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Steven A Kaplan – One of the best experts on this subject based on the ideXlab platform.

  • re twelve week prospective open label randomized trial on the effects of an anticholinergic agent or antidiuretic agent as add on therapy to an Alpha Blocker for lower urinary tract symptoms
    The Journal of Urology, 2015
    Co-Authors: Steven A Kaplan

    Abstract:

    for this article http://dx.doi.org/10.1016/j.juro.2015.08.038 available at http://jurology.com/ Editorial Comment: Precision medicine is a glossy term that is often used as a goal in delivery of optimal outcomes. Notwithstanding costs and access, this concept is a more achievable goal than in the past. For example in the arena of lower urinary tract symptoms in men the ability to hone in on types of symptoms, ie storage vs voiding, and prostate size can help us to prescribe the most appropriate therapy. With a new cadre of available agents that can address nocturia, overactive bladder symptoms and sexual dysfunction we can more precisely diagnose and treat men with lower urinary tract symptoms. This study tests that hypothesis by using either desmopressin or an anticholinergic agent as an add-on to an Alpha Blocker. The authors found that the addition of desmopressin helped decrease the number of nocturnal episodes, nocturnal urine volume and nocturnal index in men with nocturnal polyuria. Similarly the nocturnal bladder capacity index and urgency episodes decreased in the anticholinergic add-on group. Nocturia is multifactorial and not just related to benign prostatic hyperplasia. Yet we often use classic benign prostatic hyperplasia agents such as Alpha Blockers in an attempt to treat men with nocturia. Studies such as this highlight the need to hone in on what is causing nocturia in an individual, including concomitant disorders such as diabetes, sleep apnea, polydipsia, reduced bladder capacity and polyuria. The take home message is that, as experts in voiding function in men (and women!), we should tailor our therapies to the specific complaint of the patient and take into account prostate size, types of symptoms and causative etiology of nocturia to deliver better health outcomes and more durable and sustainable results. Steven A. Kaplan, MD Suggested Reading Lose G, Mattiasson A, Walter S et al: Clinical experiences with desmopressin for long-term treatment of nocturia. J Urol 2004; 172: 1021.

  • Alpha Blocker therapy current update
    Reviews in urology, 2005
    Co-Authors: Steven A Kaplan

    Abstract:

    Alpha-Blockade is the predominant form of medical therapy for the treatment of symptomatic bladder outlet obstruction due to benign prostatic hyperplasia (BPH). Recent research has shown that there is a series of Alpha(1) receptor subtypes present in humans and that the Alpha(1A) subtype appears to play a primary role in mediating prostatic smooth muscle contraction. Recent interest has therefore focussed on the development of agents specific to this Alpha(1A) receptor subtype. The approval by the Food and Drug Administration of tamsulosin, an Alpha(1A)-specific antagonist, offers physicians in the United States the opportunity to prescribe a selective Alpha(1)-Blocker for the treatment of BPH. Tamsulosin offers a pharmacologic means to better target Alpha-blockade specifically to the prostatic smooth muscle and spare the vascular smooth muscle. Use of this agent has resulted in a lower incidence of clinically relevant effects on blood pressure or heart rate and minimal cardiovascular adverse effects.

  • intermittent Alpha Blocker therapy in the treatment of men with lower urinary tract symptoms
    Urology, 1998
    Co-Authors: Steven A Kaplan, Rodolfo Borges Dos Reis, Adauto Jose Cologna, Haylton Jorge Suaid, Antonio Carlos Pereira Martins, Ira J Kohn

    Abstract:

