What is the recommended treatment approach for an older adult male with benign prostatic hyperplasia (BPH) considering alfuzosin?

Alfuzosin for Benign Prostatic Hyperplasia

Alfuzosin 10 mg once daily is an appropriate and effective first-line treatment option for older adult males with moderate to severe lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). 1

Dosing and Administration

• Take alfuzosin 10 mg once daily immediately after the same meal each day 2
• The extent of absorption is 50% lower under fasting conditions, making food intake essential 2
• Tablets must be swallowed whole—do not crush, split, or chew 2
• No dose titration is required, with onset of peak action within days of starting treatment 3

Clinical Efficacy

• Alfuzosin produces an average 4-6 point improvement in the AUA Symptom Index, which patients generally perceive as meaningful 4
• Symptom relief is rapid and maintained over 3 years of treatment 5
• Improves nocturia by approximately 25%, peak urinary flow rates, and disease-specific quality of life 5, 6
• Reduces long-term risk of overall BPH progression, acute urinary retention (2.6% over 3 years), and BPH-related surgery (5.7% over 3 years) 7, 5

Comparative Effectiveness

Alfuzosin has equal clinical effectiveness to tamsulosin, doxazosin, and terazosin for symptom relief. 1, 4 However, the adverse event profiles differ slightly:

• Alfuzosin demonstrates better tolerability with fewer systemic cardiovascular effects (including fatigue, dizziness, orthostatic hypotension) compared to non-selective agents like doxazosin and terazosin 8, 3
• Lower rate of ejaculatory dysfunction (0.4%) compared to tamsulosin, which has higher rates of ejaculatory disorders 4, 5, 6
• Dizziness is the most frequent adverse event possibly related to vasodilatation (4.5%) 5

Critical Contraindications and Warnings

Alfuzosin is absolutely contraindicated in patients with: 2

• Moderate or severe hepatic impairment (Child-Pugh categories B and C), as drug levels increase 3-4 fold 2
• Concomitant use of potent CYP3A4 inhibitors (ketoconazole, itraconazole, ritonavir), which increase alfuzosin levels 2-3 fold 2

Important warnings include: 2

• Postural hypotension and syncope can occur, particularly when beginning treatment—caution patients about driving and operating machinery initially 2
• Patients planning cataract surgery must inform their ophthalmologist about alfuzosin use due to risk of intraoperative floppy iris syndrome (IFIS), even if no longer taking the medication 4, 2

Special Populations

• Renal impairment: Mean Cmax and AUC increase by approximately 50% in mild, moderate, or severe renal impairment—use with caution 2
• Elderly patients ≥75 years: Trough levels are approximately 35% greater than in those <65 years, but no dose adjustment is specified 2
• Cardiovascular comorbidity: Alfuzosin is well tolerated when used with antihypertensive medications, with minimal changes in blood pressure even in men ≥65 years receiving antihypertensives 7, 5, 6

Combination Therapy Considerations

For patients with demonstrable prostatic enlargement (prostate volume >30cc, PSA >1.5 ng/mL, or palpable enlargement on DRE):

• Consider adding a 5-alpha reductase inhibitor (finasteride or dutasteride) to alfuzosin 1, 4
• The combination reduces long-term risk of acute urinary retention and need for surgical intervention 4
• 5-ARIs require 3-6 months to demonstrate clinical benefit 4

For patients with concomitant erectile dysfunction:

• Alfuzosin is safe when combined with phosphodiesterase type 5 inhibitors 7, 6
• Consider adding tadalafil 5 mg daily for dual benefit 4

Monitoring and Follow-up

• Reassess at 4 weeks for symptom improvement (IPSS), quality of life, and adverse effects 4
• High baseline PSA values and symptom worsening during treatment (IPSS increase ≥4 points) are the best predictors of acute urinary retention and need for surgery 5
• Patients with symptom deterioration should be identified early to optimize management and consider alternative therapies 5

Common Pitfalls to Avoid

• Do not prescribe alfuzosin to patients with moderate-severe liver disease—this is an absolute contraindication 2
• Do not combine with potent CYP3A4 inhibitors—check medication list for ketoconazole, itraconazole, ritonavir 2
• Do not assume alfuzosin treats hypertension—it is not indicated for blood pressure management 2
• Always take with food—fasting reduces absorption by 50% 2
• Delay initiation until after cataract surgery if surgery is planned in the near future 4, 2