Can FLOMAX and Sanctura Be Used Together?
Yes, FLOMAX (tamsulosin) and Sanctura (trospium) can be safely used together in older patients with BPH and overactive bladder, as combination therapy with an alpha-blocker plus an anticholinergic is supported by multiple guidelines and clinical trials for men with both voiding and storage symptoms. 1
Evidence Supporting Combination Therapy
Guideline Recommendations
The 2023 European Association of Urology guidelines explicitly support combination treatment with alpha-blockers (like tamsulosin) plus anticholinergics (like trospium) for men with bladder outlet obstruction and overactive bladder symptoms. 1
Multiple randomized controlled trials have demonstrated the efficacy and safety of this combination approach, including studies with tamsulosin combined with various anticholinergics. 1
A 2017 meta-analysis confirmed the efficacy and safety of initial combination treatment of an alpha-blocker with an anticholinergic medication in BPH patients with lower urinary tract symptoms. 1
Clinical Trial Evidence with Trospium Specifically
A 2016 study demonstrated that combination therapy with trospium 5 mg plus tamsulosin 0.4 mg in patients with BPH and severe overactive bladder symptoms resulted in significant improvement in urodynamic indices, with urinary incontinence episodes decreasing from 3.4 per day to 0.9 per day. 2
The side effect profile of the combination did not exceed levels common for antimuscarinic monotherapy, confirming safety. 2
Approximately 44% of patients with BPH have severe overactive bladder symptoms that may benefit from this combination approach. 2
Treatment Algorithm
When to Use Combination Therapy
Start with tamsulosin alone for initial management of BPH/LUTS. 1
Add trospium (or another anticholinergic) if storage symptoms (urgency, frequency, urgency incontinence, nocturia) persist after adequate trial of alpha-blocker monotherapy (typically 4-12 weeks). 1
Consider upfront combination therapy in patients presenting with both significant voiding symptoms AND severe storage symptoms (>3 incontinence episodes per day, OABSS >32). 2
Critical Safety Monitoring
Obtain baseline post-void residual (PVR) urine volume before starting anticholinergic therapy. 1
Monitor PVR at follow-up visits as anticholinergics can increase residual urine by approximately 25 mL, though urinary retention risk remains low in appropriately selected patients. 1
Avoid combination therapy in patients with:
- Elevated baseline PVR (>200-300 mL)
- History of urinary retention
- Severe bladder outlet obstruction on urodynamics 1
Important Clinical Considerations
Efficacy Expectations
Combination therapy provides superior improvement in storage symptoms compared to alpha-blocker monotherapy, with statistically significant reductions in urgency, frequency, and incontinence episodes. 3, 2, 4
Total International Prostate Symptom Score (IPSS) and quality of life scores improve more with combination therapy than with tamsulosin alone. 3, 2, 4
Maximum urinary flow rate (Qmax) improvements are similar between monotherapy and combination therapy. 3, 4
Duration of Treatment
Most clinical trials demonstrating efficacy used 12-week treatment periods, though longer-term use appears safe based on available data. 3, 2, 4
Symptom improvement with combination therapy can be observed as early as 4 weeks. 5
Common Pitfalls to Avoid
Do not withhold anticholinergics solely due to age in older patients, as studies specifically demonstrate safety and efficacy in men over 50 years. 2
Do not assume all anticholinergics are equivalent - while class effects exist, individual agents have different pharmacokinetic profiles and side effect profiles. 1
Do not forget to counsel patients about potential anticholinergic side effects (dry mouth, constipation, cognitive effects in elderly) and ejaculatory dysfunction from tamsulosin. 6