What medication to try next for BPH symptoms in a patient on maximum dose of Tamsulosin?

From the Guidelines

For a patient already on maximum dose of Tamsulosin (Flomax) for BPH symptoms, the next medication to try would be a 5-alpha reductase inhibitor such as finasteride (5mg daily) or dutasteride (0.5mg daily). These medications work by blocking the conversion of testosterone to dihydrotestosterone (DHT), which causes prostate growth. Unlike alpha-blockers like Tamsulosin that provide quick symptom relief by relaxing smooth muscles, 5-alpha reductase inhibitors actually shrink the prostate over time (typically 3-6 months for full effect) and are particularly effective for men with larger prostates (>40g) 1.

Key Considerations

• Combination therapy with both Tamsulosin and a 5-alpha reductase inhibitor is often more effective than either medication alone for moderate to severe BPH, as shown in the MTOPS and CombAT studies 1.
• The MTOPS study reported that combination therapy reduced clinical progression risk by 66% versus placebo, 34% versus finasteride, and 39% versus doxazosin 1.
• Patients should be informed that 5-alpha reductase inhibitors may cause sexual side effects including decreased libido, erectile dysfunction, and reduced ejaculate volume, and they require at least 6-12 months of therapy to evaluate effectiveness 1.
• The choice between finasteride and dutasteride should be based on individual patient factors, as both medications have similar efficacy but differ in their mechanism of action and side effect profiles 1.

Alternative Options

• If combination therapy fails, other options include anticholinergics (if storage symptoms predominate), phosphodiesterase-5 inhibitors like tadalafil, or referral for minimally invasive surgical procedures.
• Patients with larger prostates (>40g) may benefit from 5-alpha reductase inhibitors, which can reduce the risk of acute urinary retention and the need for BPH-related surgery 1.

Monitoring and Follow-up

• Patients should be monitored for changes in PSA levels, as 5-alpha reductase inhibitors can affect PSA levels, and the measured serum PSA value should be doubled to accurately gauge disease progression after 1 year of therapy 1.
• Regular follow-up appointments should be scheduled to assess symptom improvement and adjust treatment as needed.

From the FDA Drug Label

Dutasteride capsules in combination with the alpha-adrenergic antagonist, tamsulosin, are indicated for the treatment of symptomatic BPH in men with an enlarged prostate. The patient is already on the maximum dose of Tamsulosin, so the next medication to try would be Dutasteride in combination with Tamsulosin, as indicated in the drug label 2.

• The recommended dose of dutasteride is 1 capsule (0.5 mg) taken once daily, in addition to the current dose of Tamsulosin.
• Combination therapy with Dutasteride and Tamsulosin may provide additional benefits for symptomatic BPH.

From the Research

Treatment Options for BPH Symptoms

When a patient is already on the maximum dose of Tamsulosin and still experiencing BPH symptoms, there are several alternative medication options to consider:

• Combination therapy with a 5α-reductase inhibitor, such as dutasteride, has been shown to be effective in improving lower urinary tract symptoms (LUTS) and reducing the risk of acute urinary retention and BPH-related surgery 3, 4
• Finasteride, another 5α-reductase inhibitor, can also be considered, although it may have undesirable sexual side effects, such as worsening erectile dysfunction and decreasing testosterone levels 5
• Phosphodiesterase type 5 inhibitors (PDE5-Is), such as sildenafil, tadalafil, or vardenafil, can be used in combination with tamsulosin to treat LUTS secondary to BPH with or without erectile dysfunction, with sildenafil being the most effective and tolerated option 6

Comparison of Medication Efficacy

Studies have compared the efficacy of different medications for the treatment of BPH symptoms:

• Tamsulosin has been shown to improve IPSS and Qmax more quickly than finasteride 7
• Combination therapy with dutasteride and tamsulosin has been shown to be more effective than either medication alone in improving LUTS and reducing the risk of disease progression 3
• Sildenafil combined with tamsulosin has been shown to be the most effective and tolerated treatment option for BPH-LUTS with or without ED 6

Considerations for Medication Selection

When selecting a medication for a patient with BPH symptoms, it is essential to consider the potential benefits and risks of each option:

• 5α-reductase inhibitors, such as dutasteride and finasteride, can reduce prostate volume and improve LUTS, but may have undesirable sexual side effects 4, 5
• PDE5-Is, such as sildenafil, can improve LUTS and erectile dysfunction, but may have interactions with other medications and require careful dosing 6