What are good medications for prostate issues?

Medications for Prostate Issues

For benign prostatic hyperplasia (BPH), alpha blockers are the first-line pharmacological treatment due to their rapid onset of action, good efficacy, and relatively low rate of adverse events. 1

Treatment Options for BPH

Alpha-1 Adrenoceptor Antagonists (Alpha Blockers)

• First-line pharmacological treatment for BPH with rapid symptom relief 1
• Options include alfuzosin, doxazosin, tamsulosin, and terazosin, which have similar clinical effectiveness 1
• Mechanism: Relax prostatic and bladder neck smooth muscle, reducing obstruction 2
• Benefits: Significantly improve urinary symptoms and flow rate compared to placebo 1
• Common side effects: Asthenia, dizziness, orthostatic hypotension; tamsulosin has lower risk of hypotension but higher risk of ejaculatory dysfunction 1
• Most effective in patients with smaller prostates (<40 ml) 1

5-Alpha Reductase Inhibitors (5-ARIs)

• Options include finasteride and dutasteride 1
• Mechanism: Block conversion of testosterone to dihydrotestosterone, reducing prostate size 2
• Indications: Most effective for men with enlarged prostates (>30cc) 1
• Benefits: Improve symptoms by 15-30%, decrease prostate volume by 18-28%, increase maximum flow rate by 1.5-2.0 ml/s 1
• Reduce risk of acute urinary retention by 57-68% and need for surgery by 55-64% at 4 years 1
• FDA-approved for: Improving symptoms, reducing risk of acute urinary retention, and reducing need for surgery 3
• Onset of action is slow (6-12 months) compared to alpha blockers 2
• Side effects: Sexual dysfunction including reduced libido, erectile dysfunction, and ejaculation disorders 1

Phosphodiesterase-5 Inhibitors (PDE5)

• Tadalafil 5mg daily is an option for BPH treatment, particularly beneficial for patients with concurrent erectile dysfunction 1
• Mechanism: Partially understood, but results in smooth muscle relaxation 1
• Efficacy: Modest improvement in symptoms compared to placebo 1

Combination Therapies

• Alpha blocker + 5-ARI: Recommended for patients with demonstrable prostatic enlargement (>30cc on imaging, PSA >1.5ng/mL, or palpable enlargement) 1
• Shown to significantly reduce clinical progression compared to monotherapy in large studies (MTOPS and CombAT) 1
• Alpha blocker + anticholinergic agent: Option for patients with moderate to severe predominant storage symptoms 1
• Alpha blocker + beta-3-agonist: Option for patients with moderate to severe predominant storage symptoms 1
• Tadalafil + alpha blocker: Not recommended as it offers no advantages over either agent alone 1

Treatment Options for Prostate Cancer

Hormone Therapy (Androgen Deprivation Therapy - ADT)

• First-line treatment for metastatic hormone-sensitive prostate cancer 1
• Options include:
  • ADT plus docetaxel for metastatic hormone-naive disease in chemotherapy-eligible patients 1
  • ADT plus novel hormone agents (abiraterone+prednisone, apalutamide, or enzalutamide) 1
• For high-risk localized disease: External beam radiotherapy plus hormone treatment 1

Novel Androgen Receptor Inhibitors

• Abiraterone, enzalutamide, apalutamide, and darolutamide are effective in both hormone-sensitive and castration-resistant prostate cancer 4
• Recommended for asymptomatic/mildly symptomatic men with chemotherapy-naïve metastatic castration-resistant prostate cancer (CRPC) 1

Chemotherapy

• Docetaxel is recommended for metastatic CRPC 1
• Cabazitaxel is recommended in the post-docetaxel setting 1

Radiopharmaceuticals

• Radium-223 is recommended for men with bone-predominant, symptomatic metastatic CRPC without visceral metastases 1
• Lutetium-177 PSMA-617 improves survival in men with CRPC who have progressed on prior treatments 1

Treatment Algorithm for BPH

1. Initial Assessment:

   • Determine symptom severity using validated questionnaires (IPSS)
   • Assess prostate size via digital rectal exam, PSA, or imaging
   • Check post-void residual volume

2. Mild Symptoms (IPSS <8) or Non-bothersome Symptoms:

   • Watchful waiting with lifestyle modifications 1

3. Moderate to Severe Symptoms (IPSS ≥8) with Small to Moderate Prostate (<30cc):

   • Start with alpha blocker (tamsulosin, alfuzosin, doxazosin, or terazosin) 1
   • Alternative: Tadalafil 5mg daily (especially if concurrent erectile dysfunction) 1

4. Moderate to Severe Symptoms with Enlarged Prostate (>30cc):

   • Combination therapy with alpha blocker plus 5-ARI (finasteride or dutasteride) 1
   • Consider 5-ARI monotherapy if long-term treatment is planned 1

5. Predominant Storage Symptoms (urgency, frequency, nocturia):

   • Alpha blocker plus anticholinergic agent or beta-3-agonist 1

6. Treatment Failure or Complications:

   • Consider surgical options if medical therapy fails or if complications occur (recurrent infections, large residual volume >200ml, recurrent hematuria, bladder stones) 2

Common Pitfalls and Caveats

• PSA levels are reduced by approximately 50% in patients taking 5-ARIs; PSA values should be doubled for cancer screening purposes 3
• Delayed diagnosis of prostate cancer can occur with 5-ARI use if PSA adjustment is not considered 1
• Alpha blockers do not prevent disease progression, acute urinary retention, or need for surgery 1
• Anticholinergic agents should be used cautiously in men with elevated post-void residual volumes (>150ml) due to risk of urinary retention 1
• Men on long-term ADT should be monitored for side effects including osteoporosis and metabolic syndrome 1
• Regular exercise is recommended for men starting ADT as it reduces fatigue and improves quality of life 1