Context

Treatment alternatives

The NICE clinical guideline on lower urinary tract symptoms (LUTS) recommends using alpha blockers to treat men with bothersome moderate to severe LUTS, including, but not specific to, LUTS secondary to benign prostatic hyperplasia. The alpha blockers include:

  • Alfuzosin 2.5 mg 3 times daily, maximum 10 mg daily. Older people (aged over 65 years) should initially take 2.5 mg twice daily.

  • Doxazosin initially 1 mg daily; dose may be doubled at intervals of 1 to 2 weeks according to response, up to a maximum of 8 mg daily; usual maintenance 2 to 4 mg daily.

  • Tamsulosin 400 micrograms daily.

  • Terazosin initially 1 mg at bedtime; if necessary, dose may be doubled at intervals of 1 to 2 weeks according to response, up to a maximum of 10 mg once daily; usual maintenance 5 to 10 mg daily.

For men with LUTS and an enlarged prostate (larger than 30 g) or a prostate specific antigen level greater than 1.4 nanograms/ml, the NICE clinical guideline on LUTS recommends 5-alpha reductase inhibitors. The 5-alpha reductase inhibitors include:

  • Dutasteride 500 micrograms daily.

  • Finasteride 5 mg daily.

Dosing information comes from the British national formulary.

The introduction in this evidence summary gives further details on the use of different drug therapies for LUTS. For full details, see the NICE clinical guideline on LUTS.

Donatucci et al. (2011) describes how these standard drug therapies may be effective at reducing LUTS and improving urinary flow rates but are associated with commonly reported side effects. For alpha blockers, these include orthostatic hypotension, dizziness, asthaenia (weakness), ejaculatory problems and nasal congestion. For 5-alpha reductase inhibitors, they include decreased libido, ejaculatory dysfunction and erectile dysfunction. Drugs with fewer or less severe side effects have been tested, including phosphodiesterase type 5 inhibitors used in the treatment of erectile dysfunction, such as tadalafil.

Costs of treatment alternatives

The main drug treatments that NICE has recommended for LUTS associated with benign prostatic hyperplasia are alpha blockers and 5-alpha reductase inhibitors. Table 3 shows approximate annual costs of alpha blockers and 5-alpha reductase inhibitors compared with tadalafil.

Table 3 Costs of treatment alternatives

Drug

Usual dosage a

Annual cost b,c

Tadalafil tablets

1×5 mg once daily

£716.83

Alfuzosin tablets

1×2.5 mg 3 times daily

£122.28

Doxazosin tablets

1×2 mg once daily to 1×4 mg once daily

£10.95 to £15.25

Tamsulosin capsules

1×400 micrograms once daily

£65.33

Terazosin tablets

1×5 mg to 1×10 mg once daily

£32.72 to £97.12

Dutasteride capsules

1×500 micrograms once daily

£362.20

Finasteride tablets

1×5 mg once daily

£22.03

a The doses shown are usual doses taken from the relevant summary of product characteristics or British National Formulary but do not represent the full range that can be used and do not imply therapeutic equivalence.

b All costs are taken from the Drug Tariff, March 2013.

c Costs stated are for the simplest regimen, for example 1×10 mg tablet, but in some instances it may be more cost effective to prescribe the dose as 2×5 mg. See the drug tariff for a list of available strengths and costs.