BPH

Question 1

BPH

Answer 1

Enlargement of prostate due to androgen and estrogen secretion

Question 2

Selective vs Non Selective Alpha - Drugs

Answer 2

Non Selective:

• prazosin
• terazosin
• doxazosin ER

Selective:

• alfuzosin
• doxazosin (higher incidence of first dose effect)
• silodosin (higher incidence of ejaculation issue)
• tamsulosin

Question 3

Non Selective Alphas

Answer 3

• prazosin terazosin doxazosin ER (PTDer)
• Titration is recommended to reduce orthostatic hypotension
• ALL recommended to be taken at bedtime to reduce first dose effect (except ER)
• Syncope common with first dose
• Coadministration of PDE5 cause symptomatic hypotension because both are vasodilators

S/E: dizziness, HA, SOB, weakness, hypotension

Question 4

Alfuzosin

Answer 4

Non Selective 
- 10mg daily 
- give AFTER meal 
- caution in renal and hepatic 
- Drug Interactions:
    > Caution: PDE5, antiHTN, nitrates
    > Contraindicated: CYP3A4 (clarithromycin, 
      erythromycin, diltiazem, itraconazole, ketoconazole, 
      ritonavir, verapamil, grapefruit

Question 5

Silodosin

Answer 5

Non Selective
- 8mg daily 
- give WITH meal 
- CrCl 30-50: 4mg/day 
- caution in renal and hepatic 
- high incidence of ejaculation issues
- Drug interactions
    > Caution: PDE5
    > Contraindicated: CYP3A4 (clarithromycin, 
      erythromycin, diltiazem, itraconazole, ketoconazole, 
      ritonavir, verapamil, grapefruit AND P-gp's AND liver 
      failure

Question 6

Tamsulosin

Answer 6

Non Selective
- 0.4mg daily
- give AFTER meal
- can increase to 0.8 after 2-4 weeks
- no liver or renal caution
- Drug Interactions:
> Caution: PDE5, moderate CYP2D6, cimetidine,
warfarin
> Contraindicated: CYP3A4 (clarithromycin,
erythromycin, diltiazem, itraconazole, ketoconazole,
ritonavir, verapamil, grapefruit

Question 7

Adverse Effects and Side Effects for ALL Alphas

Answer 7

Adverse/Side Effects:

• orthostatics, dizziness, faint: STRONGER AFTER FIRST DOSE
• reflex tachycardia, NASAL CONGESTION, decreased ejactulation (especially with silodosin
• can lead to fractures, falls and head trauma

Question 8

Choosing Medication for BPH

Answer 8

• Alpha First
  > Use selective because has fewer a/e
  > no titration need
  > treatment effects are immediate (whereas 5ARI’s
  take about 6 mo

Question 9

5-Alpha Reductase Inhibitors (5ARI’s)

Answer 9

dutasteride and finesteride

Indications: BPH and Androgenic Alopecia

• helps with larger prostate (vs smaller)
• no benefit if PSA is less than 1.5
• may be used alone or in combo with alphas
• take up to 6 mo to work

Question 10

PSA monitoring in 5ARI’s

Answer 10

• PSA levels help determine prostatic volume
• reduces by 50% within 3-6 months
• after 3 mo - double dose for comparison to normal PSA
• if PSA increases on 5ARI then workup for prostatic cancer (even is PSA is WNL)

Question 11

Side Effects of 5ARI’s

Answer 11

impotence
ejaculation disorders
decreased sex drive 
breast enlargement and tenderness
reduces incidence of prostate cancer (however higher incidence of high grade prostate cancer)

Question 12

Alpha Indications

Answer 12

resistant HTN
BPH
pheochromocytoma