What medication should be added to tamsulosin (Flomax) for a man with benign prostatic hyperplasia and prostate volume >30 g or rising PSA?

Add a 5-Alpha Reductase Inhibitor to Tamsulosin

For men with BPH on tamsulosin who have an enlarged prostate (volume >30 mL, PSA >1.5 ng/mL, or palpable enlargement on DRE), add dutasteride 0.5 mg daily or finasteride 5 mg daily to reduce disease progression, prevent acute urinary retention, and avoid future surgery. 1, 2

Patient Selection for Combination Therapy

Combination therapy is indicated when any of the following criteria are met:

• Prostate volume >30 mL on imaging (ideally ≥40 mL for maximum benefit) 1, 3
• PSA >1.5 ng/mL 1, 4
• Palpable prostate enlargement on digital rectal examination 1
• Rising PSA levels suggesting progressive prostatic growth 1

Men with larger prostates (≥40 mL) and higher PSA values derive the greatest absolute benefit because their baseline risk of disease progression is substantially higher. 4, 3

Medication Options and Dosing

Dutasteride 0.5 mg once daily is the preferred 5-alpha reductase inhibitor, as it reduces serum DHT by approximately 95% (compared to 70% with finasteride) and has similar efficacy and safety profiles. 4, 2

Finasteride 5 mg once daily is an equally acceptable alternative with extensive long-term evidence supporting its use in combination with alpha-blockers. 1, 4

The combination regimen is:

• Tamsulosin 0.4 mg once daily (continue current dose) 2
• Plus dutasteride 0.5 mg once daily 2
• Both medications can be taken together, with or without food 2

Expected Outcomes and Timeline

Symptom improvement requires patience—5-ARIs take 3-6 months to demonstrate clinical benefit, so schedule follow-up at 3-6 months rather than the typical 4-week alpha-blocker reassessment. 1, 4

Long-term benefits of combination therapy over 4 years include: 4, 3

• 67% reduction in overall clinical progression (versus 39% for alpha-blocker alone, 34% for 5-ARI alone)
• 79% reduction in acute urinary retention risk
• 67% reduction in need for BPH-related surgery
• Number needed to treat: 13 patients for 4 years to prevent one case of urinary retention or surgical intervention 1

Combination therapy provides superior symptom relief compared to either medication alone, with significantly greater reductions in International Prostate Symptom Score maintained over 4 years. 3, 5

Critical Counseling Points

Sexual side effects are common and must be discussed upfront: 1

• Erectile dysfunction occurs in 4-15% of patients on 5-ARIs
• Decreased libido occurs in approximately 6.4% in the first year
• Ejaculatory dysfunction occurs in 3.7-14% (combined risk from both medications)
• These side effects typically decrease after the first year but may persist in some patients even after discontinuation

PSA monitoring requires adjustment: 1, 2

• 5-ARIs reduce PSA by approximately 50% after 6 months of therapy
• Double the measured PSA value after 1 year of therapy when screening for prostate cancer
• Any confirmed increase from the lowest PSA value while on dutasteride may signal prostate cancer and requires evaluation, even if PSA remains within normal range

Dutasteride capsules must be swallowed whole and not chewed or opened, as contact with capsule contents may cause oropharyngeal mucosa irritation. 2

Common Pitfalls to Avoid

Do not add a 5-ARI if the prostate is not enlarged (volume <30 mL)—this exposes patients to unnecessary side effects without benefit. 1, 4

Do not expect rapid symptom improvement from the 5-ARI component—the alpha-blocker (tamsulosin) provides the early symptom relief, while the 5-ARI prevents long-term progression. 1, 6

Do not discontinue therapy prematurely—the primary value of combination therapy is disease modification and prevention of long-term complications, requiring indefinite continuation in men with enlarged prostates. 1

Inform ophthalmologists about tamsulosin use before any eye surgery due to intraoperative floppy iris syndrome risk. 1, 7

When NOT to Add a 5-ARI

If prostate volume is <30 mL, continue tamsulosin monotherapy or consider switching to a different alpha-blocker (alfuzosin, doxazosin, silodosin, or terazosin) if side effects are problematic, as all have similar clinical effectiveness. 1

If the patient refuses combination therapy due to sexual side effect concerns or cost, continue alpha-blocker monotherapy but counsel that this does not reduce long-term risk of acute urinary retention or need for surgery. 1