Vibegron as add-on for storage symptoms in men on an alpha-blocker

Design

Systematic review and Bayesian network meta-analysis of RCTs

Population

Men with BPH and persistent storage symptoms on alpha-blockers, 18 trials

Primary outcome

Micturitions and urgency episodes per 24 hours

Effect

Vibegron vs control -0.81 voids/24 h (-1.31 to -0.38); vs mirabegron inconclusive

This Bayesian network meta-analysis included 18 randomised trials (16 with usable data) of add-on treatment for persistent overactive bladder symptoms in men with benign prostatic hyperplasia already taking an alpha-blocker.

Compared with control, vibegron reduced voids by 0.81 per 24 hours (95% credible interval 0.38 to 1.31) and urgency episodes by 0.96 per day; mirabegron reduced voids by 0.46. The indirect comparison of vibegron with mirabegron favoured vibegron numerically, but all credible intervals included no difference. Adverse event odds were inconclusive. Confidence was moderate for vibegron against control and low for the head-to-head comparison and safety; the vibegron estimates rested on two trials.

Beta-3 agonists are attractive in older men because they avoid the cognitive burden of antimuscarinics. Either vibegron or mirabegron is reasonable; choice can follow availability, cost and blood pressure. Retention risk should still be considered.

• Consider a beta-3 agonist when storage symptoms persist despite an alpha-blocker.
• Prefer beta-3 agonists over antimuscarinics in older men at risk of cognitive impairment.
• Choose between vibegron and mirabegron on availability and cost; neither was shown superior.
• Check blood pressure when starting mirabegron, and review symptoms at four to eight weeks.

Why it matters

It supports beta-3 agonists as add-on therapy without tying the choice to one agent.

Don't overread it

The vibegron estimates rest on two trials, and the comparison with mirabegron is indirect and inconclusive.

The statistics, in plain English

A credible interval is the Bayesian equivalent of a confidence interval. When it includes zero, as it did for vibegron versus mirabegron, no difference has been shown, whatever the probability figure quoted.

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