Medical treatment Flashcards
PDE5i
3 CI
6 medical conditions
Nitrates
Nicorandil
α1-blockers doxazosin and terazosin
unstable angina pectoris
recent myocardial infarction (< three months) or stroke (< six months)
myocardial insufficiency (New York Heart Association stage > 2)
hypotension
poorly controlled blood pressure
significant hepatic or renal insufficiency
anterior ischaemic optic neuropathy with sudden loss of vision is known or was reported after previous use of PDE5Is
conservative watchful waiting treatment
Recommended for - Mild to moderate LUTS, low bother:
Education and reassurance
Reasonable fluid intake – avoidance/reduction in alcohol and caffeine intake
Earlier last drink of the day
Timed voiding (bladder re-training)
Double voiding, urethral milking
Distraction techniques
Monitor with flow rate and PMBS and FVC/IPSS
Address reversible factors for example, metabolic syndrome, co-morbidity, medication
% stable on watcful waiting
81% stable after f/u 17 months WW
Netto 1999
natural history of prostatism
Ball
1981
40% stable 25% got better 30% got worse 2% AUR 10% progress to surgical intervention
efficacy of alpha blockers
reduce IPSS by 4 points in 30%
Djavan increase IPSS in 30-40%
increase flow rate 16-25%
tamulosin type
Alpha 1a selective
less hypotension than alfuzosin
retrograde ejaculation greater with tamsulosin
tamulosin type
Alpha 1a selective
less hypotension than alfuzosin
retrograde ejaculation greater with tamsulosin
retrograde ejaculation incidence tamsulosin
8.4%
side effects tamsulosin
asthenia dizziness postural hypotension retograde ejaculation rhinitis floppy iris syndrome
% stop takin tam due to lack efficacy
30% stop taking due to lack of efficacy or side effects
5ARi reduction in symptom score
by 15% but not better placebo if prostate less than 40cc
side effect 5ARI (4)
decreased libido
impotence
breast enlargement
rash
ALFAUR
10mg od age >50 no previous AUR RV 500-1500mls 360 patients ALF vs PLACEBO 2 x higher change successful TWOC with alfuzosin
theoretical risk retention anti cholinergics if pvr and qmax
pvr more than 200mls
qmax less than 5
nocturia desmopressin dosing licence
50mcg in men 25mcg in women once daily before sleeping avoid fluid one hour before and 8 hours after
in over 65s can consider start low dose 10mcg and then increase to 50mcg
action of desmopressin
AVP synthetic analogue for V2 receptor
avoids V1 receptor -hypertension
side effects desmopressin 4
3 % hyponatraemia
1% hypertension
10% headache
3% nausea
EAU recommendation for desmopressin
check sodium at baseline day 3 day 7 one month stop if below range <135 inclusion some trials sodium above 130
NICE desmopressin guidance
• The 50 μg dose of desmopressin (oral lyophilisate) is licenced for men with nocturia due to idiopathic nocturnal polyuria in all adults, including the over 65’s.
- Serum sodium monitoring is recommended only in the over 65’s before initiating treatment, in the first week (4-8 days after initiation) and again at one month.
- Treatment should be discontinued if the serum sodium falls below the lower range (<135)
- Clinically significant (moderate to severe) hyponatraemia occurred in 2% of patients receiving low dose desmopressin in the phase III clinical trials
forms of 5AR
two isoforms of the 5alpha reductase enzyme
type 1 minor expression in prostate mainly in skin and liver
type 2 in prostate
5ARI competative inhibition of enzme
NNT of finasteride to prevent AUR
25
after 2 -4 years of 5ARi treatment improvement IPSS decrease prostate volume increase flow rate
15-30%
volume <28%
qmax less than 2
finasteride vs placebo for prostate less than 40mls
same as placebo
how does finasteride reduce bleeding 3
micro vessel density
decrease VEGF expression
decrease prostatic blood flow
