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Treatment for Mr. McCracken
Jimmy McCracken, 62 yo Male
Chief Complaint
“I'm up four or five times a night feeling that I have to urinate, and then when I get to the bathroom all I do is dribble. I'm very lightheaded when I stand up, and sometimes I don't make it to the bathroom in time. I have a girlfriend now, but I am finding it difficult to be intimate with her. Also, going to the bathroom all night is really impacting my love life."
“I’m experiencing frequency to urinate throughout the night and its impacting my life.”
HPI
Jimmy McCracken is a 62-year-old man, with a long-standing history of UTIs. He has a history of urosepsis requiring hospitalization. He is being evaluated because of complaints of worsening urinary hesitancy, nocturia, and dribbling. He also has a new complaint of ED.
We are going to do a 3rd line treatment
Physical Exam
ROS
GEN - White Obese male in NAD; well-kept appearance; A & O x 3
VS - BP 110/60, P 85, RR 18, T 37°C (98.6F); Wt 115.2 kg(253.9#), Ht 6'0″ BMI 34.4
SKIN - Vertical scars on neck and lower back from laminectomies
HEENT - PERRLA; EOMI; TMs WNL; nose and throat clear w/o exudate or lesions
NECK/LYMPH NODES - Supple w/o LAD or masses; thyroid in midline
Head: (+) HA
CV:(+)lightheadedness
Throat: (-)dysphagia
GI:(-)dyspepsia (-) abd pain, (-)hematemesis,
GU:(+)frequency,(+)nocturia,(+)incontinence→ BPH, (-)rectal bleeding,
Repro:(+)impotence, (+) 1 new partner,
LUNGS/THORAX - CTA, distant sounds
CV - RRR w/o murmurs
ABD - Soft, NTND w/o masses or scars; (+) BS
GENIT/RECT - Testes , penis circumcised w/o DC; guaiac (+) stool
MS/EXT - Neurovascular intact;
distal pulses 1–2+
NEURO - DTRs 2+; CNs II–XII
grossly intact
PMH
Family History
Social History
High school graduate worked for 35 years in a grocery store; retired 7 years ago. Married once. Wife deceased 6 months ago (stroke); one daughter, two granddaughters. Lives alone but is socially active. Recently started dating a 59-year-old woman he met through his square-dancing group. Patient is emphatic about maximizing the use of natural products in his therapy, including continued use of saw palmetto. Used smokeless tobacco x 35 years; heavy ETOH in the past, occasional glass of wine now.
Labs
GU Consult
Surgical Indications
Patient treated for UTI 2 weeks ago with Cipro 250 mg Q 12 h x 3 days.
Urine clear; negative for glucose.
Bladder examination with ultrasound revealed postvoid residual estimate of 200 mL.
Prostate approximately 35 g, benign.
AUA Symptom Score = 20.
Uroflowmetry (Qmax) = 8 mL/s.
Urine Analysis
Assessment
Patients who:
Surgical Procedures
Prostates < 30ml and without a middle lobe
Prostates 30-80ml
Prostates > 80ml
Transurethral Resection of the Prostate (TURP)
European Association of Urology
Indications
Complications
Prostatic Stents
Transurethral microwave therapy (TUMT)
Emerging therapies
Non-surgical procedures
Main Medication Side Effects of Treatment
Follow Up in 2 weeks to assess medication response & impotence.
Improve BPH symptoms by:
Patient Education
Transurethral Needle Ablation of the Prostate (TUNA)
Vaporization
Lasers!!!
Enucleation
(Glucovance) Glyburide/metformin 5/500 mg po BID
MOA
Drugs Therapy Problem List
Excretion
Epidemiology
Precautions
Both act as antihyperglycemic agents, reduce blood glucose and improve glycemic control.
Glyburide stimulates functioning pancreatic beta cells to produce insulin, reducing blood glucose. Extrahepatic effects may be involved but mechanism is still unknown. Metformin improves glucose tolerance by lowering basal and postprandial plasma glucose levels. It has 3 specific actions that are to decrease hepatic glucose production, decrease intestinal glucose absorption, and improves insulin sensitivity by increasing peripheral glucose uptake and utilization.
