An elderly gentleman enters the pharmacy. He is using tamsulosin, dutasteride, atenolol and candesartan. He has a bad cold. He sounds "nasal" because he is congested. He is asking for advice on a cold product. Choose the agent least likely to worsen the BPH symptoms:
A. Oxymetazoline nasal spray, taken BID for not more than three days
D. A combination product with phenylephrine, chlorpheniramine and acetaminophen
E. A combination product with phenylephrine, diphenhydramine and ibuprofen
A. Decongestants are alpha agonists and will block the effect of the alpha antagonist (tamsulosin). A patient with BPH will find it difficult to urinate if they use an oral decongestant. Antihistamines (both chlorpheniramine and diphenhydramine) will cause urinary retention and they, too, will worsen the BPH symptoms. The best option for this patient is to use topical therapy with a drug such as oxymetazoline (Afrin, or store-brands). This medication has systemic absorption, but less than the oral decongestants. Make sure the patient understands that nasal decongestant sprays cannot be used longer than three days, or they can cause rebound congestion, which is difficult to treat.
A patient is beginning therapy for BPH with tamsulosin. When should he take the medicine?
A. Thirty minutes after the same meal each day
B. One hour before breakfast on an empty stomach
C. At bedtime
D. With lunch
E. With a light snack in the mid-afternoon
A. It is important with both tamsulosin and alfuzosin to instruct patients to take the medication 30 minutes after the same meal, each day. These medications are not well-absorbed on an empty stomach.
A patient gave the pharmacist a prescription for dutasteride. Which of the following is the correct brand name for dutasteride?
D. The brand name of dutasteride is Avodart.
Susan is a pharmacist who dropped a tablet of finasteride on the floor. While looking for it, she stepped on it. Susan does not pick up the tablet with her hands. She carefully uses paper to scoop up the pieces and disposes of the waste. Susan is cautious in handling this drug for the following reason:
A. She is aware that dust from this drug has been implicated in causing breathing difficulty, with bronchoconstriction.
B. She could develop a blistery rash.
C. She is aware that if she is pregnant, a male fetus could be harmed if she touches the medicine.
D. She is afraid of the drug causing breast cancer.
E. She is afraid of the drug causing endometrial cancer.
C. The 5 alpha-reductase inhibitors (Proscar, Propecia, Avodart) can feminize a male fetus. Tell pregnant women not to handle these drugs, especially if they are broken or crushed. Any woman of childbearing age should not handle these drugs. The semen of men using these drugs can pose a danger to a male fetus.
A patient is started on terazosin therapy. Counseling points should include the following: (Select ALL that apply.)
A. When you move from sitting to standing up, hold onto the bed rail or table until you feel steady.
B. Taking pseudoephedrine can help limit the dizziness.
C. It is best to begin taking the medication at bedtime.
D. The dose is started low and will be increased when you get used to the side effects.
E. This agent should be taken three times daily.
A, C, D. Make sure that patients starting any alpha blocker receive careful counseling on dizziness and the risk for falling, especially with the initial dose and during titration. They are usually dosed at night to help reduce these problems, but patients may be urinating at night and at risk for falls, especially in the dark.
Alfuzosin (Uroxatral) and silodosin (Rapaflo) are newer alpha-1A selective blockers, in the same class as tamsulosin. These drugs are not likely to become as popular as tamsulosin because they have the following safety consideration:
A. Alfuzosin and silodosin are CYP 450 3A4 substrates; the use of 3A4 inhibitors will decrease the alpha blocker's concentration and effectiveness.
B. Alfuzosin causes hair loss.
C. Alfuzosin prolongs the QT interval and can be dangerous in patients with cardiac conditions or those using other QT-prolongating drugs.
D. Alfuzosin must be taken at night.
E. Silodosin must be taken at night.
C. Alfuzosin is a QT prolongating agent. Silodosin can cause retrograde ejaculation and reduce sperm count. Both are CYP 450 3A4 substrates; inhibitors will increase their concentrations-the use with potent 3A4 inhibitors is contraindicated with these drugs.
If a drug used by older males contributes to sexual dysfunction, it will affect the adherence as many men have problems with sexual function as they age and would not wish to worsen or cause this condition. What is the effect of the alpha blockers on sexual function? (Select ALL that apply.)
A. Alpha blockers typically worsen erectile dysfunction.
B. Silodosin can cause retrograde ejaculation.
C. Typically, the alpha blockers do not cause sexual dysfunction.
D. Silodosin can cause an orgasm with little or no semen.
E. Alpha blockers can cause priapsim.
B, C, D, E. In clinical trials, the higher dose of tamsulosin (0.8 mg) caused abnormal ejaculation in some patients. This was not reported at the 0.4 mg dose (which is what most men are using.) Impotence has been occasionally reported with alfuzosin therapy. The most common side effect seen with silodosin is an orgasm with little or no semen (28% incidence).
If a drug decreases PSA and shrinks the prostate, it could mask prostate cancer. Which of the following drugs decrease PSA and shrink the prostate?
D. The alpha-blockers do not cause the prostate to shrink and they do not affect PSA levels. The 5-alpha-reductase inhibitors do both-these drugs prevent prostate growth-and after time, this reduces the prostate size.
Jerry is a 75 year-old male who is having difficulty with urination. He reports that he cannot "empty" his bladder when he uses the bathroom, and the urine comes out "dribbling." The urologist ruled-out prostate cancer and wrote Jerry a prescription for tamsulosin 4 mg daily. Jerry has no other known medical conditions. Choose the correct statements: (SelectALL that apply.)
