The economic impact of using alfuzosin 10 mg once daily in the management of acute urinary retention in the UK: a 6-month analysis

Terazosin versus Alfuzosin in Treatment of Acute Urinary Retention in Patients with Benign Prostatic Hypertroph

Objective

To compare the efficacy and adverse reactions of terazosin and alfuzosin in treatment of acute urinary retention in patients with benign prostatic hypertrophy.

Design

Case control study.

Setting

Emergency department of a regional hospital in Hong Kong.

Methods

Our study included all adult male with age at least 18 years old presented with acute urinary retention, having residual urine volume greater than or equal to 300 ml after urinary catheterisation and with a presumed diagnosis of benign prostatic hypertrophy. Patients treated with terazosin from December 2013 to February 2014 were retrospectively included while patients treated with alfuzosin from April to September 2014 were prospectively included. We compared the two groups on: trial without catheter (TWOC) rate, potential adverse effects including drug-associated postural hypotension, haemodynamic changes and prolongation of corrected QT interval in electrocardiogram. Cost effectiveness analysis was performed.

Results

A total of 116 patients were included with 59 and 57 patients in the terazosin and alfuzosin group respectively. Logistic regression showed that residual urine volume (odds ratio [OR]=0.998, 95% confidence interval [CI]=0.996-0.999, p=0.008) and presence of precipitating factors (OR=2.264, 95% CI=1.045-5.793, p=0.045) were independent predictors of successful TWOC. There was no significant difference in the TWOC rate for patients treated with alfuzosin and terazosin. There was significantly more symptomatic postural hypotension in the terazosin group compared with the alfuzosin group. The number need to treat with alfuzosin for terazosin to avoid one adverse drug effect was 12.3 patients (95% CI=4.7-21.6) and 9.9 patients (95% CI=5.3-84.6) to reduce one postural hypotension and symptomatic postural hypotension respectively.

Conclusions

Alfuzosin is comparable to terazosin in TWOC rate. However, alfuzosin is associated with a lower rate of symptomatic postural hypotension and less haemodynamic impact than terazosin. (Hong Kong j.emerg.med. 2015;22:210-218)

Efficacy and Safety of Silodosin and Dutasteride Combination Therapy in Acute Urinary Retention due to Benign Prostatic Hyperplasia: A Single-Arm Prospective Study

This study aimed to assess the efficacy of combination therapy with dutasteride and silodosin in patients with acute urinary retention (AUR) caused by benign prostatic hyperplasia (BPH). Eighty consecutive patients with a first episode of AUR were enrolled in this study. All patients received silodosin 8 mg and dutasteride 0.5 mg daily. Trial without catheter (TWOC) was attempted every 2 weeks until 12 weeks after the initiation of medication. The primary endpoint was the rate of catheter-free status at 12 weeks. Voided volume (VV), postvoid residual urine (PVR), uroflowmetry, International Prostatic Symptoms Score (IPSS), and quality of life due to urinary symptoms (IPSS-QOL) were also measured. All patients were followed up for more than 12 weeks and were included in this analysis. The success rate of TWOC at 12 weeks was 88.8%. VV and maximum urinary flow rate were significantly higher at 2, 4, 8, and 12 weeks compared with the time of AUR (P < 0.001). IPSS and IPSS-QOL were significantly lower at 2, 4, 8, and 12 weeks compared with the time of AUR (P < 0.001). In conclusion, a combination of dutasteride and silodosin therapy may be effective and safe for patients with AUR due to BPH.

The role of alpha blockers prior to removal of urethral catheter for acute urinary retention in men

BACKGROUND

Acute urinary retention is a urological emergency in men and requires urgent catheterisation. Any intervention which aims at improving urinary symptoms following an acute urinary retention episode could be potentially beneficial. Alpha blockers relax prostatic smooth muscle cells thereby decreasing the resistance to urinary flow and by doing so could improve urinary symptoms.

OBJECTIVES

To assess the effectiveness of alpha blockers on successful resumption of micturition following removal of a urethral urinary catheter after an episode of acute urinary retention in men. In the absence of internationally agreed outcome measures for the success of a trial without catheter, success was defined as the return to satisfactory voiding without need for re-catheterisation within 24 hours.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, and handsearching of journals and conference proceedings (searched 9 October 2013), CENTRAL (2013, Issue 5) (searched 5 June 2013), MEDLINE 1946 to May Week 4 2013, MEDLINE in Process (covering to 3 June 2013), EMBASE Classic and EMBASE 1947 to 2013 Week 22 (all searched 4 June 2013) and the reference lists of relevant articles. No language or other restrictions were imposed on the searches.

