Mirabegron Treatment for BPH Patients

Introduction to Mirabegron

Mirabegron is effective and safe for treating overactive bladder (OAB) symptoms in men with BPH, particularly when storage symptoms persist despite or alongside alpha-blocker therapy, as recommended by the European Association of Urology 1, 2

The drug works as a beta-3 adrenergic agonist, relaxing the detrusor muscle during bladder filling without affecting voiding function, according to the European Urology guidelines 1, 3

The 2023 European Association of Urology guidelines support combination therapy of mirabegron with tamsulosin for men with persistent OAB symptoms despite alpha-blocker monotherapy, with significant improvements in OAB symptoms 2
The MATCH and PLUS trials demonstrated that adding mirabegron to tamsulosin significantly improved OAB symptoms without increasing urinary retention risk, as reported in European Urology 2

Start with mirabegron 25 mg once daily, particularly in older patients (≥65 years) with multiple comorbidities, as recommended by the European Urology guidelines 4, 5
The 25 mg dose has demonstrated particular safety and efficacy in elderly patients with comorbidities, according to European Urology 3, 6

Monitor blood pressure at baseline and during initial treatment, especially in hypertensive patients, as advised by the European Urology guidelines 3, 4
Cardiovascular safety analysis shows no significant concerns with mirabegron treatment, as reported in European Urology 3, 5

If patient on alpha-blocker with persistent storage symptoms: Add mirabegron 25-50 mg once daily, as recommended by the European Association of Urology 2
If patient has both voiding and storage symptoms, treatment-naïve: Consider combination therapy from the start (alpha-blocker + mirabegron), according to the European Urology guidelines 2
If inadequate response to mirabegron + alpha-blocker after 6 months: Consider triple therapy by adding antimuscarinic (solifenacin 5 mg) to mirabegron, as suggested by the European Urology guidelines 6, 4, 5

Better adherence and persistence compared to antimuscarinics, as reported in European Urology 1

Do not use mirabegron as monotherapy for significant voiding symptoms—it should be combined with alpha-blockers in men with both obstructive and storage symptoms, as recommended by the European Association of Urology 2
Avoid starting at 50 mg in elderly patients or those with multiple comorbidities—begin with 25 mg, as advised by the European Urology guidelines 4, 5

The European Association of Urology guidelines recognize that BPH treatment requires addressing both the bladder storage symptoms and the prostatic obstruction component, and while finasteride addresses prostate enlargement, it does not directly treat overactive bladder symptoms that commonly coexist in BPH patients, with a strength of evidence supporting the use of combination therapy 7, 8
Finasteride reduces progression risk, but does not directly treat overactive bladder symptoms, making combination therapy with mirabegron a viable option for patients with BPH and overactive bladder symptoms, as recommended by the European Association of Urology guidelines 7, 8

The European Association of Urology guidelines suggest that post-void residual volume changes are not clinically significant with mirabegron addition, particularly reassuring given that finasteride patients may already have some degree of bladder outlet obstruction 7, 8
Finasteride patients may already have some degree of bladder outlet obstruction, but the addition of mirabegron does not significantly increase the risk of urinary retention, according to the European Association of Urology guidelines 7, 8

The European Association of Urology guidelines recommend not discontinuing finasteride when adding mirabegron, as finasteride provides long-term benefits in reducing acute urinary retention risk and need for surgery, with a strength of evidence supporting the continued use of finasteride 7, 8