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Using 5-Alpha Reductase Inhibitors for BPH

Author Quynh-Chi Dang covers Using 5-Alpha Reductase Inhibitors for BPH on BackTable Urology

Quynh-Chi Dang • May 28, 2021 • 66 hits

5-alpha reductase inhibitors for BPH are an effective treatment for men with large prostates since they address the root cause of BPH, prostate size. It is important to understand 5 classes of Benign prostate hyperplasia (BPH) medications, and the effects of these medications can be observed directly through the prostate-specific antigen (PSA) test. 5-alpha reductase inhibitors can also be used in combination with alpha blockers in order to increase the effectiveness of the medication.

We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable Urology Brief

• The 5 classes of BPH medication are: alpha blockers, 5-alpha reductase inhibitors, anticholinergics, beta-3 adrenergic agonists, and PDE5 inhibitors.

• 5-alpha reductase inhibitors are most effective in treating men with large prostates since they address the root of BPH, prostate size. Dr. Roehrborn estimates that, under a 5-alpha reductase inhibitor regimen, the prostate will shrink by about 25%, and the PSA test will decrease by about 50%.

• In complex patients, it is possible to couple different classes of BPH medication together to achieve desired results. A study has shown that coupling an alpha blocker with a 5-alpha reductase inhibitor for BPH is the superior treatment for large prostates.

• Pre-treatment imaging is very important, as it is a good indicator for whether a 5-alpha reductase inhibitor for BPH will be effective. Patients with prostates under 30 g are not ideal candidates for 5-alpha reductase inhibitors.

5-alpha reductase inhibitors for BPH

Table of Contents

(1) Classification of BPH Medication

(2) 5-Alpha Reductase Inhibitors Effectively Treat Large Prostates

(3) Prostate Imaging Predicts Effectiveness of 5-Alpha Reductase Inhibitors

Classification of BPH Medication

The 5 classes of BPH medication are alpha-1 blockers, 5-alpha reductase inhibitors, anticholinergics, beta-3 adrenergic agonists, and phosphodiesterase 5 (PDE5) inhibitors. Dr. Roehrborn does not recommend over-the-counter supplements for BPH patients, as he believes them to be ineffective.

[Dr. Aditya Bagrodia]
Give us just a broad stroke of classes of medications that we're talking about here that are in your arsenal of treatment.

[Dr. Claus Roehrborn]
...So, the classes we're talking about is the the alpha-1 blocker, the 5-alpha reductase inhibitor, the anticholinergics, and now also the beta-3 adrenergic agonists...those are the classes of drugs that are available, approved, are able to work alone or in combination, and that's how we have to examine them.

...A lot of [BPH] patients were already in the drugstore, they were already in the supplement store, and they already have Saw Palmetto, Pygeum Africanum, Selenium, you name it, right, these supplements. Comes at 30 to 50 dollar a month, and they ask the same question, "Does it work?" My answer is no, it doesn't work because almost all of them were tested and were found to be no better than placebo in placebo controlled trials.

[Dr. Aditya Bagrodia]
And Claus, obviously, this is your area of expertise, but Cialis, is that still a part of the armamentarium for lower urinary tract symptom management?

[Dr. Claus Roehrborn]
Yeah, I was going to get to that category also, the PDE5 inhibitors for BPH, of which there's one drug, namely Cialis, and thanks for reminding me, approved, that will be our additional class.

[Dr. Aditya Bagrodia]
...I think just to kind of keep it in our brains when we're treating these patients, there's really five class of drugs, alpha blockers, there's the 5-alpha reductase inhibitors, there's anticholinergics, there's beta-3 agonists, there's phosphodiesterase inhibitors, and then maybe we say supplements. It can get overwhelming, but maybe just to make it digestible, I would say that those are going to be our options.

[Dr. Claus Roehrborn]
..So, globally speaking, you can take patients, categorize them, and allocate them for the best treatment. alpha blocker alone, 5-alpha reductase inhibitor plus alpha blocker, anticholinergic or a beta-3 adrenergic agonist plus/minus an alpha blocker, And then the PDE5 inhibitors for BPH is usually a mono therapy. But if it's a big prostate, you can couple them with the 5-alpha reductase inhibitor. And those are your classes of medical therapies for your patients to send them out of the door with.

