Is there a place for combination medical therapy?

Medical therapy for lower urinary tract symptoms and benign prostatic hyperplasia with either alpha adrenergic receptor blockers or 5α-reductase inhibitors has become the most common treatment choice over the past 10 years, replacing transurethral resection of the prostate as the standard intervention. Both classes of drugs have demonstrated efficacy and safety in numerous randomized, placebo-controlled clinical trials. Because of the two different mechanisms of action proposed for these two classes of drugs, the idea of utilizing both to enhance efficacy appears logical and promising. However, few well-conducted trials are available to address the issue of combination medical therapy for lower urinary tract symptoms and benign prostatic hyperplasia, the majority of the data available coming from trials with significant design flaws. Two prospective, randomized, placebo-controlled studies have been conducted comparing the safety and efficacy of an alpha blocker-finasteride combination versus placebo in large numbers of patients. Neither one of the two trials suggests superior efficacy of the combination therapy, whereas some of the less well-controlled studies do. Recent evidence suggests superior efficacy of finasteride in men with large glands and higher serum prostate-specific antigen levels in terms of symptoms and outcome prevention. A trial addressing this specific patient population, in whom theoretically the most benefit might be gained from combining both classes of drugs to address symptoms and prevent outcomes, would be a welcome addition to our knowledge base.