East Region Formulary

Watchful waiting may be preferable to treatment in men with mild to moderate symptoms. Tamsulosin should be prescribed generically as tamsulosin m/r capsule.

400micrograms daily.

Watchful waiting may be preferable to treatment in men with mild to moderate symptoms. The 2.5mg tablets are reserved for use when lower doses are required (e.g. elderly).

10mg once daily.

2.5mg three times daily (elderly, initially 2.5mg twice daily dose adjusted according to response). Max 10mg daily.

Only to be used in patients who have tolerance issues with other agents.

Initially 1mg daily; dose may be doubled at intervals of 1-2 weeks according to response; usual maintenance 2-4mg daily. Max 8mg per day.

Prescribing Notes:

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, and the benefit may be maintained for up to 3 years in those who continue to take the drug. There is a lack of published data on effect beyond 3 years.
All alpha-blockers are equally effective but there are differences in tolerability. Alfuzosin and tamsulosin are similar in terms of effectiveness and cost. Doxazosin may be prescribed if side-effects are encountered.
Tamsulosin and doxazosin are once daily preparations. Do not prescribe doxazosin modified release.
Alpha-blockers reduce blood pressure, and first doses may cause drowsiness and dizziness. Patients also receiving antihypertensives may need lower doses and supervision.
If symptoms of urinary frequency/urgency persist despite treatment with an α-blocker alone consider combining with an anti-muscarinic such as tolterodine or solifenacin – see ‘Treatment of urinary frequency/urgency’ pathway. Tamsulosin may be prescribed ‘off-label’ as short term therapy to enhance medical expulsion of ureteral stones. Specialist recommendation only.
In acute urinary retention associated with benign prostatic hyperplasia in men over 65 years, alfuzosin 10mg daily is given for 2-3 days during catheterisation and for one day after removal of catheter. Maximum of 4 days for this indication.
In patients co-prescribed a PDE-5 inhibitor there should be at least a 4 hour gap between taking sildenafil and the alpha-blocker and at least a 6 hour gap for vardenafil. Tadalafil should be avoided due to an enhanced hypotensive effect.

History Notes

18/05/2022

East Region Formulary content agreed.

Alternative first-line treatment in patients with large prostates. It may also be recommended when alpha-blockers are ineffective, contra-indicated or not tolerated.

5mg daily.

500micrograms daily.

Prescribing Notes:

5α-reductase inhibitors are used in the treatment of BPH. They reduce prostate size, reducing obstructive symptoms and increasing urinary flow rate.
Finasteride and dutasteride are appropriate alternatives to alpha-blockers. Although there is no clear evidence regarding who should receive which drug, finasteride has been shown to be most effective in men with prostate volumes exceeding 40ml, and has been shown to reduce the risk of acute urinary retention and the need for surgery. 5α-reductase inhibitors reduce prostate size, reducing obstructive symptoms and increasing urinary flow rate.
Prior to initiating treatment, please consider the implications of finasteride on the patient’s sexual health and/or sexual function. Please only initiate treatment after individualised assessment. Refer to specialist services if treatment initiation is deemed inappropriate or unacceptable to the patient. Common side effects in more than 1 in 100 people include: loss of libido, erectile & ejaculatory dysfunction.
Finasteride has also been associated with depression and suicidal thoughts, refer to MHRA Drug Safety Update Finasteride: reminder of the risk of psychiatric side-effects and of sexual side effects (which may persist after discontinuation of treatment).
Treatment with finasteride or dutasteride should be reviewed after 3-6 months, then every 6-12 months. Several months’ treatment may be required before benefit is obtained and any observed benefit may be lost after 3-6 months if treatment is discontinued.
Dutasteride is an alternative 5α-reductase inhibitor that might be used in patients intolerant of finasteride but is more expensive.

History Notes

28/08/2024

Update to prescribing information, ERWG May 24

18/05/2022

East Region Formulary content agreed.

400micrograms daily.

5mg daily.

1 capsule daily.

Prescribing Notes:

A combination of an alpha blocker and 5α-reductase inhibitor may be used for severe symptoms when benign prostatic enlargement is the most likely cause of symptoms.
5α-reductase inhibitors are used in the treatment of BPH. They reduce prostate size, reducing obstructive symptoms and increasing urinary flow rate.
In patients co-prescribed a PDE-5 inhibitor there should be at least a 4 hour gap between taking sildenafil and the alpha-blocker and at least a 6 hour gap for vardenafil. Tadalafil should be avoided due to an enhanced hypotensive effect.
Prior to initiating treatment, please consider the implications of finasteride on the patient’s sexual health and/or sexual function. Please only initiate treatment after individualised assessment. Refer to specialist services if treatment initiation is deemed inappropriate or unacceptable to the patient. Common side effects in more than 1 in 100 people include: loss of libido, erectile & ejaculatory dysfunction.
Finasteride has also been associated with depression and suicidal thoughts, refer to MHRA Drug Safety Update Finasteride: reminder of the risk of psychiatric side-effects and of sexual side effects (which may persist after discontinuation of treatment).

History Notes

28/08/2024

Update to prescribing information, ERWG May 24

07/03/2023

Deleted Tamsulosin and dutasteride information note

18/05/2022

East Region Formulary content agreed.

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