Listen to the Full Podcast

Contemporary Medical Management of BPH with Dr. Claus Roehrborn and Dr. Aditya Bagrodia on the BackTable Urology Podcast)
Ep 5 Contemporary Medical Management of BPH with Dr. Claus Roehrborn and Dr. Aditya Bagrodia
00:00 / 01:04

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5-Alpha Reductase Inhibitors Effectively Treat Large Prostates

5-alpha reductase inhibitors for BPH are most effective in patients with large prostates. Dr. Roehrborn notes that the effectiveness of 5-alpha reductase inhibitors can be seen through a drastic decrease in the PSA test. Additionally, he cites a study that shows promising results for the combination of an alpha blocker with a 5-alpha reductase inhibitor.

[Dr. Claus Roehrborn]
So, if you now go to the next group of patients where you know this is a big prostate, you did a DRE, you think, "Wow, that's pretty large." PSA is, let's say, three. You think, "Wow, that's got to be a big prostate." Those patients can benefit from a 5-ARI. The 5-ARIs are the only drugs that really treat BPH, right? They treat the actual disease, because if you give it, the prostate will shrink by about 25%, the PSA will go down by about 50%, and the actual disease BPH is addressed, and it only works if you give it to men who have a large prostate and it takes time, it takes three to six months to fully take its effect.

So, for that reason, and because the largest studies ever done in our space, that is the MTOPS and CombaT studies, Most cases, if not all cases, the 5-ARI is given together with an alpha blocker. And why? Because you have early on, the symptom improvement from the alpha blocker, and then behind the scenes, so to speak, the 5-ARI addresses the size, the volume issue and shrinks the prostate. And together, they are unbeatable. The MTOPS study and the CombaT study showed that invariably, the combination of an alpha blocker and an 5-ARI is a superior treatment for men with larger glands.

Prostate Imaging Predicts Effectiveness of 5-Alpha Reductase Inhibitors

Using an ultrasound, an MRI, or a CT scan to estimate prostate size is important before deciding to treat BPH patients with 5-alpha reductase inhibitors. 5-alpha reductase inhibitors are only effective in men with prostates greater than 30 grams. For prostates under 30 g, the 5-alpha reductase inhibitor acts as a placebo.

[Dr. Claus Roehrborn]
Since I'm on the guideline committee, I can tell you that in 2021, the AUA guideline medical and surgical BPH guidelines will be blended, and in that blended version, there will be a “could” inserted instead of a “should”. So, it will be as follows. It will say, "If you're thinking about invasive treatment, you should have an imaging of the prostate, either you do an ultrasound, or you already have a cross sectional imaging, an MRI or CT scan. If you have the patient in front of you and you want to give him your best shot for medication, you could think about a prostate size imaging." Not quite the same push here in the guidelines, but the suggestion.

Now, why is that? The reason is pretty obvious. If you have a prostate of 60, 70 grams, the efficacy of the alpha blockers is very limited, right? And if you have a prostate of 20 grams, you shouldn't fool with a 5-ARI, because the 1990s Finasteride studies showed that in prostates under 30 grams, the 5-ARIs act like a placebo, they do nothing. So, there really is good reason to have in these blended guidelines, the recommendation for size and shape assessment also for men with medical treatment. I think this gets us a little bit into the choice of medical therapy. So, I kind of said it already and I let the cat out of the bag. So, the guidelines will push more and more for imaging studies.

Podcast Contributors

Dr. Claus Roehrborn discusses Contemporary Medical Management of BPH on the BackTable 5 Podcast

Dr. Claus Roehrborn

Dr. Claus Roehrborn is a urologist with UT Southwestern in Dallas, Texas.

Dr. Aditya Bagrodia discusses Contemporary Medical Management of BPH on the BackTable 5 Podcast

Dr. Aditya Bagrodia

Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.

Cite This Podcast

BackTable, LLC (Producer). (2021, April 22). Ep. 5 – Contemporary Medical Management of BPH [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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