A. Tamsulosin blocks alpha receptors in prostate tissue.
B. The dose of tamsulosin is correct.
C. The brand name of tamsulosin is Flomax.
D. Tamsulosin commonly causes erectile dysfunction.
E. Dizziness and orthostasis occur more commonly with tamsulosin than doxazosin.
A, C. The patient has benign prostatic hyperplasia (BPH). The correct dose of tamsulosin is 0.4 mg once daily. This is the most commonly used agent for BPH. Tamsulosin does not commonly cause sexual problems. It can cause dizziness and orthostasis, but much less commonly than older agents in the same class.
A patient with prostate enlargement was prescribed doxazosin. He experienced dizziness and found that when he went from sitting to standing, or lying down to sitting, he felt dizzy and his head "swooned." The physician is considering switching him to tamsulosin. Choose the correct statement:
A. The dizziness would be about the same with tamsulosin.
B. If the doctor wished to avoid the dizziness, he should switch the patient to terazosin.
C. A better option would be to start pseudoephedrine therapy with the doxazosin.
D. A drug with the same mechanism of action as doxazosin but with less dizziness is finasteride.
E. Tamsulosin is an alpha 1a-selective blocker and causes less dizziness and orthostasis than doxazosin.
E. Tamsulosin is an alpha blocker used for BPH that is selective for the 1A receptor. There are 3 types of alpha receptors: 1A (which are primarily on the prostate), 1B and 1D. Terazosin (Hytrin) and doxazosin (Cardura) are non-selective alpha blockers with BPH indications. The non-selective agents cause more problems with dizziness and changes in blood pressure.
A patient presents with symptoms of prostate enlargement. Prior to initiating treatment, the physician wishes to rule out prostate cancer. Which tests could be used to check for the possibility of prostate cancer? (Select ALL that apply.)
A. Creatine Phosphokinase (CPK)
B. Prostate specific antigen (PSA)
E. Digital rectal exam (DRE)
B, E. It is important to rule out prostate cancer prior to the initiation of BPH medications; otherwise, the BPH medication might cover up symptoms of prostate cancer and the opportunity to treat at an earlier stage would be missed.
An elderly gentleman with benign prostatic hyperplasia (BPH) has gone to see the physician and presents to the pharmacy with a prescription for finasteride. He had already been using tamsulosin for two months but states it has not helped enough. Choose the correct statement regarding finasteride: (Select ALL that apply.)
A. Finasteride blocks the 5-alpha reductase enzyme that converts testosterone to DHT.
B. Finasteride is an alpha-1A selective receptor blocker.
C. Finasteride starts working in 1-2 days.
D. Finasteride is Pregnancy Category X.
E. Finasteride and tamsulosin should not be used together.
A, D. The 5 alpha-reductase inhibitors take months to work and they are often prescribed concurrently with alpha blockers (the alpha blocker for faster symptom relief.) Although they work slower, they are more effective than alpha blockers. Eventually, or in some cases initially, the patient may prefer a surgical option.
Jerry uses tadalafil for erectile dysfunction. His other medications are lisinopril-HCT and pravastatin. Jerry has gone to the doctor and answered questions regarding how bothersome his BPH symptoms are currently. Based on his score, the physician decided to start tamsulosin (Flomax). Should the pharmacist dispense the alpha blocker to this patient?
A. Yes, but he should receive 0.8 mg daily to start.
B. Yes, but caution is advised about additive hypotension and dizziness.
C. No; he is using a PDE-5 inhibitor.
D. No, he has hypertension.
E. No, he should use a non-selective alpha blocker first-line.
B. Although the selective agents cause less dizziness and blood pressure changes, you must still use caution with these (and with the non-selective agents) when they are used in combination with the PDE5 inhibitors. What ever agent you are starting second, use the lower end of the dosing range.
An elderly gentleman with benign prostatic hyperplasia (BPH) has gone to see the physician and presents to the pharmacy with a prescription for finasteride. Choose the most appropriate counseling statements concerning sexual dysfunction and the 5 alpha-reductase inhibitors: (Select ALL that apply.)
A. These drugs often cause impotence.
B. A small number of men (under 10%) will have problems with sexual function on these drugs, but in most cases it does not remain a problem.
C. If you have any concerns, please discuss them with your healthcare provider.
D. The incidence of impotence can be decreased by taking decongestants.
E. The incidence of impotence can be decreased by taking antihistamines.
B, C. Be careful on how you counsel for sexual dysfunction with these drugs: they do cause sexual dysfunction but the incidence is low and near placebo-levels at about one year of therapy. You should inform, but not over-worry, the patient.
Tadalafil has been approved for use in BPH. Which of the following statement/s are correct? (Select ALL that apply.)
A. Use caution due to dizziness, possible drop in blood pressure and headache.
B. At this low dose the risk of vision or hearing loss is not relevant; these conditions occur at the higher end of the dosing range only and counseling on these possible adverse effects is not required.
C. The brand name is Levitra.
D. Blurred vision, difficulty distinguishing between blue and green, or haziness around lights, which can make driving at night difficult.
E. If the man uses this drug for BPH, he will still need to take an additional dose for erectile dysfunction.
A, D. The brand name is Cialis, and for BPH it is dosed at 5 mg daily. Or 2.5 mg daily if the CrCl is 30-50 mL/min. Tadalafil is not used with severe renal insufficiency. This dose would also treat the problem of erectile dysfunction; they should not need to take additional PDE-5 inhibitor.
A patient gave the pharmacist a prescription for finasteride 5 mg one tablet by mouth each morning #30. Which of the following is the correct brand name for finasteride when used for prostate enlargement?
B. Finasteride is used for prostate enlargement (as Proscar) and for hair loss (as Propecia).