    Abstract Objectives. To determine the safety and efficacy of intermittent AlphaBlocker therapy in men with lower urinary tract symptoms (LUTS) in a prospective study. AlphaBlockers have been demonstrated to be safe and effective in the treatment of men with LUTS. To date, the role of varying dosing regimens in responding patients has not been well studied. Methods. Men with LUTS were entered into this prospective open label, parallel, randomized trial. In phase 1, patients were treated with alfuzosin, 2.5 mg three times daily for 3 months. In phase 2, those patients who had a significant therapeutic response were randomized into one of the following three groups: (1) maintenance of alfuzosin; (2) alfuzosin every other day; and (3) discontinuation of alfuzosin (ie, no treatment). Patients were followed up for a total of 6 months. Parameters of evaluation included the International Prostate Symptom Score (IPSS), global satisfaction, peak urinary flow rate (Qmax), and adverse events. Results. At 3 months, there were 79 patients who were categorized as having obtained a therapeutic response: IPSS decreased to 7.6 ± 3.2 and Qmax increased to 11.3 ± 2.9 mL/s. After randomization, IPSS was 7.1 ± 2.9 and 6.5 ± 2.5 for group 1; 6.5 ± 3.2 and 6.7 ± 2.1 for group 2; and 11.4 ± 4.8 and 12.3 ± 4.9 for group 3 at 3 and 6 months, respectively. Qmax was 12.7 ± 4.8 and 11.7 ± 5.2 mL/s for group 1; 12.2 ± 3.9 and 11.9 ± 3.7 mL/s for group 2; and 9.7 ± 2.5 and 9.3 ± 2.1 mL/s for group 3 at 3 and 6 months, respectively. Global satisfaction at 6 months was the same for groups 1 and 2. There were no differences in adverse events among the three groups. Conclusions. In men with LUTS who responded to alfuzosin, changing the dosing regimen from daily to once every other day resulted in similar efficacy and safety at 3 and 6 months. By contrast, complete cessation of alfuzosin resulted in recurrence of both symptoms and impaired urinary flow. These data provide evidence that in responding patients, intermittent AlphaBlocker therapy may be a reasonable therapeutic regimen. The role of intermittent AlphaBlocker therapy using other agents, as well as in a large cohort of men with LUTS, remains to be determined.

Philipp Dahm – One of the best experts on this subject based on the ideXlab platform.

  • AlphaBlockers after shock wave lithotripsy for renal or ureteral stones in adults.
    The Cochrane database of systematic reviews, 2020
    Co-Authors: Makinna Oestreich, Robin W.m. Vernooij, Niranjan J. Sathianathen, Eu Chang Hwang, Gretchen M Kuntz, Alex Koziarz, Charles D. Scales, Philipp Dahm

    Abstract:

    Background Shock wave lithotripsy (SWL) is a widely used method to treat renal and ureteral stone. It fragments stones into smaller pieces that are then able to pass spontaneously down the ureter and into the bladder. AlphaBlockers may assist in promoting the passage of stone fragments, but their effectiveness remains uncertain. OBJECTIVES: To assess the effects of AlphaBlockers as adjuvant medical expulsive therapy plus usual care compared to placebo and usual care or usual care alone in adults undergoing shock wave lithotripsy for renal or ureteral stones. Search methods We performed a comprehensive literature search of the Cochrane Library, the Cochrane Database of Systematic Reviews, MEDLINE, Embase, several clinical trial registries and grey literature for published and unpublished studies irrespective of language. The date of the most recent search was 27 February 2020. Selection criteria We included randomized controlled trials of adults undergoing SWL. Participants in the intervention group had to have received an AlphaBlocker as adjuvant medical expulsive therapy plus usual care. For the comparator group, we considered studies in which participants received placebo. Data collection and analysis Two review authors independently selected studies for inclusion/exclusion, and performed data abstraction and risk of bias assessment. We conducted meta-analysis for the identified dichotomous and continuous outcomes using RevManWeb according to Cochrane methods using a random-effects model. We judged the certainty of evidence on a per outcome basis using GRADE. Main results We included 40 studies with 4793 participants randomized to usual care and an AlphaBlocker versus usual care alone. Only four studies were placebo controlled. The mean age of participants was 28.6 to 56.8 years and the mean stone size prior to SWL was 7.1 mm to 13.2 mm. The most widely used AlphaBlocker was tamsulosin; others were silodosin, doxazosin, terazosin and alfuzosin. AlphaBlockers may improve clearance of stone fragments after SWL (risk ratio (RR) 1.16, 95% confidence interval (CI) 1.09 to 1.23; I² = 78%; studies = 36; participants = 4084; low certainty evidence). Based on the stone clearance rate of 69.3% observed in the control arm, an AlphaBlocker may increase stone clearance to 80.4%. This corresponds to 111 more (62 more to 159 more) participants per 1000 clearing their stone fragments. AlphaBlockers may reduce the need for auxiliary treatments after SWL (RR 0.67, 95% CI 0.45 to 1.00; I² = 16%; studies = 12; participants = 1251; low certainty evidence), but also includes the possibility of no effect. Based on a rate of auxiliary treatments in the usual care arm of 9.7%, AlphaBlockers may reduce the rate to 6.5%. This corresponds 32 fewer (53 fewer to 0 fewer) participants per 1000 undergoing auxiliary treatments. AlphaBlockers may reduce major adverse events (RR 0.60, 95% CI 0.46 to 0.80; I² = 0%; studies = 7; participants = 747; low certainty evidence). Major adverse events occurred in 25.8% of participants in the usual care group; AlphaBlockers would reduce this to 15.5%. This corresponds to 103 fewer (139 fewer to 52 fewer) major adverse events per 1000 with AlphaBlocker treatment. None of the reported major adverse events appeared drug-related; most were emergency room visits or rehospitalizations. AlphaBlockers may reduce stone clearance time in days (mean difference (MD) -3.74, 95% CI -5.25 to -2.23; I² = 86%; studies = 14; participants = 1790; low certainty evidence). We found no evidence for the outcome of quality of life. For those outcomes for which we were able to perform subgroup analyses, we found no evidence of interaction with stone location, stone size or type of AlphaBlocker. We were unable to conduct an analysis by lithotripter type. The results were also largely unchanged when the analyses were limited to placebo controlled studies and those in which participants explicitly only received a single SWL session. Authors’ conclusions Based on low certainty evidence, adjuvant AlphaBlocker therapy following SWL in addition to usual care may result in improved stone clearance, less need for auxiliary treatments, fewer major adverse events and a reduced stone clearance time compared to usual care alone. We did not find evidence for quality of life. The low certainty of evidence means that our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect.

  • desmopressin for treating nocturia in men
    Cochrane Database of Systematic Reviews, 2017
    Co-Authors: Jae Hung Jung, Caitlin J Bakker, Mark H Ebell, Philipp Dahm

    Abstract:

    Background
    Nocturia is the bothersome symptom of awakening one or more times per night to void. Desmopressin is a commonly used medication for treating nocturia.

    Objectives
    To assess the effects of desmopressin as compared to other interventions in the treatment of nocturia in men.

    Search methods
    We performed a comprehensive search of medical literature with no restrictions on the language of publication or publication status. The date of the latest search of all databases was August 2017.

    Selection criteria
    We included randomized or quasi-randomized trials. Inclusion criteria were men with nocturia defined as one or more voids per night. Trials of children, adults with primary or secondary enuresis or underlying distinct disorders were excluded.

    Data collection and analysis
    Two review authors independently classified studies and abstracted data from the included studies. We performed statistical analyses using a random-effects model and interpreted data according to the Cochrane Handbook for Systematic Reviews of Interventions.

    Main results
    We included 14 studies with 2966 randomized men across five comparisons.

    Desmopressin versus placebo: based on short-term follow-up (up to three months), desmopressin may have a similar effect on the number of nocturnal voids (mean difference (MD) -0.46, 95% confidence interval (CI) -0.94 to 0.01; low-quality evidence). We are uncertain about the effect of desmopressin on major adverse events at short-term follow-up (risk ratio (RR) 0.97, 95% CI 0.10 to 9.03; very low-quality evidence). For intermediate-term follow-up (three to 12 months), desmopressin may reduce the number of nocturnal voids in an appreciable number of participants (MD -0.85, 95% CI -1.17 to -0.53; low-quality evidence). Desmopressin may result in little or no difference in major adverse events at intermediate-term follow-up (RR 3.05, 95% CI 0.13 to 73.39; low-quality evidence). We found no evidence on quality of life. Subgroup analyses suggest a larger effect with oral, higher-dose formulations of desmopressin and in men with documented nocturnal polyuria.

    Desmopressin versus behavior modification: there were no data regarding the effect on the number of nocturnal voids, quality of life, or major adverse events.

    Desmopressin versus AlphaBlocker: based on short-term follow-up, desmopressin likely has a similar effect on the number of nocturnal voids (MD 0.30, 95% CI -0.20 to 0.80; moderate-quality evidence) and quality of life (MD 0.00, 95% CI -0.35 to 0.35; moderate-quality evidence). There were no major adverse events in either study group.

    Desmopressin plus AlphaBlocker versus AlphaBlocker alone: based on short-term follow-up, combination therapy likely results in a small, unimportant reduction in the number of nocturnal voids (MD -0.47, 95% CI -0.73 to -0.21; moderate-quality evidence) and quality of life (MD -0.29, 95% CI -0.51 to -0.07; moderate-quality evidence). The risk of major adverse events may be similar (RR 0.30, 95% CI 0.01 to 7.32; low-quality evidence).

    Desmopressin plus AlphaBlocker versus AlphaBlocker plus an anticholinergic: based on short-term follow-up, combination therapy likely results in little or no difference in the number of nocturnal voids (MD -0.43, 95% CI -0.97 to 0.11; moderate-quality evidence). We found no evidence on quality of life. There were no major adverse events in either study group.

