pharmacotherapy BPH

8/3/2019 pharmacotherapy BPH

1/4

Pharmacotherapy of ____Benign Prostatic Hyperplasia_______________Barry VanDenHeuvel, PharmD Candidate 2007

Epidemiology The prevalence of histopathologic BPH is age dependant.

BPH is very rare in men younger than 50

By 60 years of age, its prevalence is greater than 50%, by the age of 85; its prevalence is ashigh as 90%.

About one half of men who have a histological diagnosis have moderate to severe lower urinary

tract symptoms (LUTS) BPH accounts for more than 400,000 hospital stays each year.

In 2000, approximately 4.5 million visits to physicians offices were made for a primarydiagnosis of BPH, and nearly 8 million doctor visits were made with either a primary orsecondary diagnosis of BPH.

BPH is an expensive disease, with treatments costing more than $4 billion USD per year. Asthe male population ages, the cost of BPH is expected to increase even further.

BPH costs $1.1 billion annually in direct expenditures for medical services provided at hospitalinpatient and outpatient settings, emergency departments, and physicians offices.

Disease State

Definition

Benign prostatic hyperplasia is defined histologically as a disease process characterized by

stromal and epithelial cell hyperplasia beginning in the periurethral zone of the prostate The chief complaint of the patient with BPH is usually bothersome LUTS typified by urinary

frequency, urgency, nocturia, decreased and intermittent force of stream and the sensation ofincomplete bladder emptying.

The relationship between BPH and LUTS is complex, however, because not all men withhistological evidence of BPH will develop LUTS. In addition, LUTS are neither specific to norexclusive of BPH; other conditions in the lower urinary tract and elsewhere may be causative.Moreover, not all patients with BPH and LUTS will have prostate enlargement, and prostateenlargement may exist in the absence of LUTS.

Patho-

physiology

While the precise pathophysiologic mechanisms that cause BPH remain unclear, the role ofintraprostatic DHT and type II 5a-reductase in the development of BPH is evidenced by several

observations: BPH does not develop in men who are castrated before puberty.

Castration causes an enlarged prostate to shrink.

Patients with type II 5a-reductase enzyme deficiency do not develop BPH.

Administration of testosterone to orchiectomized dogs of advanced age produces BPH.

The pathogenesis of BPH is often described as resulting from both static and dynamic factors.

Static factors relate to anatomic enlargement of the prostate gland, which produces a physicalblock at the bladder neck and thereby obstructs urinary outflow.

Dynamic factors relate to excessive a-adrenergic tone of the stromal component of the prostategland, bladder neck, and posterior urethra, which results in contraction of the prostate glandaround the urethra and narrowing of the urethral lumen.

Symptoms of BPH disease may result from static and/or dynamic factors, and this must be recognizedwhen drug therapy is considered.

Clinical

Presentation

General

Patient is in no acute distress unless he has severe complications of BPHSymptoms

Urinary frequency, urgency, intermittency, nocturia, decreased force of stream, hesitancy, andstraining.

Signs

Student Name, PharmD Candidate 2007 Pharmacotherapy Presentation Pharmaceutical Care RotationUniversity of Maryland School of Pharmacy Happy Harrys Pharmacy Patient Care Center, Perryville, MD


2/4

Digital rectal examination reveals an enlarged prostate (>20g).Laboratory Tests

Increased BUN and serum creatinine, elevated PSA.Other Diagnostic Tests

Increased AUA Symptoms Score and decreased urinary flow rate (


3/4

Desired

Therapeutic

Outcomes*

*Reference of

Guidelines Used

The primary therapeutic outcome of BPH therapy is restoration of adequate urinary flow withoutadverse effects. As a disease in which therapy is directed at those symptoms the patient finds mostbothersome, assessment of outcomes likewise depends on how the patient perceives the effectivenessand acceptability of therapy. The use of a validated, standardized instrument, such as the AUASymptom Index, for assessing patient quality of life is important in this process.

Guidelines: American Urological Association Clinical Guidelines, Management of BPH.

Treatment

Options**

(Non-drug and

Drug Therapy

include all

therapeutic

classes/agents

available and

preferences

per treatment

guidelines)

**See Treatment

Options Table

Patients with only mild symptoms or moderate to severe symptoms that are not bothersome generallywill not benefit from therapy because these symptoms do not significantly impact quality of life. Inaddition, the risks of medical therapy outweigh the benefits of symptom improvement in this group ofmen. For these patients, watchful waiting is recommended.

Treatment options for patients with moderate to severe symptoms of BPHWatchful Waiting

Includes yearly monitoring, education, and lifestyle modificationsMedical Therapies- only considered interim measures that only delay complication and the need

for surgery.

Alpha-adrenergic blockersAlfuzosin, Doxazosin, Tamsulosin, Terazosin

5 Alpha-reductase inhibitorsDutasteride, Finasteride

Combination therapy (alpha blocker and 5 alphareductase inhibitor)Minimally Invasive Therapies

Transurethral microwave heat treatmentsCoreTherm, Prostatron, Targis, TherMatrx*

Transurethral needle ablationUroLume stent

Surgical Therapies

Transurethral resection of the prostateTransurethral electrovaporizationTransurethral incision of the prostate

Transurethral holmium laser resection/enucleationTransurethral laser vaporizationTransurethral laser coagulation (e.g., visual laser ablation)Open prostatectomy.

Monitoring

(Efficacy and

Toxicity

Parameters)

EfficacyValidated Survey Tool Score, eg. AUA Symptom Index ScoreDigital Rectal ExamUrinary Flow RatePostvoid Residual Urine VolumeChem 7: BUN, serum creatnine

ToxicityErectile dysfunction (all)Nausea, abdominal pain, asthenia, dizziness, flatulence, headache, rash, muscle weakness, andgynocomastia. (5a-reductase inhibitors)Orthostatic hypotension, dizziness, tiredness, ejaculatory problems, and nasal congestion. (alphablockers)UTI, bleeding, infection, hematuria, urinary retention, incontinence, erectile or ejaculatory problems.(major or minor surgical procedures.)



4/4


pharmacotherapy BPH

Documents

Transcript of pharmacotherapy BPH