Glyburide is 50% biliary and 50% renal. Metformin is Renal
alcohol intake, excessive due to increase risk of lactic acidosis and or hypoglycemia, elderly there is an increased risk of lactic acidosis, renal dysfunction there is an increased drug exposure and risk of lactic acidosis, calcium deficiency, increased risk for development of subnormal vit B12 levels, stress, potential loss for glycemic control, surgical procedures requiring food or fluid restriction can interrupt therapy
Cobalamin deficiency, hypoglycemia, abdominal pain, diarrhea, nausea, vomiting, dizziness, headache, URI
*Serious, but rare adverse effects: Lactic acidosis, hemolytic anemia, cholestatic jaundice syndrome
HbA1c twice yearly in patients who are meeting their goals and every 3 months if medication is being changed. Blood Glucose self-monitoring. Renal function annually, and more frequent if renal impairment. Vitamin B12 levels every 2-3 years
Reference: Micromedex
Terazosin 10 mg po QD
Saw palmetto 200 mg po BID
*MOA: is an alpha-1-selective adrenoceptor in the neck of the urinary bladder and prostate gland, thereby producing relaxation of smooth muscles in these sites. Causes vasodilation resulting in orthostatic hypotension by inhibiting alpha-1-adrenoceptors
*Absorption:Peak time is 1 hour
*Distribution:Protein binding
*Metabolism:Hepatic
*Excretion:Fecal and renal
Saw Palmetto
*Adverse effects: Back pain, stomach pain, change in sex drive, constipation, cramping, diarrhea, difficulty urinating, headache, impotence, nausea, dizziness
Plant, the ripe fruit is used. Known for its use in decreasing symptoms of an enlarged prostate. It shrinks the inner lining that puts pressure on the tubes that carry urine, it does not reduce the enlargement and should therefore only be used in mild to moderate BPH. Used to increase urine flow to promote relaxation (as a sedative) and to enhance sexual drive
*Caution: liver damage, pancreas damage
Unknown if safe for periods longer than 30 days
May slow clotting, stop use 2 weeks before surgery
Ibuprofen 800 mg po BID
Terazosin 10 mg po QD
Amitriptyline 50 mg po at bedtime
*Precautions: Syncope, sudden LOC, orthostatic hypotension, priapism
*Patient Education: avoid activities requiring mental alertness or coordination, may cause dizziness, slowly rise from sitting or lying position, drug may cause nasal congestion and asthenia, take drug at night time to minimize side effects, no alcohol while taking this medication
Ibuprofen
*MOA: nonsteroidal anti-inflammatory that exhibits analgesic and antipyretic activities by inhibiting prostaglandin synthesis
*BB warning: Increase the risk of CVA and stroke, Can cause serious GI effects including bleeding
*Contraindication: Asthma, urticaria, allergic reaction
Adverse Effects
*Precautions:Known cardiac disease, Known GI problems, Can increase fluid retention, May slow clotting, Hypotension, Caution in liver dysfunction
*Drug interaction: moderate with glyburide (increases the effects of ibuprofen -unknown mechanism)
*Adverse Effects: dizziness, headache, hypotension, fluid retention, dizziness
*Metabolism liver
*Excretion is renal
Don’t drink or smoke while taking
*MOA: TCA that exhibits sedative properties, it promotes neuronal activity by blocking the membrane pump mechanism which is responsible for the absorption of serotonin and norepi in serotonergic and adrenergic
neurons
*Metabolism is hepatic
P450 CYP2D6, excreted renal
Claritin-D 24-hour (Loratadine/Pseudoephedrine sulfate) one tablet po daily (allergy to cats)
Claritin D
*MOA: second generation H1 histamine antagonist. Structure closely resembles TCAs.
Contraindication is urinary retention, severe CAD
*Precautions: DM, elderly greater than 60 years old, hepatic insufficiency, hypertension, hyperthyroidism, ischemic heart disease, prostatic hypertrophy, renal impairment
*Adverse Effects: xerostomia, insomnia, pharyngitis
Monitor CNS stimulation or depression
*Drug can cause: decreased mental alertness or coordination, dizziness, somnolence, anticholinergic effects, headache, insomnia, nervousness, fatigue
Patient should not drink alcohol
BPH
Amitriptyline 50 mg po at bedtime
*Precautions: Use caution in patients with impaired liver function, Use caution in patients with history of urinary retention due to the anticholinergic effects. Use caution in patients undergoing and elective surgery
*Adverse effects: Weight gain, constipation, xerostomia, dizziness, headache, somnolence, blurred vision, cardiac dysrhythmia, agranulocytosis, hepatotoxicity, jaundice, depression, suicidal thoughts
Patient should not drink alcohol while taking this drug
Monitoring
Other medical conditions to rule out
Prostatic enlargement is dependent on androgen dihydrotestosterone (DHT). In the prostate gland type II 5-alpha-reductase metabolizes circulating testosterone into DHT, which acts locally. There are a large number of alpha-1-adrenergic receptors in the smooth muscle of the stroma, the capsule of the prostate and the bladder neck. When these receptors get stimulated via the DHT, it causes an increase in smooth muscle tone, which can worsen the symptoms associated with BPH.
