Tuesday, September 18, 2012

Medical Management of Comorbid BPH/LUTS and ED: Defining the Current Treatment Algorithm part 6

You decide to prescribe tamsulosin to treat the patient's BPH/LUTS. Because he is taking sildenafil for mild ED, what is the new treatment plan for this patient?
Stop sildenafil, and start α-blocker at recommended dose
Lower sildenafil dose, and start α-blocker at recommended dose
Maintain sildenafil dose, and start α-blocker at lowest effective dose
Increase sildenafil dose, and start α-blocker at lowest dose

Maintain the patient's current sildenafil regimen, and start an α-blocker at the lowest effective dose.
To ensure safety, the physician must carefully review the following and ensure the patient is cognizant وإذ تدرك of the potential blood pressure–lowering effects of sildenafil.
§  Patients should be stable on α-blocker therapy prior to initiating sildenafil. Patients who demonstrate hemodynamic instability on α-blocker therapy alone are at increased risk of symptomatic hypotension with concomitant use of PDE5 inhibitors
§  In patients who are stable on α-blocker therapy, sildenafil should be initiated at the lowest recommended starting dose
§  In patients already on an optimized PDE5 inhibitor regimen, α-blocker therapy should be initiated at the lowest dose. Stepwise dose increases in α-blocker therapy when taking sildenafil may be associated with further lowering blood pressure
§  The safety of concomitant therapy with a PDE5 inhibitor and an α-blocker may be affected by other variables, including intravascular volume depletion and other antihypertensive drugs

Treatment Plan

For treatment of BPH/LUTS, prescribe once-daily tamsulosin 0.4 mg to be taken 30 minutes after the same meal each day. Continue on-demand sildenafil 25 mg for mild ED.


At his follow-up visit, the patient states he has adhered to therapy and noticed a marked change in his BPH/LUTS (AUA-SI score improved to 6, mild LUTS). His wife also attends to support their complaint of AEs with the α-blocker medication, however. Because they are very sexually active (3 or 4 times per week), they express great concern about the sexual AEs of the medication, including reduced libido and abnormal ejaculation (ie, decreased ejaculatory volume, decreased pleasure, and pain at ejaculation).


The physician and the patient should discuss AEs when making treatment choices, and the physician should proactively address the patient's concerns before formulating a treatment plan. Also, physicians should regularly assess for sexual dysfunction in patients being treated for BPH/LUTS, because adherence to medication may suffer.
α-Blockers, 5ARIs, and PDE5 inhibitors have all been shown to improve BPH/LUTS. It is crucial for clinicians to understand how the differentiating properties of BPH/LUTS therapies (eg, onset of action, mechanism of action, AE profile) potentially affect treatment outcomes. For example, therapies differ in onset of action (α1-blockers have a rapid onset), reduction in prostate volume (5ARIs only), and risk of BPH progression (5ARIs only). Some potential AEs of α-blockers that should be discussed with patients are dizziness, hypotension, and ejaculatory dysfunction.



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