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March 21, 2007

Treatment of Men With Lower Urinary Tract Symptoms and Overactive Bladder

Author Affiliations

Letters Section Editor: Robert M. Golub, MD, Senior Editor.

JAMA. 2007;297(11):1191-1193. doi:10.1001/jama.297.11.1192-a

To the Editor: Dr Kaplan and colleagues1 assessed the efficacy of tolterodine and tamsulosin for treatment of men with lower urinary tract symptoms and overactive bladder. We are concerned about 2 issues that may have had an effect on the observed efficacy and tolerability of the evaluated treatments.

First, there was no mention of adrenergic agonists or drugs with adverse anticholinergic effects in the list of excluded medical treatments. Adrenergic agonists, particularly those that possess activity at the α-1 receptor—such as pseudoephedrine, ephedrine, and phenylephrine—can exacerbate the symptoms of BPH.2 Use of an α-1 agonist would also be expected to decrease the response to tamsulosin due to competitive inhibition at the receptor. In addition, first-generation antihistamines—such as chlorpheniramine and diphenhydramine—cause adverse anticholinergic effects and can be associated with urinary difficulties in men with a history of prostate problems.3 If the exclusion criteria of antimuscarinic agents included antihistamines, it was not clearly stated. Because the trial occurred in winter and spring, there was the potential for frequent use of these products. The additive or inhibitory effect of decongestants or antihistamines with tolterodine or tamsulosin could have led to decreased efficacy and increased adverse effects if allowed in the treatment groups.

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