© The Canadian Journal of Urology™; 21(Supplement 2); June 2014
There are two 5-ARIs available, finasteride and
dutasteride, Table 5. Both medications showed
significant improvement over placebo in reducing
prostate size and reducing the risks of symptom
progression, acute urinary tract retention and surgical
intervention.
50
Comparison between the medications,
indirect and one direct, indicate similar efficacy.
50,51
The
PCP must be cognizant that quick relief will not occur
with the 5-ARI alone as both medications generally
require 3-6 months before the affect is noted.
Advocacy of the combination of a 5-ARI with an
alpha-blocker has been studied over a duration of
many years and has shown a significant improvement
in symptom and bother scores as compared to
monotherapy with either medication.
52,53
There were
similar results in a study showing the combination
of a PDE5i and a 5-ARI significantly outperformed
monotherapy with a 5-ARI in reduction of the IPSS at
26weeks.
54
Questions have been raised regarding early
adoption versus late adoption of combination therapy
and whether the medication treating the dynamic
component should eventually be stopped. Morlock
et al have shown that early combination results in
better outcomes in preventing clinical progression,
acute urinary retention or the need for surgery.
55
In
regards to stopping combination therapy in favor
of monotherapy, expert opinion favors continuing
combination therapy in the at-risk patient.
11,24
The most commonly reported adverse reactions
of the 5-ARIs include decreased libido, ejaculatory
disorders, ED and gynecomastia.
33
The PCP should be
aware that the PSAlevel will reduce approximately 50%
within the first year and shouldnever increase as long as
the 5-ARI is still used. Any elevation should therefore
be investigated.
1
Two crucial trials on prostate cancer
chemoprevention found a slightly higher incidence of
high grade cancers in the 5-ARI patients as compared to
those taking placebo.
56,57
Although experts have debated
the relationship the patient should be made aware of
the risk and monitored appropriately.
Follow up on chosen treatment
Alpha-blockers and PDE5is work reasonably quickly
so symptom resolution should be expected in the short
time frame. This is also the same for the antimuscarinics
and beta 3 agonists. No response to these therapies in
2-4weeks requires consideration of medication titration
switching medications or consideration of a referral to
the specialist. The 5-ARIs take longer given the overall
burden of the prostate size, so no improvement in 3
months or somaywarrant a re-evaluation and possible
referral.
When to call in the specialist
The treating PCP should consider referral for the
patient with symptoms, bother and who is refractory
to therapy. When to designate a patient’s symptoms as
refractory to therapy is going to be physician specific.
However, in an effort to keep the patient informed and
involved, these parameters should be communicated
to them. Referral should also be considered if any of
the key indicators listed in Table 4 are noted during
the evaluation or treatment.
Summary
The prevalence of BPH is high and the treatment
is low which results in many patients suffering
needlessly. They may in fact not know therapy is
available, their healthcare provider may not be aware
of their symptoms or the treatment they were given
did not adequately address the symptoms and risk
that they had. Regardless of the cause, education of
the gatekeepers probably is the key. Awareness of
the symptoms, understanding the disease and the
associated risk factors as well as realizing that there are
many different treatment options may open the door
for more patients to benefit. As shown in this paper,
this can all be performed safely in the office of the PCP.
It starts with education and ends in better patient care
and quality-of-life.
Disclosure
Dr Matt T. Rosenberg has been a speaker and consultant
for Astellas, Easai, Ferring, Forest, Horizon, Ortho-
McNeil, Lilly, Pfizer and Bayer. Erik S. Witt has no
potential conflict of interest. Dr. Martin Miner has been
a consultant for Abbvie and Endo. He has also done
research for Forest. Dr. Jack Barkin has been a clinical
investigator, speaker and medical advisory board
member and consultant forAbbott, Lilly, Bayer, Paladin,
Actavis, AstraZeneca, Astellas, Pfizer and Triton.
References
1. Rosenberg MT, Miner MM, Riley PA et al. STEP: Simplified
treatment of the enlarged prostate.
Int J Clin Pract
2010;64(4):
488-496.
2. WeinAJ, Rovner ES. Definition and epidemiology of overactive
bladder.
Urology
2002;60(5-Suppl 1):7-12.
3. Abrams P. Urodynamics. 3
rd
ed. London, England: Springer;
2005.
4. Wei JT, Calhoun E, Jacobsen SJ. Urologic diseases in America
Project: Benignprostatic hyperplasia.
J Urol
2005;173(4):1256-1261.
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