Is the combination of antimuscarinics with alpha-blockers safe and effective for managing symptomatic benign prostatic hyperplasia?
This updated evidence review found minimal benefit with the addition of antimuscarinics to alpha-blockers for treating lower urinary tract symptoms in adults with BPH. Patients treated with antimuscarinics are at a higher risk of urinary retention, dry mouth, constipation, and dizziness. The antimuscarinics studied included oxybutynin, solifenacin, mirabegron, tolterodine, trospium, and vibegron, among others.
Meta-analysis (randomized controlled trials)
Self-funded or unfunded
Previous individual studies (of fesoterodine and mirabegron) and an evidence review have reported minimal additional benefit to antimuscarinics in the management of lower urinary tract symptoms due to benign prostatic hyperplasia (BPH). These investigators thoroughly searched PubMed, MEDLINE, EMBASE, and the Cochrane databases for English language–only randomized trials that compared the efficacy and safety of antimuscarinics plus alpha-blockers vs alpha-blockers alone or placebo in treating patients with BPH and bothersome lower urinary tract symptoms. Two reviewers independently assessed studies for inclusion eligibility and risk of bias using the Cochrane Risk of Bias scoring tool. Resolution of any disagreements occurred after consensus discussion with a third reviewer. A total of 12 independent studies (N = 4634) met the inclusion criteria. Less than one-third of the studies were at low risk of bias; the remaining were at moderate to high risk. Overall, the use of antimuscarinics resulted in no significant reduction of the number of urgency episodes per day and only a small reduction of micturition episodes per day (equivalent to approximately one less episode of nocturia every 6 nights). The addition of antimuscarinics significantly increased the risk of acute urinary retention, dry mouth, dizziness, and constipation.
David C. Slawson, MD
Professor and Vice Chair of Family Medicine for Education and Scholarship
Professor of Family Medicine, UNC Chapel Hill