Pharm: Tx of BPH

What symptoms present with BPH?

Lower Urinary Tract Symptoms -> decreased force of stream, weak flow, dribbling, small voided volume

What would be found on lab work of BPH?

Slightly elevated PSA level

What are the 3 AUA symptom index scores based on severity?

Mild: 0-7

Moderate: 8-19

Severe: 20-35

What lifestyle modifications can be added to BPH therapy? (3)

1. Limit fluids before bed

2. Avoid caffeine and alcohol

3. Frequent scheduled voiding

What drugs exacerbate BPH symptoms? (8)

1. Testosterone

2. Adrenergic agonists

3. Decongestant/Pseudophedrine

4. Anticholinergics

5. Antihistamines

6. TCAs

7. Antispasmodics

8. Diuretics

What are the Alpha-1 antagonists that can be used for Mod/Severe BPH treatment? (5)

1. Tamsulosin

2. Doxazosin

3. Terazosin

4. Silodosin

5. Alfuzosin

What are the 5-Alpha Reductase Inhibitors that can be used for Mod/Severe BPH treatment? (2)

1. Finasteride

2. Dutasteride -> may lower dihydrotestosterone more than Finasteride

What is the first-line therapy for uncomplicated BPH?

Alpha-1 antagonists -> reduces AUA

Onset takes days to weeks symptom score by 30-40%

What are the drug-drug interactions of Alpha-1 antagonists?

CYP450 Metabolism

ADE of Alpha-1 antagonists (3)

1. Dizziness

2. Syncope -> take at bedtime

3. Hypotension

More common in non-selective agents

What are the non-selective Alpha-1 antagonists (2)

1. Terazosin

2. Doxazosin

Onset of weeks

What are the selective Alpha-1 antagonists (3)

1. Tamsulosin

2. Silodosin

3. Alfuzosin -> higher concentration in prostate than serum, decreased blood-brain penetration, extended release formula

Onset of days

What are the clinical pearls of Alpha-1 antagonists

1. Titrate slowly to prevent hypotension and syncope

2. Lowers BP

3. If initial starting dose doesn't provide sx relief -> increase Terazosin to 10 mg and Doxazosin to 8 mg

Tamsulosin (Flomax) dosing and administration (3)

Dose: 0.4-0.8 mg daily

2. Administer 30 min after meal

3. Do not crush or chew

Uroselective agent

Finasteride dosing

5 mg daily

What BPH treatment if first-line in Mod/Severe symptoms?

5-Alpha-Reductase Inhibitors -> most effective in patients with larger prostates (> 40 mL)

Onset of action is 3-6 months

What are the contraindications to 5-Alpha-Reductase Inhibitors (3)

1. Pregnancy -> do not handle drug or come into contact with semen taking this medication

2. Men should not give blood until 6 months after last dose

3. Male cause abnormal development of male genital tract

What is the efficacy of 5-Alpha-Reductase Inhibitors

More effective than monotherapy but increased risk of adverse effects with combo therapy

What is the Type-5 (PDE-5) inhibitor used for BPH treatment?

Tadalafil (Cialis) -> do not use with Alpha-1 antagonists due to hypotension risk

What is an alternative/natural therapy for BPH?

Saw Palmetto -> not recommended by current guidelines; may be beneficial as complementary treatment