Presentation
Natural History
Irritative:
Obstructive:
AUA (American Urological Association) Symptom Index Scale
DHT binds to androgen receptors in the cell nuclei and can cause hyperplasia, which potentially results in BPH. The hyperplasia may restrict the flow of urine from the bladder. As the prostate enlarges, the surrounding capsule prevents it from radially expanding and that causes urethral compression. In addition, the irritation from urethral compression causes the bladder to thicken and hypertrophy and itself to be more irritable. Therefore, the bladder now has increased sensitivity to small volumes of urine and causes increased urinary frequency. Eventually the bladder may gradual weaken and lose the ability to empty completely, which leads to the increased residual urine volume and urinary retention.
Total score: 0-7 mild symptoms; 8-19 moderate symptoms; 20-35 severe symptoms
Symptom
Index
Scale
AUA= 20 Severe
Medication
Natural History
Goals of Pharmacotherapy
Alpha Blocker goal (Terazosin, doxazosin, tamsulosin, alfuzosin, silodosin):
Goals of Pharmacotherapy
5-Alpha-Reductase Inhibitor goal (Finasteride and dutasteride):
Treatment
Pygeum africanum
“As the physician assistant in the team, you perform a literature search on the use of saw palmetto for BPH. You discover that there are reports of the dietary supplement both improving and worsening symptoms of ED. Because the patient's ED symptoms began while he was taking saw palmetto, you decide that it is plausible that saw palmetto could be contributing to ED symptoms. In addition, your readings indicate that saw palmetto should really only be used by patients with mild to moderate BPH.
Alternative Treatment
Based on this information, your recommendation is to stop the saw palmetto. However, because the patient is emphatic about wanting to continue a natural product, you search for alternative dietary supplements that may provide some benefit for this patient's BPH without contributing to ED. Would Pygeum africanum be a reasonable option to consider?”
Pygeum africanum
Terazosin (Hytrin) (Currently taking 10 mg)
Adverse effects: Syncope (Esp. 1st dose), dizziness, somnolence, asthenia, nausea, nasal congestion, palpitations,impotence, orthostatic hypotension, blurred vision, peripheral edema, priapism (rare)
Avoid: Verapamil, other antihypertensives
would be a reasonable option
to consider replacing Saw
Palmetto in regards to positive
evidence provided from the
18 RCTs.
5α - reductase inhibitors
6 month treatment then assess
Adverse effects: Decrease libido, impotence, ejaculatory failure, gynecomastia. Finasteride can falsify the PSA level by 50% after 6 months of treatment. Use with caution in hepatic insufficiency. Swallow don’t chew.
α adrenergic antagonist or α blockers
Finasteride (Proscar)
Dutasteride (Avodart)
5α - reductase inhibitors
Doxazosin (Cardura)
Adverse effects: Syncope (Esp. 1st dose), dizziness, HA, drowsiness, weakness, palpitation, GI upset, edema, orthostatic hypotension, dyspnea, vertigo, depression, nervousness, rash, urinary frequency, blurred vision, reddened sclera, epistaxis, dry mouth, nasal congestion, priapism (rare)
Avoid: impaired liver function, monitor BP
Tamsulosin HCl (Flomax)
Adverse effects: Dizziness, HA,
abnormal ejaculation,
caution with sulfa allergy
Avoid: Cimetidine, warfarin
α adrenergic antagonist or α blockers (Cont.)
α adrenergic antagonist or α blockers
Prazosin (Minipress)
Adverse effects: Dizziness, fatigue, hypotension, edema, dyspnea, priapism (rare)
Avoid: ETOH, propranolol, diuretics
α adrenergic antagonist or α blockers (Cont.)