Tools for Practice


#164 Alpha blockers for BPH-LUTS: Let it flow or still slow?


CLINICAL QUESTION
How effective are alpha-blockers in reducing lower urinary tract symptoms (LUTS) in men with benign prostatic hypertrophy (BPH)?

BOTTOM LINE
Alpha-blockers are effective as first line therapy for LUTS-BPH. Compared to placebo, around 1 in 10 will have improved symptoms and/or avoid symptom progression while approximately 1 in 50 will experience hypotension or dizziness. Mainly indirect comparisons suggest doxazosin and terazosin may be slightly more effective but have increased risk of adverse events.  


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EVIDENCE
  • 15 systematic reviews of alpha-blockers in symptomatic BPH.1 
    • Versus placebo (26 Randomized Controlled Trials (RCTs)): Alpha-blockers:2 
      • Improved peak urinary flow (Qmax): 1.32 ml⁄s. 
      • Decreased symptoms [International Prostate Symptom Score (IPSS)]: -1.92. 
    • Network meta-analysis (124 RCTs)3 compared doxazosin, terazosin, alfuzosin, and tamsulosin:  
      • Improved Qmax (ml/s): 1.95, 1.21, 1.07 and 1.07 respectively. 
      • Decreased IPSS by: -3.67, -3.37, -2.13, and -2.07 respectively. 
        • Doxazosin significantly better for both outcomes. 
      • Doxazosin and terazosin (non-uroselective): Significant increase in adverse events (dizziness and headache). 
  • Systematic review compares alpha-blockers to finasteride (alpha-reductase inhibitor). 
    • 23 RCTs (20,821 patients) finasteride:4 
      • Inferior to doxazosin and terazosin for Qmax and IPSS at one year. 
      • Non-inferior to tamsulosin. 
    • Finasteride and dutasteride similarly effective.5,6 
  • RCT (3,047 men) of placebo versus doxazosin, finasteride, or combination. Compared to placebo, doxazosin:7 
    • Reduced BPH symptom progression, Number Needed to Treat (NNT)=15 over four years. 
    • Increased hypotension (Number Needed to Harm (NNH)=58) and dizziness (NNH=48). 
  • Three pooled RCTs (955 patients):8 More men receiving alfuzosin (76%) reached ≥3 point improvement on IPSS than placebo (62%), NNT=7. 
Context: 
  • Guidelines recommend alpha-blockers as first line therapy for symptomatic BPH.9,10 
  • Clinically meaningful improvement of IPSS is ≥2-6, depending on baseline.11 
  • Transurethral resection12,13 of the prostate improves Qmax 10-11 ml/s and decreases IPSS 16.7. 
  • Alpha blockers associated with increased risk of falls (NNT=589) and fracture (NNT=1,667).14 
  • 2013 systematic review comparing alpha-blockers to combination therapy with alpha reductase inhibitors: Combination therapy effective for enlarged prostates and treatment for >1 year.15 
June 6, 2016

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Author(s):

  • Christina Korownyk MD CCFP
  • Mathieos Belayneh

1. Yuan J, Liu Y, Yang Z, et al. Curr Med Res Opin. 2013; 29:279-87.

2. Nickel JC, Sander S, Moon TD. Int J Clin Pract. 2008; 62:1547-59.

3. Yuan JQ, Mao C, Wong SY, et al. Medicine (Baltimore). 2015; 94:e974.

4. Tacklind J, Fink HA, MacDonald R, et al. Cochrane Database Syst Rev. 2010; 10:CD006015

5. Nickel JC, Gilling P, Tammela TL, et al. BJU Int. 2011; 108:388-94.

6. Kaplan SA. J Urol. 2012; 187:584-5.

7. McConnell JD, Roehrborn CG, Bautista OM, et al. N Engl J Med. 2003; 349:2387-98.

8. Roehrborn CG, Van Kerrebroeck P, Nordling J. BJU Int. 2003; 92:257-61.

9. McVary KT, Roehrborn CG, Avins AL, et al. J Urol. 2011; 185(5):1793-803.

10. Nickel, JC, Méndez-Probst CE, Whelan TF, et al. Can Urol Assoc J. 2010 Oct; 4(5):310-6.

11. Barry MJ, Williford WO, Chang YC, et al. J Urol. 1995; 154:1770.

12. Milonas D, Verikaite J, Jievaltas M. Cent European J Urol. 2015; 68:169-74.

13. Reich O, Gratzke C, Bachmann A, et al. J Urol. 2008; 180:246-9.

14. Welk B, McArthur E, Fraser LA, et al. BMJ. 2015; 351:h5398.

15. Füllhase C, Chapple C, Cornu JN, et al. Eur Urol. 2013; 64:228-43.

Authors do not have any conflicts to disclose.