SELECTION CRITERIA

Only randomised and quasi-randomised clinical trials of alpha blockers for trial without a urethral catheter following an episode of acute urinary retention in men were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently examined all the citations and abstracts derived from the search strategy. Any disagreement about trial selection and inclusion was resolved by discussion. A third independent judgement was sought where disagreement persisted. Two review authors extracted independently, cross-checked and processed the data as described in the Cochrane Handbook for Systematic Reviews of Intervention. Quality of evidence of the critical outcomes was assessed by adopting the GRADE approach.

MAIN RESULTS

Nine randomised clinical trials were included in this review. Eight trials compared alpha blockers versus placebo (five trials tested alfuzosin and two trials tested tamsulosin, one trial tested both alfuzosin and tamsulosin, one trial tested silodosin) and one trial compared an alpha blocker (doxazosin) versus no treatment. Trial without catheter was performed after treatment with the drug for one to three days in seven trials and for eight and 32 days in two other trials respectively. There was moderate quality evidence to suggest that the rate of successful trial without catheter favoured alpha blockers over placebo ( 366/608, 60.2%, of men using an alpha blocker were able to void spontaneously after catheter removal compared with 185/486, 38.1%, using placebo, risk ratio (RR) 1.55, 95% confidence interval (CI) 1.36 to 1.76). The incidence of recurrent acute urinary retention was lower in groups treated with an alpha blocker (RR 0.69, 95% CI 0.60 to 0.79). This evidence was of moderate quality and was statistically significant for alfuzosin, tamsulosin and silodosin, though not for doxazosin. Of the trials mentioning adverse effects (for example, postural hypotension, dizziness), there was not enough information to detect statistically significant differences between the groups (RR 1.19, 95% CI 0.75 to 1.89) and the evidence was of low quality. Overall, adverse effect rates were low for both placebo and alpha blockers and, for example, vasodilatation-related adverse effects did not often result in discontinuation.

AUTHORS' CONCLUSIONS

There was some evidence to suggest that alpha blockers increase the success rates of trial without catheter, and the incidence of adverse effects was low. There was some evidence of a decreased incidence of acute urinary retention. The need for further surgery, cost effectiveness and recommended duration of alpha blocker treatment after successful trial without catheter remain unknown as these were not reported by any trial. There is a lack of internationally agreed outcome measures for what constitutes successful trial without catheter. This makes meta-analysis difficult. Large, well-designed controlled trials, which use the recommendations set out in the CONSORT statement, and include clinically important outcome measures, are required.

Analysis of the treatment of two types of acute urinary retention

PURPOSE

This study analyzed the type of acute urinary retention (AUR) and evaluated the treatments used, including trial without catheter (TWOC).

MATERIALS AND METHODS

This study was based on 299 patients who were treated for AUR from January 2007 to August 2009. The patients were classified into the spontaneous AUR group (group S) and the precipitated AUR group (group P), in which AUR was consecutive to triggering events. The treatment modalities including TWOC, the success rate of TWOC, age, prostate-specific antigen (PSA) levels, the volume of the prostate, and the drained volume at catheterization were analyzed in each group.

RESULTS

Of 299 men with AUR, 160 (54%) had spontaneous AUR and 139 (46%) had precipitated AUR. Compared with group P, patients in group S were more likely to be treated by surgery, either immediately (16.9% vs. 3.6%, p<0.05) or after prolonged catheterization (42.2% vs. 29.1%, p<0.05). The success rate of TWOC was lower in men of older ages (≥70 years) and in those with enlarged prostates (≥50 ml), higher PSA levels (≥3 ng/ml), and a large drained volume at catheterization (≥1,000 ml).

CONCLUSIONS

In this group of AUR patients, there were slightly more patients with spontaneous AUR (54%) than with precipitated AUR (46%). The success rate of TWOC was more than 70% regardless of the type of AUR. Although TWOC is recommended primarily in the treatment of AUR, early surgical intervention should be considered if the patient has an enlarged prostate (≥50 ml) or a large drained volume at catheterization (≥1,000 ml).

The infusion method trial of void vs standard catheter removal in the outpatient setting: a prospective randomized trial

OBJECTIVE

• To ascertain if filling the bladder with warm normal saline before trial of void (TOV) reduces time to decision of outcome of TOV and time to discharge compared with standard in-dwelling catheter (IDC) removal in the outpatient setting.

PATIENTS AND METHODS

• A prospective randomized controlled trial (not blinded) was carried out in the day procedure unit. Randomization was done using computer-generated random numbers. The sample size was calculated based on initial pilot data using α= 0.05 and β= 0.2 and a clinically important reduction of ≥60 min for time to decision of outcome of TOV (primary outcome measure). • In all, 60 consecutive patients were recruited from two referral sources: presentations of acute urinary retention to the emergency department and patients discharged home after failing TOV postoperatively. • The infusion method group (32 patients) had 300-500 mL warm normal saline infused into the bladder before removing their IDC and the control group (28) had standard IDC removal. • Data were collected and analysed using the two-tailed Mann-Whitney U-test. Statistical significance was set at P < 0.05.

