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.
Follow-up
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).
Discussion
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.
