Using 5-Alpha Reductase Inhibitors for BPH

[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.

[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.