RESULTS

• The median time to decision was 135.0 (95% confidence interval CI 95.0-190.0) min in the infusion group and 247.5 (95% CI 189.6-294.1) min in the control group. • Patients undergoing a bladder infusion had a shorter discharge time [180.0 (95% CI 126.0-226.9) min] than patients in the standard-IDC-removal group [262.5 (95% CI 233.8-315.0) min]. • The infusion arm shortened time to decision by 112.5 min (P < 0.001) and time to discharge by 82.5 min (P < 0.001). • Furthermore, patients in the infusion group were 1.56 times more likely to achieve catheter-free state after TOV (risk ratio 1.56, 95% CI 1.03-2.36; P= 0.03).

CONCLUSION

• The infusion method for TOV is safe and expeditious, making it ideal for the outpatient setting. This randomized study shows that the infusion method enables a rapid determination of outcome of TOV with a greater chance of success and shortened discharge times.

Alpha blockers prior to removal of a catheter for acute urinary retention in adult men

BACKGROUND

Acute urinary retention is a urological emergency in men and requires urgent catheterisation. Any intervention which aims at increasing the rate of a successful trial without a catheter following an acute urinary retention episode would be considered potentially beneficial. Alpha blockers relax prostatic smooth muscle cells thereby decreasing the resistance to urinary flow and by doing so improve urinary symptoms.

OBJECTIVES

To assess the effects of alpha blockers on successful resumption of micturition following removal of a urethral urinary catheter after an episode of acute urinary retention in men.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (11 February 2009) and the reference lists of relevant articles. No language or other restrictions were imposed on the searches.

SELECTION CRITERIA

Only randomised and quasi-randomised clinical trials of alpha blockers for trial without a urethral catheter following an episode of acute urinary retention in men were included.

DATA COLLECTION AND ANALYSIS

Both review authors independently examined all the citations and abstracts derived from the search strategy. Any disagreement about trial selection and inclusion was resolved by discussion. A third independent judgement was sought where disagreement persisted. Both review authors extracted independently, cross-checked and processed the data as described in the Cochrane Collaboration Handbook (Higgins 2008).

MAIN RESULTS

Five randomised clinical trials were eligible for inclusion in this review. All five trials compared alpha blockers versus placebo. In four trials alpha blockers were used between 24 to 72 hours (in one study up to a maximum of eight days) before trial without a catheter (TWOC); in one trial alpha blockers were used for eight days prior to trial without a catheter. Four trials tested alfuzosin and one trial tested tamsulosin. Four trials favoured alpha blockers and one trial favoured placebo. Overall rates of successful TWOC tended to favour alpha blockers over placebo. This was statistically significant (RR 1.39, 95% CI 1.18 to 1.64) irrespective of the alpha blocker used (alfuzosin: RR 1.31, 95% CI 1.10 to 1.56; tamsulosin: RR 1.86, 95% CI 1.17 to 2.97).With regard to causing fewer vasodilatation-related side effects (for example hypotension, dizziness), two studies favoured placebo and one favoured alpha blockers. Overall side effects were low for both placebo and alpha blockers. Failure rates were high and mainly caused by the need for re-catheterisation rather than vasodilatation-related side effects.

AUTHORS' CONCLUSIONS

The limited available evidence suggests that alpha blockers increase success rates of TWOC. Alpha blocker side effects are low and comparable to placebo. It is uncertain whether alpha blockers reduce the risk of recurrent urinary retention and need for prostate surgery. The cost effectiveness and recommended duration of alpha blocker treatment after successful TWOC remains unknown. There are a lack of internationally agreed outcome measures for what constitutes successful TWOC. This makes meta-analysis difficult. More randomised clinical trials are needed to address these issues.

Medical therapy options for aging men with benign prostatic hyperplasia: focus on alfuzosin 10 mg once daily

Lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) are common in aging men and can significantly affect quality of life. Men with bothersome LUTS/BPH often present with various other age-related conditions, including sexual dysfunction, heart disease, hypertension, diabetes, and the metabolic syndrome, which can complicate management decisions. Therefore, healthcare providers should be familiar with first-line treatment options for LUTS/BPH and their differing safety profiles, particularly with respect to cardiovascular and sexual function side effects. This article presents a review of first-line medical therapy options for managing aging men with LUTS/BPH and patient considerations when evaluating and selecting these therapies, with a focus on the clinical efficacy and cardiovascular and sexual function safety profiles of the uroselective alpha1-adrenergic receptor antagonist alfuzosin 10 mg once daily. Alfuzosin improves LUTS, peak urinary flow rates, and disease-specific quality of life, reduces the long-term risk of overall BPH progression, and is well tolerated in aging men, with minimal vasodilatory and sexual function side effects, even in those with comorbidities. Alfuzosin is well tolerated when used in combination with antihypertensive medications and phosphodiesterase type 5 inhibitors for the treatment of erectile dysfunction. The long-term clinical efficacy and good cardiovascular and sexual function safety profile of alfuzosin can contribute to an improved quality of life for aging men with LUTS/BPH.

