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19 Cards in this Set
- Front
- Back
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How do you categorize severity of BPH?
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AUA score
Mild is 7 or less Moderate is 8-19 Severe is 20 or higher |
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What are your general therapy options for each case of severity?
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Mild - watchful waiting
Moderate - 5 alpha reductase inhibitors or alpha antagonists Severe - surgery |
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Describe the Pathophysiology of BPH.
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Prostate contains alpha adrenergic receptors that stimulate smooth muscle contraction
DHT (converted from testosterone via 5 alpha reductase) stimulates prostate growth Detrusor muscle (bladder) isn't able to contract strong enough to pass urine past constricted prostate |
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What are some drugs that can exacerbate BPH?
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Testosterone (Increased DHT leads to increased stimulation and prostate growth)
Alpha adrenergic agonists (Constrict prostate smooth muscle) - Decongestants like pseudoephedrine Anti-cholinergics (relax detrusor muscle) - Tri-cyclic anti-depressants like amitriptyline or |
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What are your pharmacologic options in moderate BPH?
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Alpha adrenergic antagonists (Tamsulosin, Doxazosin, Terazosin, Alfuzosin)
5 alpha reductase inhibitors (Dutasteride,Finasteride) |
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Which alpha antgonist is alpha 1 selective and what is the significance of this?
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Tamsulosin (3rd generation)
This means that this agent will not cause peripheral vasodilation. It is a good choice in patients that cannot tolerate hypotension. If the patient has hypertension, a nonselective agent would be ideal. |
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Terazosin, Doxazosin and alfuzosin are 2nd generation alpha adrenergic antagonists. Which of these will tend to cause the least peripheral vasodilation?
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Alfuzosin
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What is the indication to start 5 alpha reductase inhibitors?
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Prostate size > 40 g
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What is a major consideration in starting a 5 alpha reductase inhibitor?
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Sexual dysfunction. Is this patient sexually active?
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How do you want to counsel someone taking a nonselective alpha antagonist? (Terazosin, Doxazosin, Alfuzosin)
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Take it at bedtime to avoid hypotensive side effects during the day (increased risk of falls)
Rise slowly to avoid falls |
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How would you counsel someone taking a 5 alpha reductase inhibitor like finasteride or dutasteride?
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It will take 3-6 months to shrink the prostate and work
Possible sexual dysfunction |
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How would you treat someone with symptoms of BPH and a prostate larger than 40 g?
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You want to use both an alpha antagonist to help relief symptoms now and a 5 alpha reductase inhibitor to shrink the prostate gland. Your choice of alpha blocker will be based on the patients risk of hypotension. Finasteride and Dutasteride are both good options showing similar efficacy.
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Which drugs need to be titrated slowly and why?
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Terazosin and Doxazosin b/c these are 2nd generation alpha antagonists that cause peripheral vasodilation. You titrate up slowly to avoid orthostatic hypotension and first-dose syncope.
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If a patient is at risk for hypotension, you would want to go with Tamsulosin to minimize the risk of orthostatic hypotension. However, what if this patient also began having ejaculatory dysfunction as well?
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You would want to switch to alfuzosin, because it tends to cause less peripheral effects than the other 2nd generation agents, and also causes less ejaculatory dysfunction than Tamsulosin.
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How would you treat a patient who has more mild symptoms of BPH, with a prostate size > 40g?
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You could then leave out the alpha antagonist as long as he is not in distress, but you would want to chemically reduce the prostate with a 5 alpha reductase inhibitor.
Starting a 5 alpha reductase inhibitor monotherapy however is very rare. |
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What is the dose for Tamsulosin?
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0.4 mg po daily
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What is the dose for Terazosin?
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1 mg po daily - Titrate up slowly from this dose
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What is the dose for Alfuzosin?
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10 mg po daily
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What is the dose for Finasteride?
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5 mg pg daily
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