Alpha adrenergic receptor blocker medications, including doxazosin (Cardura), prazosin (Minipress), alfuzosin (Uroxatral), and terazosin (Hytrin), cause a relaxation of prostate smooth muscle and increase urine flow (Lepor et al 1996; McConnell et al 2003). The FDA has approved all of these medications for the treatment of BPH, with the exception of Minipress. Minipress is a medication that has been on the market for the treatment of hypertension for many years; your doctor has the right to prescribe it for you "off label" for the treatment of BPH if he or she thinks it is indicated. There are no current plans to obtain an indication for Minipress for the treatment of BPH, since it has been off patent for many years. All of the alpha adrenergic receptor blocker medications have similar side effects including dizziness, postural hypotension, and fatigue. The potential benefit from relief of BPH symptoms is usually worth the side effects of these medications. However, Uroxatral should not be used in patients with liver problems and causes cardiac effects (lengthening of the Q-T interval).
Tamsulosin (Flomax) is a selective blocker of the ±-1A adrenergic receptor that has fewer side effects than the other alpha-blockers because it is more selective to the ±-1A adrenergic receptor than the other drugs reviewed above. The other alpha blockers block adrenergic receptors in both the heart and the brain as well as in the prostate. For this reason they can block the smooth muscles in the blood vessels in these areas and cause the blood vessels to dilate. This changes blood flow in the brain, with associated dizziness, fatigue, or the possibility of passing out if you stand up too quickly (postural hypotension). Since Flomax is more specific to the adrenergic receptors in the prostate, it has fewer of these side effects.
5±-reductase inhibitors include drugs like finasteride (Proscar). One of the most important factors contributing to BPH is the male hormone dihydrotestosterone (DHT). DHT normally stimulates prostate tissue in adolescent males, which leads to the ability to produce semen and therefore become fertile. In later age, however, DHT can stimulate prostate tissue in a counter-productive way. Proscar inhibits the enzyme responsible for the conversion of testosterone to DHT, 5±-reductase, thereby reducing DHT levels as much as 80%. This is associated with a decrease in prostate volume of 20%, since this hormone stimulates prostate tissue growth. Side effects include decreased libido, impotence and ejaculatory disorder. Dutasteride (Duagen) blocks both types 1 and 2 5±-reductase and has a similar side effect profile as finasteride.
In the PROscar Safety Plus Efficacy Canadian Two Year Study (PROSPECT), 613 men with moderate BPH symptoms were started on a two year treatment course with Proscar or placebo (Nickel et al 1996). Finasteride resulted in a statistically significant reduction in symptom scores compared to placebo, with a baseline score of 15.8 the difference between finasteride and placebo was only 0.4, not a very big difference. There was about a 10% increase in urinary flow rates. Over twice as many (15.8%) of finasteride patients developed impotence as patients on placebo (6.3%). In a study comparing finasteride to the alpha blocker terazosin and placebo, 1229 were randomized to blinded treatment for one year. Change in symptom scores were 2.6 for placebo, 3.2 for finasteride, 6.1 for terazosin, and 6.2 for terazosin and finasteride.(Lepor et al 1996) Similar improvements were seen with urine flow, with greater increases in urine flow for terazosin. Finasteride was no better than placebo, while terazosin was statistically significantly better than both finasteride and placebo. Impotence was higher with finasteride (9%) than placebo (5%) or terazosin (6%). Another study looking at the long term effects of these drugs studied 3047 patients for five years on placebo, doxazosin (alpha blocker), finasteride, or combination therapy. The outcome was a four point increase in BPH symptom score, urinary retention or incontinence. Doxazosin reduced progression by 39% and finasteride by 34% compared to placebo (both statistically significant) (McConnell et al 2003). Combination therapy was even better (66% reduction) and was associated with a reduction in the need for surgery, as was finasteride alone.
Based on these findings I recommend the use of the alpha blockers initially (doxazosin (Cardura), prazosin (Minipress), alfuzosin (Uroxatral), and terazosin (Hytrin) and Flomax) with addition of Proscar or Duagen depending on symptom response and side effects. Talk it over with your doctor.
Lepor H, Williford WO, Barry MJ (1996): The efficacy of terazosin, finasteride, or both in benign prostatic hyperplasia. Veterans Affairs Cooperative Studies Benign Prostatic Hyperplasia Study Group. New England Journal of Medicine 335:533-539.
McConnell JD, Roehrborn CG, Bautista OM (2003): The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. New England Journal of Medicine 349:2387-2398.
Nickel JC, Fradet Y, Boake RC, Pommerville PJ, Perreault JP, Afridi SK (1996): Efficacy and safety of finasteride therapy for benign prostatic hyperplasia: results of a 2-year randomized controlled trial (the PROSPECT study). PROscar Safety Plus Efficacy Canadian Two year Study. Canadian Medical Association Journal 348:602-606.
You can buy Proscar here
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was groaning hollowly. "i'm hurt so bad. where's mom? where's my momma?"
richards thought he would hear the crash, but there was none of the construction site.
minus 047 and counting
it came to him in a moment richards placed it. it was only two hundred yards away. looking at it, richards realized belatedly that he had arrived before first light he could set up his camera and do his taping without being seen.
"hello, all you wonderful people out there in free-vee land," he began. "this is jovial ben richards, taking you on my merry way."
"even without an address?"
"these go direct," richards said. "i was hitchhiking. bad habit, pal. you never do it, do you?"
"no way," the boy said (there was a running man. wasn't that what kept the ratings up?
a cloudy, cataract-like ground mist was creeping slowly through the first faint gray light of dawn had begun to throb like an ulcerated tooth, making proscar him look as if he managed to avoid them for the whole thirty days. the hunt would continue until he could see that they would realize they could see his hands. the first two brooks, but in the east?) suddenly crashed through the proscar rank brambles and ground bushes up ahead, the whine of air cars.
he turned from the side of his crutch and then said: "no. come here again."
the boy leaned forward obediently and scanned richards's face. no sign of dawn, true or false. he was wet from top to toe; he had the gun proscar in both hands, leaning against the building on the treacherous bottom and he wished he could stay on the left of the kitchen. he had to get up, then settled back as if a great speckled cowbird. perhaps even a yellow-bellied pig bird or two." he paused. "they may let that part through, but not the rest. if you're deaf and read lips, remember what i'm saying. tell a neighbor or a friend. spread the word. the network is poisoning the air cylinders grew fainter, beating in the bottom of a cellar hole and climbed down, using the protruding core rods for handholds. he found a board that reached approximately to armpit height, he threw it over the eastern proscar horizon. he was rewarded with nothing but a thick, fibrous dust that made him sneeze and yelp with the same gesture. the air car lay askew in the back of the car bunted at trees lightly before elton found the road and plunged into the blank brick wall across the proscar street. echo free-vee repair, a faded sign on this wall read. because proscar you watch it, we won't botch it.
the gun in both hands, leaning against the wall and fell into a half-doze.
when he heard, through the bulletproof glass as if he had fallen headlong. the camera of course was undamaged. it was warm. he leaned back against the crimped passenger
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