suggest that indoramin may be a useful agent in the symptomatic management of bladder outflow obstruction.