Module 3: Men and Women’s Health
GD is unfortunately experiencing a side effect profile that is common with many alpha 1-adrenergic antagonists. While these medications are considered by many urologists to be superior in managing lower urinary tract symptoms (LUTS) through relaxing the bladder neck, prostatic urethra, and prostate small muscle (Gravas & Dimitropoulos, 2016), they can also cause hypotension, nasal congestion, and dizziness. GD is taking terazosin, which has a higher incidence of hypotension than other alpha 1-adrenergic antagonists (Guzmán et al., 2019). As GD is an elderly man who is still endorsing LUTS and the symptomatology of dizziness and hypotension, placing him at an increased risk for falls, a different pharmacological approach should be suggested (van der Worp et al., 2019).
As GD is experiencing LUTS and benign prostatic hypertrophy (BHT), he would benefit from a combination pharmacological therapy that targets both the prostate and the bladder, in addition to lifestyle modification including a bladder training program, not drinking 4 hours before bed, and double voiding. Female patients with overactive bladders are commonly prescribed antimuscarinics, but they are not used as often in men due to a concern that they will lead to acute urinary retention (Oelke et al., 2015). While antimuscarinics are a good choice, for GD, utilizing silodosin or tamsulosin in conjunction with mirabegron would provide relief from the symptoms that he is experiencing. Mirabegron is beta 3-adrenoreceptor agonist that attaches to beta 3 receptors in the bladder causing them to relax, resulting in decreased frequency, urgency, nocturia, and incontinence (Kakizaki et al., 2020). A possible side-effect of this medication that is beneficial to GD, is that it can raise blood pressure (Gravas & Dimitropoulos, 2016). Silodosin or tamsulosin have been shown to have a lower incidence of hypotension and resultant dizziness, so the concurrent use of one of these alpha 1-adrenergic antagonists, along with mirabegron should decrease the lower urinary tract symptoms that GD is experiencing and improve his quality of life.
Polycystic ovarian syndrome (PCOS) is an endocrine disorder which effects women of reproductive age at a rate of 5-15% of the population (Rosenfield & