Virtually all men eventually develop benign prostatic hypertrophy (BPH). Our goals of therapy are twofold, improve quality of life and prevent surgery. Today’s NEJM has an important article – summarized in this story – Drug Combo Can Fight Enlarged Prostate

The two drugs in the study, doxazosin and finasteride, are now widely used, but not normally combined, to treat an enlarged prostate. The study was designed to decide if they can be teamed up for a stronger effect. Often, such a drug combination fails to greatly boost effectiveness.

This time, though, it succeeded. On its own, each drug reduced the risk of worsening symptoms by about a third. Together, they worked twice as well, cutting the risk by two-thirds.

Over five years, the condition worsened in about 10 percent of patients on only one drug, but in only 5 percent of those who took the combination. Without either drug, the condition deteriorated in 17 percent.

“Although we had predicted that combination therapy would be more effective than either drug alone, the magnitude of risk reduction was surprising,” said chief researcher Dr. John McConnell, also at Southwestern Medical Center.

Doxazosin relaxes muscles that tend to choke off the flow of urine. It is usually the first drug given for an enlarged prostate. Finasteride, which also goes by the brand name Proscar, slowly shrinks the prostate gland itself. It is contained in smaller amounts in the baldness drug Propecia.

The two-drug combination can cost about $3 a day.

Half of men ages 51 to 60 and up to 90 percent of those over 80 have enlarged prostates, according to the American Urological Association.

For those who subscribe to NEJM – The Long-Term Effect of Doxazosin, Finasteride, and Combination Therapy on the Clinical Progression of Benign Prostatic Hyperplasia. The accompanying editorial puts the issue into proper perspective.

McConnell et al., concentrating on the risk of disease progression, confirmed that combination therapy was no better than monotherapy at one year. But whereas there was disease progression in the placebo group over a four-year period, combination therapy reduced the risk of symptom progression by 66 percent, the risk of acute urinary retention by 81 percent, and the need for invasive therapy by 67 percent. The authors concluded that combination therapy with an alpha-blocker and a 5-reductase inhibitor reduced the risk of overall clinical progression of benign prostatic hyperplasia significantly more than did treatment with either drug alone. Thus, two drugs are better than one.

This study should change practice. If (or rather when) I develop symptomatic BPH I have a study to guide my treatment.

If any readers are wondering whether they have clinical significant BPH, the AUA symptom score can help. All patients in the study had a score of at least 8. CHECK YOUR AUA SYMPTOM SCORE

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