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Endocrinology > Pharmacologic Therapy of Benign Prostatic Hyperplasia > Flashcards

Pharmacologic Therapy of Benign Prostatic Hyperplasia Flashcards

1
Q

Benign Prostatic Hyperplasia

A
  • Abnormal enlargement of the prostate gland that appears to occur with aging
  • Produces persistant lower urinary tract symptoms (LUTS)
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2
Q

Prostate Gland

A
  • Walnut-sized gland located between bladder and penis
  • Urethra runs through center of the prostate
  • Prostate secretes fluid that nourishes and protects sperm
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3
Q

What are the three types of prostate tissue?

A
  • Epithelial
  • Stromal
  • Capsule
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4
Q

Epithelial tissue

A
  • Glandular tissue
  • Produces ejaculate secretions
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5
Q

Stromal tissue

A
  • Smooth muscle tissue
  • Contains **alpha-1 adrenergic receptors **
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6
Q

Capsule tissue

A
  • Outer shell
  • Compromised of fibrous connective tissue with alpha-1 adrenergic receptors
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7
Q

5-alpha reductase

A

Converts testosterone and androstenedione to dihydrotestosterone (DHT) which causes prostate enlargement and growth

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8
Q

What are some obstructive symptoms of BPH?

A
  • Hesitancy
  • Dribbling
  • Incomplete emptying
  • Interrupted stream
  • Impaired force or size of urinary stream
  • Strain or push to urinate
  • acute retention
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9
Q

What are some irritative symptoms of BPH?

A
  • Frequency
  • Urgency
  • Nocturia
  • Pain or burning on urination
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10
Q

What are the complications of BPH?

A
  • Urinary retention
  • Overflow urinary incontinence
  • Renal insufficiency
  • Urinary tract infection
  • Gross hematuria
  • Bladder stones
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11
Q

What is used to screen for prostate cancer?

A

Prostate specific antigen (PSA) and digital rectal exam (DRE)
* PSA > 1.4 ng/mL –> at risk for developing complications of disease

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12
Q

What is the peak and average urinary flow rate?

A

10-15 mL/sec

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13
Q

What are some medications that can exacerbate symptoms of BPH?

A
  • Anticholinergics
  • Bronchodilators
  • Psychotropics
  • Antidepressants that have anticholinergic effects
  • Antiarrhythmics/antianginals that have anticholinergic effects
  • Antihistamines
  • OTC medications – cough and cold
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14
Q

What are some treatment options?

A
  • Watchful waiting
  • Behavorial interventions
  • Surgery
    • Prostatectomy (transurethrally “TURP” or suprapubically)
    • Balloon dilation
  • Pharmacologic options
    • Alpha-adrenergic blockade
    • 5-alpha reductase inhibition
    • Phosphodiesterase-5 (PDE-5) inhibitors
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15
Q

Alpha-1 antagonist

A
  • MOA: Blockade alpha-1 adrenergic receptors in the prostatic stromal tissue
  • Faster at reducing LUTS
  • **Do NOT reproduce prostate size **
  • NO effect on PSA
  • SLOW titration to treatment maintenance dose is needed
  • No dosage reduction in renal failure
  • Should NOT be used as a single agent in patients with BPH and HTN (ALLHAT trials)
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16
Q

What medications are Alpha-1 antagonist?

A
  • Doxazosin
  • Prazosin
  • Terazosin
17
Q

What are the adverse effects of Alpha-1 antagonist?

A
  • Dizziness
  • Syncope
  • Orthostatic hypotension
  • Headache
  • CNS effects
18
Q

Selective alpha-1 antagonists

A
  • MOA: Selective for prostatic alpha-1A receptors WITHOUT causing peripheral vascular smooth muscle relaxation
  • Take approximately** 30 minutes** AFTER the same meal every day
    -Dose titration is minimal or NOT needed (only silodosin)
  • **Good choice for patients with CAD, volume depletion, cardiac arrhythmias, or those taking multiple BP meds **
19
Q

What are the drug interactions of selective alpha-1 antagonist?

A
  • Cimetidine and diltiazem (decrease metabolism)
  • Carbamazepibe and phenytoin (increase metabolism)
20
Q

What medications are selective alpha-1 antagonists?

A
  • Alfuzosin
  • Silodosin
  • Tamsulosin
21
Q

What are the adverse effects of alfuzosin?

A
  • Dizziness
  • Fatigue
  • Ejaculatory dysfunction
  • LESS hypotension
22
Q

What are the adverse effects of silodosin?

A
  • Dizziness
  • Headache
  • Ejaculatory dysfunction
23
Q

What are the adverse effects of tamsulosin?

A

LESS hypotension

24
Q

5-alpha reductase inhibitors

A
  • MOA: Competitively inhibits **type 1 and/or type II 5-alpha reductase **
  • **Management of moderate to severe BPH **
  • Reduces prostate size by ~25% and serum PSA levels by ~50% **
    -Delayed onset of clinical effect–> 6-12 months
    -First choice in patients with significantly enlarged prostate (>40 g)
    -Choice for those who can not tolerate CV effects of alpha-blockers (angina, arrhythmias)
    -NO renal dosage adjustments or clinically relevant DDIs
    -    FDA pregnancy category – X**
25
Q

What medications are 5-alpha reductase inhibitors?

A
  • Dutasteride
  • Finasteride
26
Q

What are the adverse effects of 5-alpha reductase inhibitors?

A
  • Impotence
  • Decreased libido
  • Gynecomastia
27
Q

PDE-5i

A
  • MOA: Prevents the metabolism of **cGMP **
    • NO/cGMP pathway is one of the major regulators of smooth muscle contractility
    • Following NO release, cGMP formation elicits smooth muscle relaxation
  • **Tadalafil (Cialis®) is the only medication in this used for BPH or BPH with ED (erectile dysfunction) **
  • Renal dose adjustment
28
Q

What medications are PDE-5i?

A

Tadalafil

29
Q

What is a contraindication of tadalafil?

A

Any form of organic nitrate

30
Q

What are some adverse effects of tadalafil?

A
  • Headache
  • Dyspepsia
  • Back pain
  • Myalgia
  • Nasal congestion
  • Flushing
  • Pain in limb
31
Q

What are some drug interactions of tadalafil?

A
  • CYP3A4 inhibitors (e.g. ketoconazole, ritonavir) INCREASE tadalafil exposure
  • CYP3A4 inducers (e.g. rifampin) DECREASE tadalafil exposure
32
Q

What are some warnings/precautions of tadalafil?

A
  • Use with alpha-blockers, antihypertensives, or substantial amounts of alcohol may lead to hypotension
  • Patients should seek emergency treatment for an erection **lasting > 4 hours **
  • Use with caution in patients predisposed to **priapism **
  • Patients should stop use and seek medical care if a sudden loss of vision occurs in one or both eyes – could be a sign of **Non-Arteritic Ischemic Optic Neuropathy (NAION) **
  • Patients should stop use and seek prompt medication attention in the event of sudden decrease or loss of hearing
33
Q

Floppy Iris Syndrome

A
  • Adverse effect found to be associated with **doxazosin, silodosin, and tamsulosin **
  • Patients need to tell their ophthalmologist if they are taking an alpha-1 adrenergic antagonist!
34
Q

Who is the combination therapy indicated for?

A
  • Severe symptoms
  • Prostate gland > 40 g
  • PSA > 1.4 ng/mL

Endocrinology (10 decks)

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