OBJECTIVES: Alpha-blockers (α-blockers) are considered as the first-line therapy, even though a range of drugs are available to treat benign prostatic hyperplasia (BPH). The present study aims to estimate the comparative effectiveness along with the safety of α-blockers for BPH.

METHODS: A comprehensive electronic search of PubMed, EMBASE and Cochrane was carried out for relevant studies till August 2022. Randomised controlled trials that compare the efficacy and safety of α-blockers with one another or placebo were eligible for inclusion. Frequentist network meta-analysis (NMA) was employed to synthesize direct and indirect evidence. The drugs were ranked based on the p-scores derived using the surface under the cumulative ranking (SUCRA).

RESULTS: The NMA synthesized evidence from 22 studies covering 3,371 patients and six kinds of α-blockers with 12 dose categories. Compared with the placebo, tamsulosin 0.4 mg (SMD: -6.31; 95% CI: [-10.05; -2.57]), naftopidil 50mg (SMD: -5.17; 95% CI: [-9.76; -0.58]) and silodosin 8mg (SMD: -3.84; 95% CI: [-7.72; 0.04]) has significantly reduced international prostate symptom score (IPSS). According to the pairwise comparison, doxazosin 8mg (SMD: -1.35; 95% CI: [-4.68; 1.98]) improved the quality of life (QoL). Additionally, tamsulosin 0.4 mg (SMD: -15.99; 95% CI: [ -3.15; 35.12]) reduced the post-void residual (PVR). Based on the p-score, tamsulosin 0.4 mg had the highest probability of ranking for IPSS, PVR, and maximum urinary flow rate (Qmax), whereas doxazosin 8 mg had the highest probability of improving QoL. A total of 297 adverse events were reported among the α-blockers, silodosin (190) dominated with a notable number of AEs. The most prominent AEs included ejaculation dysfunction, dizziness and hypotension.

CONCLUSIONS: Generated evidence suggests that α-blockers are beneficial for BPH, tamsulosin being the most effective and comparatively safe as first-line therapy, with relatively few AEs.