What is the next step in managing a 60-year-old male with Lower Urinary Tract Symptoms (LUTS) who has been partially controlled with Tamsulosin (tamsulosin), an alpha-blocker?

From the Guidelines

For a 60-year-old male with LUTS partially controlled on tamsulosin, the next step should be to add a 5-alpha reductase inhibitor (5-ARI) such as finasteride, provided the patient has a prostate volume of >30cc on imaging, a PSA >1.5ng/mL, or palpable prostate enlargement on DRE, as this combination has been shown to be effective in reducing symptom progression and decreasing the need for surgical intervention 1. When a patient has persistent lower urinary tract symptoms despite alpha-blocker therapy (tamsulosin), combination therapy with a 5-ARI like finasteride is the appropriate next step before considering surgical intervention.

Key Considerations

• The patient's prostate size, PSA level, and digital rectal examination (DRE) findings should be taken into account when deciding on the addition of a 5-ARI, as the guidelines recommend this combination only for patients with demonstrable prostatic enlargement 1.
• The combination of an alpha-blocker and a 5-ARI has been shown to be more effective than either medication alone in reducing symptom progression and decreasing the need for surgical intervention, particularly in men with enlarged prostates, as demonstrated by large studies such as the Medical Therapy of Prostatic Symptoms (MTOPS) and Combination of Avodart and Tamsulosin (CombAT) trials 1.
• Other combination therapies, such as adding anticholinergic agents or beta-3-agonists to an alpha-blocker, may be considered for patients with moderate to severe predominant storage LUTS, but the evidence for these combinations is not as strong as for the combination of an alpha-blocker and a 5-ARI 1.

Important Factors

• The patient's symptoms and quality of life should be carefully evaluated when deciding on the next step in management, as the goal of treatment is to improve symptoms and prevent complications.
• The potential benefits and risks of combination therapy, including the potential for side effects and interactions, should be carefully considered and discussed with the patient.
• Regular follow-up and monitoring of the patient's symptoms, prostate size, and PSA level are essential to assess the effectiveness of treatment and adjust the management plan as needed.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Next Steps in Managing LUTS

The next step in managing a 60-year-old male with Lower Urinary Tract Symptoms (LUTS) who has been partially controlled with Tamsulosin, an alpha-blocker, could involve:

• Considering combination therapy with a 5-alpha reductase inhibitor (5-ARI) such as dutasteride, as studies have shown that combination therapy can be more effective in improving symptoms and reducing the risk of disease progression 2, 3, 4
• Assessing the patient's prostate size and prostate-specific antigen (PSA) level to determine if they would benefit from 5-ARI therapy, as these medications have been shown to be more effective in men with larger prostates and higher PSA levels 3, 5
• Evaluating the patient's symptoms and quality of life to determine if they would benefit from additional therapies, such as phosphodiesterase-5 (PDE-5) inhibitors, which have been shown to improve BPH-related symptoms 2

Considerations for Combination Therapy

Combination therapy with dutasteride and tamsulosin has been shown to be effective in:

• Reducing the risk of acute urinary retention and BPH-related surgery 3, 4, 6
• Improving lower urinary tract symptoms and quality of life 4, 6
• Reducing the risk of clinical progression of BPH 3, 5, 6
• Being generally well-tolerated in patients with symptomatic BPH 4

Patient Evaluation

It is essential to evaluate the patient's baseline characteristics, including:

• Prostate volume and PSA level to determine if they would benefit from 5-ARI therapy 3, 6
• International Prostate Symptom Score (IPSS) and health-related quality of life (HRQL) to determine the severity of symptoms and impact on quality of life 6
• Peak urinary flow rate and body-mass index (BMI) to determine if they would benefit from additional therapies 6