Drugs used in benign prostatic hypertrophy (BPH)
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| Type | Recommendation |
|---|---|
| When to deprescribe | |
| CBR |
We suggest deprescribing drugs used for benign prostatic hypertrophy (BPH) in people:
|
| GPS |
Deprescribing decisions should be made in consultation with the person and their GP and/or specialist providers to ensure it aligns with their preferences, goals and overall treatment plans (ungraded good practice statement). |
| Ongoing treatment | |
| CBR | We suggest continuing drugs used for BPH in older men with persistent and severe symptoms, with regular assessments to evaluate the need for ongoing therapy. For men who remain on alpha-blockers, we suggest periodic blood pressure monitoring alongside reviews of the long-term necessity of the treatment. |
| CBR | If deprescribing is unsuccessful despite multiple attempts, we suggest maintaining the lowest effective dose, with periodic reassessment of the need for long-term therapy. |
| How to deprescribe | |
| CBR |
We suggest deprescribing without the need for tapering; however, some patients may prefer gradual tapering by reducing the dose or dosing frequency per week that the medicine is taken. For individuals who continue to have mild to moderate symptoms, we suggest a trial of lifestyle modifications (e.g. limit fluid intake, limit bladder irritants, maintain a healthy weight) and behavioural strategies (e.g. timed voiding regimens, double-voiding techniques, pelvic floor exercises) before restarting pharmacological treatment. |
| Monitoring | |
| CBR |
We suggest periodic evaluation of individual preferences and psychological effects of deprescribing, and advising individuals to report to their healthcare professionals any symptoms of recurrence or disease exacerbation (e.g. any return or worsening of urgency, frequency, incontinence, or nocturia) after stopping drugs used for BPH. |
| GPS | Healthcare professionals should advise individuals to keep a record that they have taken drugs for BPH in the past if receiving eye surgery due to the risk of intraoperative floppy iris syndrome (ungraded good practice statement). |
CBR, consensus-based recommendation; GPS, good practice statement
Benign prostatic hyperplasia (BPH) is common in older men, with treatment guided by symptom severity, often assessed using the International Prostate Symptom Score (IPSS). Before initiating BPH treatment, other causes of lower urinary tract symptoms (LUTS), including overactive bladder, urethral stricture, and prostate cancer, should be ruled out. Combination therapy, such as dutasteride with tamsulosin, is commonly preferred when both rapid symptom relief and prostate size reduction are needed, as it lowers the risk of acute urinary retention and surgery [211].
Refer to the narrative evidence summary, the GRADE Summary of Findings table in the guidelines, and the Technical Report for a complete presentation of the deprescribing evidence based on the GRADE framework (including other factors considered in developing the recommendations).
While selective alpha-blockers including tamsulosin have fewer systemic effects than non-selective alpha-blockers, they can still cause hypotension, which has been linked to a small but significant increase in the risk of falls, fractures, and head trauma in older people [480].
There is limited guidance on the optimal duration of combination therapy or whether selective alpha-blockers can be discontinued in people without worsening urinary symptoms. A small study (n = 7) suggested that changes in pupil diameter during tamsulosin therapy may be reversible in short-term users, with a significant increase in post-dilation pupil diameter observed after 30 days of discontinuation [481]. Selective alpha-blockers may interfere with mydriasis during surgery, increasing the risk of intraoperative floppy iris syndrome [482-484]. Notably, tamsulosin has been strongly associated with serious ophthalmic complications following cataract surgery [485].
For individuals with mild symptoms that do not significantly impact quality of life, lifestyle modifications are recommended as first-line management. These include limiting fluid intake before bedtime, reducing alcohol and caffeine consumption (due to their mild diuretic effects), avoiding bladder irritants (e.g. spicy foods), preventing constipation, and using behavioural strategies such as pelvic floor exercises, double-voiding, and timed voiding. People who have undergone transurethral resection of the prostate (TURP) or prostatectomy generally do not require pharmacological therapy post-surgery [482].
We identified one RCT related to deprescribing drugs used in BPH from the systematic review and meta-analysis [486].
Overall, there is no direct evidence of the benefits or harms related to the deprescribing of drugs used in BPH. The only evidence we identified was a comparison of the effect of deprescribing from combination therapy to monotherapy. If discontinuation is considered appropriate, monitoring may involve symptoms indicative of clinical BPH progression (e.g. any return or worsening of urgency, frequency, incontinence, or nocturia). The reported outcomes in the study are of very low certainty and remain insufficient to inform evidence-based recommendations. An accompanying editorial stated that “considering the minor effect of its discontinuation, this study clearly suggests that after a priming period, alpha-blockers might be discontinued”. However, the lack of a placebo control group makes it difficult to attribute the observed outcomes specifically to the removal of alpha-blockers, as opposed to other factors.
Key study characteristics and results
Lin 2014 compared the discontinuation of either drug from the combination therapy consisting of alpha-blocker (doxazosin) and 5-alpha-reductase inhibitor (dutasteride) in men with moderate to severe urinary tract symptoms. During the two-year combination therapy, improvements in symptom scores, urine flow, and prostate measures were observed. These measures appeared to deteriorate in both groups upon commencing monotherapy after receiving combination therapy for two years. At 12 months, deprescribing of either drug was not associated with a significant difference in the clinical BPH progression in terms of International Prostate Symptom Score, maximum flow rate, post-void residual urine volume, the need for surgical resection of the prostate, and overall BPH/ lower urinary tract symptom progression. However, a significantly greater proportion of participants with 5-alpha-reductase inhibitor discontinued had a total prostate volume increased ≥ 20% and resumed the medicine, when compared to the group with alpha-blocker discontinued. After 12 months, 135/230 (59%) participants continued with monotherapy. Additionally, the study reported that men with larger total prostatic volume (TPV) were significantly more likely to resume combination therapy.
The method of deprescribing was not specified, but it appears to have involved abrupt discontinuation.