What is the best non alpha blocker (alpha blocker) for Benign Prostatic Hyperplasia (BPH)?

From the Guidelines

For benign prostatic hyperplasia (BPH) treatment without using alpha blockers, 5-alpha reductase inhibitors like dutasteride (0.5mg daily) are generally considered the best alternative option, as they have been shown to be more effective in reducing DHT levels and prostate size compared to finasteride 1.

Key Points

• 5-alpha reductase inhibitors work by blocking the conversion of testosterone to dihydrotestosterone (DHT), which causes prostate growth.
• Dutasteride inhibits both type I and II 5AR isoenzymes, reducing serum levels of DHT by approximately 95%, compared to 70% with finasteride 1.
• These medications can reduce prostate size by 15-25% at six months, improve urinary symptoms, and decrease the risk of urinary retention and need for surgery.
• Unlike alpha blockers, 5-alpha reductase inhibitors take several months to show full benefits but address the underlying cause of BPH.
• Side effects may include decreased libido, erectile dysfunction, and reduced ejaculate volume.
• PDE5 inhibitors like tadalafil (5mg daily) are another option, particularly beneficial for men with concurrent erectile dysfunction.
• For milder symptoms, plant-based supplements like saw palmetto may provide modest relief, though evidence for their effectiveness is less robust than for prescription medications.

Considerations

• Treatment with 5-ARIs and combination therapy hinges on prostate volume and PSA threshold; therefore, obtaining imaging with TRUS (or reviewing existing cross-sectional imaging) to objectively assess prostate size is reasonable, with reservation of 5-ARIs for those with appropriately enlarged glands 1.
• A minimum prostate volume of >30cc or PSA >1.5ng/mL is necessary for a reliable 5-ARI response, but the larger the gland, the more pronounced the effects.
• When providers are screening men for prostate cancer who are on 5-ARIs, patients should be informed of alterations in PSA due to the medication, and the measured serum PSA value should be doubled to accurately gauge disease progression after 1 year of 5-ARI therapy 1.

From the FDA Drug Label

The efficacy and safety of tadalafil for once daily use for the treatment of the signs and symptoms of BPH was evaluated in 3 randomized, multinational, double-blinded, placebo-controlled, parallel-design, efficacy and safety studies of 12 weeks duration The primary efficacy endpoint in the two studies that evaluated the effect of tadalafil for the signs and symptoms of BPH was the International Prostate Symptom Score (IPSS), a four week recall questionnaire that was administered at the beginning and end of a placebo run-in period and subsequently at follow-up visits after randomization In each of these 2 trials, tadalafil 5 mg for once daily use resulted in statistically significant improvement in the total IPSS compared to placebo

The best non alpha blocker for Benign Prostatic Hyperplasia (BPH) is tadalafil at a dose of 5 mg once daily, as it has been shown to improve symptoms and reduce the risk of acute urinary retention and the need for surgery 2.

• Key benefits:
  • Improves symptoms of BPH
  • Reduces the risk of acute urinary retention
  • Reduces the risk of the need for surgery
• Recommended dose: 5 mg once daily
• Note: Tadalafil is not an alpha blocker, but rather a phosphodiesterase type 5 (PDE5) inhibitor that has been shown to be effective in treating BPH symptoms.

From the Research

Non Alpha Blocker Options for BPH

• 5-alpha reductase inhibitors, such as finasteride (Proscar) and dutasteride (Avodart), are effective in shrinking prostate stroma, resulting in improved voiding, and reducing the need for future BPH-related surgery and the risk of future urinary retention 3, 4, 5.
• Phosphidiucer-5 (PDE-5) inhibitor class, such as tadalafil, has been shown to improve BPH-related symptoms and is currently approved to treat patients with BPH 3.
• Hormonal manipulation, including luteinizing hormone-releasing (LHRH) antagonists and growth hormone-releasing (GHRH) antagonists, may also be effective in treating BPH, although further study is needed 4.

Considerations for Treatment

• The choice of treatment should be based on the severity of symptoms, prostate size, and patient preferences 4, 6.
• Combination therapy may be considered for patients with larger prostates or more severe symptoms, but may not have an advantage over monotherapy in all cases 4.
• Watchful waiting may be recommended for patients with mild symptoms that do not affect their quality of life 6.

Efficacy and Safety

• Finasteride and dutasteride have been shown to have equal efficacy and safety for the treatment and prevention of progression of BPH 4, 5.
• Alpha-blockers, including selective and nonselective options, are effective in relieving bothersome LUTS and are often used as first-line therapy 7.