NAPLEX: Male & Female Health - BPH

benign prostatic hyperplasia (BPH)

Layer of tissue surrounding the enlarged prostate stops it from expanding, causing gland to press against or pinch urethra → lower urinary tract sx → bladder becomes thicker + irritated → contracts when small amounts of urine → frequent urination + eventually loses ability to empty itself

when does prostate gland enlargement start to typically cause problems

>65 y/o

drugs that can worsen BPH

Centrally acting anticholinergics (benztropine)

Drugs with anticholinergic effects

- Antihistamines (diphenhydramine)

- Decongestants (pseudophedrine)

- Phenothiazines (prochlorperazine)

TCAs (amitriptyline)

Caffeine

Diuretics

SNRI

Testosterone products

BPH diagnostic criteria

Digital rectal exam

Urinalysis

Serum prostate specific antigen (PSA)

BPH sx

Hesitancy, intermittent urine flow, straining or weak stream of urine

Urinary urgency and leaking or dribbling

Urinary frequency especially nocturia

Incomplete emptying of bladder (bladder feels full)

Bladder outlet obstruction

BPH complications

acute renal failure

BPH treatment

mild disease

watchful waiting

yearly assessments

BPH treatment

moderate-severe disease

1st line = alpha blockers

add on or alt: 5 alpha reductase inhibitors (for men with enlarged prostate)

peripherally acting anticholinergics (tolterodine)

- if PVR <250-300 mL

beta 3 receptor agonists

PDE-5 inhibitors: tadalafil (cialis)

alpha blockers and cataracts surgery

Risk of developing intraoperative floppy iris syndrome during cataract surgery

If cataract surgery planned delay alpha blocker treatment until surgery complete

alpha blocker DDIs

Caution when co administered with PDE-5 inhibitors d/t additive HoTN effects

Caution w drugs that lower BP

Tamsulosin, alfuzosin, silodosin are major CYP450 3A4 substrates - do not use with strong CYP3A4 inhibitors

Silodosin cannot be used with strong P-gp inhibitors such as cyclosporine

Alfuzosin can cause QT prolongation - do not use with other QT prolonging drugs

5 alpha reductase inhibitor DDIs

Finasteride, dutasteride are minor CYP3A4 substrates; strong CYP3A4 inhibitors can increase levels

Do not use proscar if using Propecia for hair loss

beta 3 recepto agonist indication

Can be used for men without elevated post void residual (PVR) urine and when LUTS are predominantly irritative

natural products for BPH

Saw palmetto - unlikely to be effective

Pygeum

Pumpkin seed (beta-sitosterol)

Rye pollen

Lycopene - for prostate cancer prevention

non selective alpha 1 blocker examples

- doxazosin (cardura XL)

- terazosin

selective alpha 1 blockers

- tamsulosin

- alfuzosin

- sidlodosin

alpha 1 blocker SE

Intraoperative floppy iris syndrome

Dizziness

Fatigue

Headache

Abnormal ejaculation (especially with tamsulosin and silodosin)

Fluid retention

Rhinitis (tamsulosin)

Orthostatic HoTN/syncope with first dose

Priapsim

Angina

alpha 1 blocker CI

Silodosin, alfuzosin with strong CYP3A4 inhibitors

Hepatic impairment (C for silodosin, B/C for alfuzosin)

Severe renal impairment (silodosin)

when should alpha 1 blockers be taken

at bedtime to minimize first dose effect of orthostasis/dizziness

how long does it take for non selective alpha 1 blockers to work

4-6 wks

true or false

alpha blockers shrink the prostate and decrease PSA levels

FALSE

Alpha blockers do NOT shrink prostate and do NOT change PSA levels

doxazosin counseling

Cardura is an OROS formulation and can leave a ghost tablet in stool

silodosin counseling

Silodosin can cause retrograde ejaculation - reversible upon discontinuation

populations to avoid alfuzosin in

pt at risk for QT prolongation

5 alpha reductase inhibitor examples

- finasteride

- dutasteride

5 alpha reductase inhibitor SE

Impotence

Decreased libido

Ejaculation disturbances

Breast enlargement / tenderness

Rash

Sexual SE (decrease w time + return to baseline after 1 yr of use)

5 alpha reductase inhibitor CI

Women of child bearing potential

Pregnancy

Children

5 alpha reductase inhibitor preparation warning

Pregnant women should not take or handle these medications as active ingredient can be absorbed through skin from broken or crushed tablets and be detrimental to fetus (NIOSH hazardous drug)

how long does it take to see maximal efficacy of 5 alpha reductase inhibitors

6 mo or more

true or false

5 alpha reductase inhibitors shrink the prostate and decrease PSA levels

TRUE

dutasteride counseling

Swallow dutasteride whole - do not open or chew as contents can cause oropharyngeal irritation

non selective alpha blockers (terazosin, doxazosin) counseling

titrate slowly

give at bedtime

tamsulosin/dutasteride

jalyn

tamsulosin dosing

0.4 mg once daily

no need to titrate for effectiveness