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Step-down treatment in BPH

 

Clinical bottom line

Initiation of combination therapy with finasteride and an alpha-blocker makes clinical sense in some men with BPH, but is expensive. This study indicates that for most men the alpha blocker can be discontinued after nine to 12 months.


Reference

KC Baldwin et al. Discontinuation of alpha-blockade after initial treatment with finasteride and doxazosin in men with lower urinary tract symptoms and clinical evidence of benign prostatic hyperplasia. Urology 2001 58: 203-209.

Study

This was study to examine whether men BPH could be started on dual alpha-blocker and reductase inhibitor treatment, and the alpha-blocker withdrawn.

Men with clinical BPH, prostates of 40 cc or larger, AUS symptom score of 20 or more and PSA or less than 4 ng/mL were enrolled. They were given an initial treatment regimen of 5 mg finasteride and 2 mg doxazosin daily, and the doxazosin dose was titrated up to 4 or 8 mg. One month later their symptoms were reassessed, and those with a reduction in symptom score and who tolerated the medicines continued in the study.

These were randomised into dosage groups of 2, 4 and 8 mg doxazosin daily, together with 5 mg finasteride daily. They were also randomly assigned to discontinue doxazosin at 3, 6, 9 or 12 months. Patients were evaluated every three months until discontinuation, and then one month after discontinuation of the doxazosin.

The final evaluation consisted on symptom score measurement and the question "would you like to restart the doxazosin?". Successful discontinuation was defined by both the absence of any increase in symptom score following discontinuation and a negative response to the question.

Results

The average age of the men was 66 years, and their average prostate size was 54 cc.

The rates of successful discontinuation of doxazosin rose from about 20% after 3 months, to about 80% or more at nine and 12 months (Figure 1).

Figure 1: Successful discontinuations of doxazosin


Comment

Finasteride is effective over the longer term, and continues to reduce the size of the prostate over at least four years. Alpha-blockers have effects on maximum flow rates almost immediately, but there is no subsequent improvement with longer term use. Combination therapy seems sensible, but is expensive. This study indicates that for most men the alpha blocker can be discontinued after nine to 12 months.