Alpha-blockers relax smooth muscle in benign prostatic hyperplasia producing an increase in urinary flow rate and | improvement in obstructive symptoms. Watchful waiting may be preferable to treatment in men with mild to moderate | symptoms. Alpha-blockers are the treatment of choice for benign prostatic obstruction, and are likely to provide symptom relief in | men with prostates of any size. The effect should be noticed within several days, with full response after 4-6 weeks. They appear | to be equally effective but there are differences in tolerability. All alpha-blockers reduce blood pressure, and first doses may | cause drowsiness and dizziness. Modified release preparations may reduce these effects. Patients also receiving antihypertensives | may need lower doses and supervision. | Tamsulosin capsules m/r should be used first line, but some patients may experience a higher incidence of adverse sexual | dysfunction, so alfuzosin m/r is often preferable for those in whom this is an issue. | | First Line | GREEN Tamsulosin capsules m/r 400microgram | | Second Line | GREEN Alfuzosin tablets m/r 5mg, 10mg | tablets 2.5mg | GREEN Doxazosin tablets 1mg, 2mg, 4mg | (Note M/R preps of Doxazosin should NOT be prescribed.) | GREEN Terazosin tablets 2mg, 5mg | AMBER Tamsulosin 400mcg/dutasteride 500mcg | | Parasympathomimetics | AMBER Bethanechol tablets 10mg, 25mg (rarely used) | RED Distigmine tablets 5mg (for post-operative use in gynaecology patients only) | | | Urinary incontinence | Bladder training lasting for a minimum of 6 weeks should be offered as first-line treatment to women with urge or mixed urinary | incontinence. A trial of supervised pelvic floor muscle training of at least 3 months’ duration should be offered as first-line | treatment to women with stress or mixed Urinary incontinence. Tolterodine or Oxybutynin should be offered to women with | Over Active Bladder (OAB) or mixed Urinary Incontinence as first-line drug treatment if bladder training has been ineffective. | When offering antimuscarinic drugs to treat OAB always take account of: |
> coexisting conditions (for example, poor bladder emptying, constipation, glaucoma) |
> use of other existing medication affecting the total antimuscarinic load |
> risk of adverse effects |
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Discuss with patient: |
> the likelihood of success and associated common adverse effects, and |
> the frequency and route of administration, and |
> that some adverse events such as dry mouth and constipation may indicate that treatment is starting to have an effect, |
and that they may not see the full benefits until they have been taking the treatment for 4 weeks. |
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Oxybutynin immediate release is recommended by NICE but some patients may not tolerate its adverse effects if used on a |
regular basis. However, some patients prefer to use an immediate release product to enable them to take prior to certain |
situations, allowing them to use it 'as required'. This can also be helpful in allowing patients to balance the benefits with the side |
effects, enabling them to retain control of the timing of their treatment. |
If after a 4 week trial first choice treatment is ineffective or not tolerated then solifenacin, darifenacin or trospium should be |
considered as second line alternatives. Women should be counselled about the adverse effects of antimuscarinic drugs. |
The need for continuing antimuscarinic drug therapy should be reviewed after 6 months. |
In accordance with NICE TA290 Mirabegron is recommended as an option ONLY for patients in whom antimuscarinic drugs are |
ineffective, contra-indicated, or not tolerated. |
If treatment remains ineffective or is not tolerated patients should be referred to secondary care for further investigations. |
Propiverine and Fesoterodine are available as treatment options as AMBER traffic light drugs. |
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GREEN Tolterodine capsules (IR) 2mg (twice daily) |
GREEN Tolterodine capsules (m/r) 4mg (once daily) |
GREEN Oxybutynin tablets (I/R) 5mg (2-3 times daily |
GREEN Oxybutynin tablets m/r 5mg, 10mg (once daily) |
AMBER Oxybutynin patches 3.9mg/24hrs (Kentera®) |
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Second Line Choices |
GREEN Solifenacin tablets 5mg, 10mg |
GREEN Darifenacin tablets m/r 7.5mg, 15mg |
GREEN Trospium capsules m/r 60mg |
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Other options available to secondary care |
AMBER Propiverine Hydrochloride tablets 15mg |
AMBER Propiverine Hydrochloride m/r capsules 30mg |
AMBER Fesoterodine MR tablets 4mg, 8mg |
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Mirabegron is recommended by NICE TA290 as an option for treating the symptoms of overactive bladder only for people in whom |
antimuscarinic drugs are contraindicated or clinically ineffective, or have unacceptable side effects. The dose needs to be reduced |
in renal/hepatic impairment. Patient’s should be reviewed 4 weeks after initiating. |
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Following a review by the European Medicines Agency and the Medicines and Healthcare products Regulatory Agency (MHRA), |
there are now new recommendations for the use of Betmiga▼ (mirabegron). |
The new recommendations follow a review by the European Medicines Agency of cumulative data associated with mirabegron and |
increased blood pressure. Serious cases of hypertension and increased blood pressure have been reported in patients on |
mirabegron treatment. |
In addition, there have been some reports of hypertensive crisis and cerebrovascular and cardiac events associated with |
hypertension with a clear temporal relationship with the use of mirabegron. |
Its use in patients with severe uncontrolled high blood pressure is now contraindicated. Blood pressure should be measured |
at the start of treatment and monitored regularly, especially in patients with hypertension. |
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GREEN Mirabegron tablets 25mg, 50mg |
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Oxybutyin patches are not routinely recommended and should be reserved only for individuals who are unable to tolerate oral |
medication. |
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A guideline for the management of the condition can be found here |
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