    Authors’ conclusions
    Desmopressin may reduce the number of nocturnal voids in an appreciable number of participants compared to placebo in intermediate-term (three to 12 months) follow-up without increase in major adverse events. We found no evidence to compare its effects to behavior modification. The effect on the number of nocturnal voids is likely similar to that of AlphaBlockers short-term with very infrequent major adverse events. There appears to be no added benefit in the combined use of desmopressin with an AlphaBlocker or an anticholinergic. The findings of this review were limited by short-term follow-up, study limitations, and imprecision.

  • Desmopressin for treating nocturia in men.
    The Cochrane database of systematic reviews, 2017
    Co-Authors: Jae Hung Jung, Caitlin J Bakker, Mark H Ebell, Philipp Dahm

    Abstract:

    Nocturia is the bothersome symptom of awakening one or more times per night to void. Desmopressin is a commonly used medication for treating nocturia.
    To assess the effects of desmopressin as compared to other interventions in the treatment of nocturia in men.
    We performed a comprehensive search of medical literature with no restrictions on the language of publication or publication status. The date of the latest search of all databases was August 2017.
    We included randomized or quasi-randomized trials. Inclusion criteria were men with nocturia defined as one or more voids per night. Trials of children, adults with primary or secondary enuresis or underlying distinct disorders were excluded.
    Two review authors independently classified studies and abstracted data from the included studies. We performed statistical analyses using a random-effects model and interpreted data according to the Cochrane Handbook for Systematic Reviews of Interventions.
    We included 14 studies with 2966 randomized men across five comparisons. Desmopressin versus placebo: based on short-term follow-up (up to three months), desmopressin may have a similar effect on the number of nocturnal voids (mean difference (MD) -0.46, 95% confidence interval (CI) -0.94 to 0.01; low-quality evidence). We are uncertain about the effect of desmopressin on major adverse events at short-term follow-up (risk ratio (RR) 0.97, 95% CI 0.10 to 9.03; very low-quality evidence). For intermediate-term follow-up (three to 12 months), desmopressin may reduce the number of nocturnal voids in an appreciable number of participants (MD -0.85, 95% CI -1.17 to -0.53; low-quality evidence). Desmopressin may result in little or no difference in major adverse events at intermediate-term follow-up (RR 3.05, 95% CI 0.13 to 73.39; low-quality evidence). We found no evidence on quality of life. Subgroup analyses suggest a larger effect with oral, higher-dose formulations of desmopressin and in men with documented nocturnal polyuria. Desmopressin versus behavior modification: there were no data regarding the effect on the number of nocturnal voids, quality of life, or major adverse events. Desmopressin versus AlphaBlocker: based on short-term follow-up, desmopressin likely has a similar effect on the number of nocturnal voids (MD 0.30, 95% CI -0.20 to 0.80; moderate-quality evidence) and quality of life (MD 0.00, 95% CI -0.35 to 0.35; moderate-quality evidence). There were no major adverse events in either study group. Desmopressin plus AlphaBlocker versus AlphaBlocker alone: based on short-term follow-up, combination therapy likely results in a small, unimportant reduction in the number of nocturnal voids (MD -0.47, 95% CI -0.73 to -0.21; moderate-quality evidence) and quality of life (MD -0.29, 95% CI -0.51 to -0.07; moderate-quality evidence). The risk of major adverse events may be similar (RR 0.30, 95% CI 0.01 to 7.32; low-quality evidence). Desmopressin plus AlphaBlocker versus AlphaBlocker plus an anticholinergic: based on short-term follow-up, combination therapy likely results in little or no difference in the number of nocturnal voids (MD -0.43, 95% CI -0.97 to 0.11; moderate-quality evidence). We found no evidence on quality of life. There were no major adverse events in either study group.
    Desmopressin may reduce the number of nocturnal voids in an appreciable number of participants compared to placebo in intermediate-term (three to 12 months) follow-up without increase in major adverse events. We found no evidence to compare its effects to behavior modification. The effect on the number of nocturnal voids is likely similar to that of AlphaBlockers short-term with very infrequent major adverse events. There appears to be no added benefit in the combined use of desmopressin with an AlphaBlocker or an anticholinergic. The findings of this review were limited by short-term follow-up, study limitations, and imprecision.

Richard C Rink – One of the best experts on this subject based on the ideXlab platform.

