BPH is a common problem as our male patients age. Symptoms of urinary retention and frequency can often be very problematic for patients which results in the use of medications. We also run into polypharmacy concerns in many patients as they get older with a growing number of health conditions. Here are some thoughts on reducing polypharmacy in BPH.
Your first thought should be to review the medication list to ensure that medication is not worsening the common symptoms of retention and frequency. Urinary retention can be exacerbated by two common mechanisms. Drugs with anticholinergic activity like hydroxyzine, diphenhydramine, TCA’s, and many others will have the potential to worsen retention and lead to the initial use of BPH agents or dose increases. The other mechanism of action I pay attention to is those that may have alpha-agonist activity. The most common drug I’ve seen do this are decongestants like pseudoephedrine.
Urinary frequency can also be exacerbated by many medications. Loop and thiazide diuretics used in hypertension, heart failure, or management of fluid retention are the most common agent that will cause frequency. SGLT2 inhibitors may also contribute to urinary frequency.
The two most commonly used medications in BPH symptom management include the 5 alpha-reductase inhibitors and alpha-blockers. Can we look to get rid of any of these medications over time to reduce polypharmacy? It is possible. Alpha-blockers are going to have a significantly quicker onset than 5 alpha-reductase inhibitors. The 5 alpha-reductase inhibitors will shrink the prostate over time which is going to help relieve symptoms. If the patient wants to reduce medications and has been on one of these for a period of months to years, a trial off of the alpha-blocker would be the more likely agent to try off of to see if it still remains beneficial and necessary.
Summarizing my strategies for reducing polypharmacy in BPH and preventing the prescribing cascade, you have to first review for medications that worsen BPH. After that has been accomplished, one might consider a possible trial hold in the alpha-blocker after the 5 alpha-reductase inhibitor has been on board for a significant number of months.