Experience with the spanner prostatic stent in patients unfit for surgery: an observational study

BACKGROUND

Prostatic stents offer a third clinical option for patients with bladder-outlet obstruction who are unfit for surgical relief and wish to avoid long-term catheterization. We report our experience with the Abbey-Moor Spanner temporary prostatic stent in patients with acute and chronic symptoms of bladder-outlet obstruction secondary to benign or malignant disease who were unfit for surgery because of age or cardiorespiratory disease.

PATIENTS AND METHODS

A series of 43 consecutive patients stented March 2004 through November 2005 were reviewed retrospectively. Stents were removed and replaced every 3 months if tolerated.

RESULTS

More than half of the patients (63%) had an unsatisfactory outcome, namely, immediate or delayed retention or elective removal because of unbearable symptoms. The remaining 37% of patients had a satisfactory outcome and either continue to have the stent in situ after a mean of five changes or are stent free after a successful voiding trial.

CONCLUSION

Only 21% of the patients in whom stenting was indicated continued to have a stent in situ at the end of the study. We suggest that in such patients, a temporary stent such as the AbbeyMoor Spanner should be used for only 3 months as a trial of stenting followed by a trial of stent-free voiding, with the patient converted to permanent prostatic stenting if voiding is unsuccessful.

Acute urinary retention: who is at risk and how best to manage it?

In recent years, we have begun to understand the progressive nature of benign prostatic hyperplasia. By careful analysis of population studies and clinical trials, we can determine the factors most likely to predict progression to one of its most distressing complications, acute urinary retention. Acute urinary retention is a common urologic emergency and causes significant suffering, although rarely has it any serious consequences. Using our knowledge regarding the progression of benign prostatic hyperplasia, new treatment modalities are being assessed for their effectiveness at halting progression and ultimately preventing this distressing condition.

Alfuzosin: an alpha1-receptor blocker for the treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia

Alpha1-receptor blockers have become first-line therapy for the medical management of lower urinary tract symptoms associated with benign prostatic hyperplasia. However, adverse effects such as cardiovascular intolerance can limit their use. This article focuses on alfuzosin, a clinically uroselective, alpha1-adrenergic antagonist that is available as a novel once-daily formulation that does not require dose titration. Alfuzosin is less vasoactive than other non-subtype selective alpha1-receptor blockers. In addition to effects on lower urinary tract symptoms, it is also used as an adjunct to urethral catheterisation in patients with acute urinary retention related to benign prostatic hyperplasia, and can improve sexual function and health-related quality of life in benign prostatic hyperplasia sufferers.

The economics of benign prostatic hyperplasia and lower urinary tract symptoms in the united states

Throughout the past several decades, interest in health care economics has increased as health care spending has soared--currently in excess of 1.5 trillion dollars and comprising approximately 16% of the nation's Gross Domestic Product. Benign prostatic hyperplasia (BPH) and its associated clinical manifestation of lower urinary tract symptoms is one of the most common medical conditions of aging men. BPH has been, and continues to be, a major factor in health care expenditures in the United States, costing up to 4 billion dollars each year. During the past 15 years, considerable changes in the patterns of care for BPH patients have evolved, resulting in similarly profound economic alterations. In this article, we examine contemporary trends in practice patterns for BPH and their associated impact on the cost of care for this condition.

Spontaneous versus precipitated AUR: the same?

The differentiation between spontaneous and precipitated acute urinary retention was initially made by the PLESS study group. Acute urinary retention (AUR) occurring in the PLESS study, whether considered spontaneous or precipitated, was BPH-related as it occurred in a carefully selected population. It is known that AUR can be precipitated in patients without BPH by events such as anaesthesia and CVA. Therefore when assessing how to manage a patient with AUR, one should first consider whether or not the event is BPH-related. If BPH is thought to be present, then the management is likely to involve a trial without catheter following administration of an alpha-blocker. The presence of a factor that is considered to have precipitated or provoked the episode of AUR may influence the outcome in the longer term but there is little evidence that it alters the likelihood of a successful trial of voiding. Consequently spontaneous and precipitated AUR may be considered to be the same when they are BPH-related, as the approach to management need not be altered. Such differentiation is only likely to influence immediate management when AUR is truly precipitated in the absence of BPH.