Antibiotics and alpha-blockers best for chronic prostatitis: meta-analysis
Last Updated: 2011-01-04 17:40:30 -0400 (Reuters Health)
By Karla Gale
NEW YORK (Reuters Health) - Alpha-blockers and antibiotics relieve symptoms of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) better than other drug therapies, according to a meta-analysis published online today in the Journal of the American Medical Association.
But the best tack to take for this difficult-to-treat condition may be to target these and other treatments - anti-inflammatories, finasteride, glycosaminoglycans - to each patient's symptoms, the researchers suggest.
Because the treatment options are so numerous and the number of studies for each option was limited, they had to base their conclusions on more statistical inference than usual.
Led by Dr. Thunyarat Anothaisintawee at Ramathibodi Hospital in Bangkok, Thailand, the research team found that the benefits of any treatment were modest, probably reflecting the diversity of clinical phenotypes "based on the various etiologies and pathogenic pathways that underlie this enigmatic condition."
Indeed, Dr. Scott I. Zeitlin, who reviewed the study for Reuters Health, said "treatment should be directed in a multimodal fashion based upon the phenotypic domains that the patients fall under."
"There is a role for alpha blockers and antibiotics," he added, "but I tend to see patients that are far from treatment naïve and they need to be treated like snowflakes -- each one being unique." Dr. Zeitlin, based at the David Geffen School of Medicine at UCLA, was not involved in this research.
Dr. Anothaisintawee and colleagues searched MEDLINE and EMBASE for randomized controlled trials comparing drug treatments for CP/CPPS categories IIIA (inflammatory) or IIIB (noninflammatory).
They identified 23 trials, published since 1999, studying alpha-blockers, antibiotics, steroidal and nonsteroidal anti-inflammatory drugs, finasteride, glycosaminoglycans, phytotherapy, pregabalin, and placebo.
Sample sizes were generally small (range 17 to 321 per trial). The mean age of the subjects varied from 29 to 56, and treatments lasted from four weeks to one year.
Because of the large number of treatment options and small number of studies for any given treatment, the authors conducted a network meta-analysis to better identify the most effective treatment. (In a network meta-analysis, rather than summing the results from trials that compared the same two (or more) treatments, the researchers compare different treatments by inference. For instance, if Alaska is bigger than New York, and New York is bigger than Rhode Island, then Alaska must be bigger than Rhode Island. This type of analysis is more vulnerable to error than a regular meta-analysis.)
The National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) was the primary outcome.
Total symptom scores at follow-up were identified from 13 studies of 1541 subjects. The reduction in score compared with placebo was greatest for alpha-blockers plus antibiotics (-13.8 units). Results were also statistically significant for alpha-blocker monotherapy (-11.0), antibiotic monotherapy (-9.8) and finasteride (-4.6). But after correcting for publication bias and small-study effects, alpha-blockers on their own had no significant treatment effect.
Pain scores followed a similar pattern (-5.7, -4.1, -4.4 and -3.0, respectively).
Thirteen studies included data on voiding scores for 631 participants, for which only alpha-blockers and antibiotics were significantly better than placebo; dual therapy was most effective. Twelve studies examining quality of life showed the same outcome.
However, in studies of treatment response rate, anti-inflammatories were best (relative risk 1.8), followed by phytotherapy (RR 1.6) and alpha-blockers (RR 1.3) compared with placebo.
The authors advise that when voiding is the worst problem, an alpha blocker may be most helpful, whereas patients with a history of urinary tract infection might respond best to antibiotics. When pain is predominant, an anti-inflammatory and/or gabapentinoid would be the best choice.
"Alpha blockers can easily be daily drugs (and we use these indefinitely in patients with voiding dysfunction)," Dr. Zeitlin said in his email. But antibiotics pose greater risks, he warned. "In addition to the common side effects, there is a black box warning associated with quinolone antibiotics that is quite worrisome."
"CP/CPPS therapy goes beyond pharmaceuticals," he continued. "It includes phytotherapies and adjuvant non medication therapies as well...such as cognitive-behavioral and physical therapies, acupuncture and biofeedback. Further phenotypically guided studies will determine what is best for our patients."
He pointed out that CP/CPPS patients are very heterogeneous and are better described using the phenotypic system termed UPOINT, which contains six domains (urinary, psychosocial, organ specific, infection, neurologic/systemic, and tenderness of skeletal muscles).
"I am optimistic that when we make the best diagnoses we will make the best decisions," Dr. Zeitlin concluded. "In 2011 the best treatment(s) for this group of patients remains frustrating and elusive, and as the general in the 1983 movie WarGames said, 'Goddammit, I'd piss on a spark plug if I thought it'd do any good!'"
Source:http://bit.ly/fegPF2
JAMA 2011;305:78-86.
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