What are the dosage and treatment guidelines for Benign Prostatic Hyperplasia (BPH)?

From the Guidelines

The treatment of benign prostatic hyperplasia (BPH) should follow a stepwise approach based on symptom severity, with medication as the first-line treatment for moderate to severe symptoms, and combination therapy with alpha-blockers and 5-alpha reductase inhibitors considered for patients with larger prostates (>30cc) or PSA >1.5 ng/mL, as recommended by the most recent guidelines 1.

Treatment Approach

The treatment approach for BPH typically involves:

• Watchful waiting with lifestyle modifications for mild symptoms
• Medication as the first-line treatment for moderate to severe symptoms
• Combination therapy with alpha-blockers and 5-alpha reductase inhibitors for patients with larger prostates or higher PSA levels

Medication Options

Medication options for BPH include:

• Alpha-blockers such as tamsulosin (0.4 mg daily), alfuzosin (10 mg daily), or silodosin (8 mg daily) to provide rapid symptom relief by relaxing prostate smooth muscle
• 5-alpha reductase inhibitors like finasteride (5 mg daily) or dutasteride (0.5 mg daily) to reduce prostate size over 3-6 months by blocking testosterone conversion to dihydrotestosterone

Combination Therapy

Combination therapy with alpha-blockers and 5-alpha reductase inhibitors is recommended for patients with:

• Larger prostates (>30cc) as judged by imaging
• PSA >1.5 ng/mL
• Palpable prostate enlargement on digital rectal examination (DRE) This approach is supported by the most recent guidelines 1 and is based on evidence from large studies such as the Medical Therapy of Prostatic Symptoms (MTOPS) and Combination of Avodart and Tamsulosin (CombAT) trials.

Additional Considerations

Additional considerations in the treatment of BPH include:

• Anticholinergics may be added for overactive bladder symptoms if post-void residual volume is low
• PDE5 inhibitors like tadalafil (5 mg daily) can also improve BPH symptoms, especially with concurrent erectile dysfunction
• Surgical options like transurethral resection of the prostate (TURP) or newer minimally invasive procedures should be considered if medications fail or complications occur (recurrent UTIs, bladder stones, renal insufficiency) 1.

From the FDA Drug Label

Tamsulosin Hydrochloride Capsules 0.4 mg once daily is recommended as the dose for the treatment of the signs and symptoms of BPH. The recommended dosage is one 10 mg UROXATRAL (alfuzosin HCl) extended-release tablet once daily. Finasteride tablets 5 mg/day

The dosage of treatment for BPH is as follows:

• Tamsulosin: 0.4 mg once daily, which can be increased to 0.8 mg once daily if patients fail to respond after 2 to 4 weeks of dosing 2
• Alfuzosin: 10 mg once daily, taken immediately after the same meal each day 3
• Finasteride: 5 mg/day 4

Guidelines for administration:

• Tamsulosin should be administered approximately one-half hour following the same meal each day and should not be crushed, chewed, or opened 2
• Alfuzosin should be taken immediately after the same meal each day and the tablets should not be chewed or crushed 3
• Finasteride can be taken with or without food 4

From the Research

BPH Treatment Guidelines

• The pharmacological treatment of benign prostatic hyperplasia (BPH) is indicated when men suffer from lower urinary tract symptoms (LUTS) but there are no absolute indications for prostate surgery or severe bladder outlet obstruction 5.
• Patients eligible for drug treatment are those with mild to moderate symptoms of BPH and no strong indications for surgery 6.
• Medical therapy is becoming increasingly important in the treatment of patients with moderate symptoms of BPH, with both androgen-suppressing therapy and alpha-adrenoceptor blockade being well-tolerated and effective modalities 7.

Treatment Options

• Alpha-blockers can quickly and effectively decrease LUTS and symptomatic disease progression 5.
• 5 alpha-reductase inhibitors (5ARIs) can significantly decrease LUTS and disease progression in men with larger prostates (> 30-40 ml) 5.
• Phosphodiesterase type 5 inhibitors (PDE5-Is) are an alternative to alpha-blockers when men experience bothersome side effects from alpha-blockers or erectile dysfunction 5.
• Muscarinic receptor antagonists are a viable treatment option for patients with bladder storage symptoms and a small prostate 5.
• Combination therapy with alpha-blocker plus muscarinic receptor antagonist is more efficacious in reducing LUTS than single drugs alone 5.
• Combination therapy with 5ARI plus alpha-blocker can reduce LUTS and disease progression more effectively than drug monotherapy 5, 8.

Dosage and Administration

• Terazosin, doxazosin, and tamsulosin can be administered once daily 7.
• Prazosin, alfuzosin, and indoramin must be administered twice daily, which may have a negative impact on patient compliance 7.
• Finasteride must be given for 6 months before its effectiveness can be assessed, and for at least 12 months to achieve maximum prostate shrinkage and beneficial effects 6, 7.
• Tamsulosin lacks significant effects on blood pressure and does not require dosage titration due to its specificity for alpha 1A-receptors 7.