  • Alpha Blocker therapy for children with dysfunctional voiding and urinary retention.
    The Journal of Urology, 2003
    Co-Authors: Mark P Cain, Paul F Austin, C D Anthony Herndon, Richard C Rink

    Abstract:

    ABSTRACTPurpose: Alpha Blocker therapy has been successfully used to decrease residual urine in children with complex neuropathic and nonneuropathic voiding dysfunction. We evaluated the safety and efficacy of using selective Alpha Blocker therapy for children with uncomplicated voiding dysfunction and underlying poor bladder emptying.Materials and Methods: A total of 55 patients with a mean age of 7.9 years presented with symptoms of urinary incontinence, urgency and urinary tract infection. All patients had increased post-void residual (PVR) on bladder ultrasound, with a mean residual volume of 65 ml (22% of age expected capacity). All patients were treated with doxazosin, a selective α-1 adrenergic antagonist, at dosages of 0.5 mg to 2.0 mg daily. Of the patients 38 were treated at presentation with a regimen of anticholinergics, timed voiding and antibiotic prophylaxis before initiating Alpha Blocker therapy. Patients were reevaluated with post-void ultrasound of the bladder 6 weeks after initiating a…

  • Alpha Blocker therapy for children with dysfunctional voiding and urinary retention.
    The Journal of urology, 2003
    Co-Authors: Mark P Cain, Paul F Austin, C D Anthony Herndon, Richard C Rink

    Abstract:

    Alpha Blocker therapy has been successfully used to decrease residual urine in children with complex neuropathic and nonneuropathic voiding dysfunction. We evaluated the safety and efficacy of using selective Alpha Blocker therapy for children with uncomplicated voiding dysfunction and underlying poor bladder emptying.
    A total of 55 patients with a mean age of 7.9 years presented with symptoms of urinary incontinence, urgency and urinary tract infection. All patients had increased post-void residual (PVR) on bladder ultrasound, with a mean residual volume of 65 ml (22% of age expected capacity). All patients were treated with doxazosin, a selective Alpha-1 adrenergic antagonist, at dosages of 0.5 mg to 2.0 mg daily. Of the patients 38 were treated at presentation with a regimen of anticholinergics, timed voiding and antibiotic prophylaxis before initiating Alpha Blocker therapy. Patients were reevaluated with post-void ultrasound of the bladder 6 weeks after initiating Alpha Blocker therapy.
    After starting doxazosin average PVR decreased to 8 ml (p <0.0001), representing an 88% reduction in residual urine (or reduction to only 2.7% of age expected bladder capacity). Medication was discontinued in 2 patients due to minor side effects.
    Selective Alpha Blocker therapy appears to be effective for improving bladder emptying in children with an overactive bladder, wetting, recurrent infection and increased PVR urine. This therapy may be used as either a replacement or in addition to biofeedback in patients with urinary retention. Further investigation, including a prospective randomized trial of Alpha Blocker therapy in children with urinary tract dysfunction, is warranted based on the findings of our study.

  • Voiding Dysfunction Alpha Blocker THERAPY FOR CHILDREN WITH DYSFUNCTIONAL VOIDING AND URINARY RETENTION
    , 2003
    Co-Authors: Mark P Cain, Paul F Austin, C D Anthony Herndon, Richard C Rink

    Abstract:

    Purpose: Alpha Blocker therapy has been successfully used to decrease residual urine in children with complex neuropathic and nonneuropathic voiding dysfunction. We evaluated the safety and efficacy of using selective Alpha Blocker therapy for children with uncomplicated voiding dysfunction and underlying poor bladder emptying. Materials and Methods: A total of 55 patients with a mean age of 7.9 years presented with symptoms of urinary incontinence, urgency and urinary tract infection. All patients had increased post-void residual (PVR) on bladder ultrasound, with a mean residual volume of 65 ml (22% of age expected capacity). All patients were treated with doxazosin, a selective -1 adrenergic antagonist, at dosages of 0.5 mg to 2.0 mg daily. Of the patients 38 were treated at presentation with a regimen of anticholinergics, timed voiding and antibiotic prophylaxis before initiating Alpha Blocker therapy. Patients were reevaluated with post-void ultrasound of the bladder 6 weeks after initiating Alpha Blocker therapy. Results: After starting doxazosin average PVR decreased to 8 ml (p 0.0001), representing an 88% reduction in residual urine (or reduction to only 2.7% of age expected bladder capacity). Medication was discontinued in 2 patients due to minor side effects. Conclusions: Selective Alpha Blocker therapy appears to be effective for improving bladder emptying in children with an overactive bladder, wetting, recurrent infection and increased PVR urine. This therapy may be used as either a replacement or in addition to biofeedback in patients with urinary retention. Further investigation, including a prospective randomized trial of Alpha Blocker therapy in children with urinary tract dysfunction, is warranted based on the findings of our study.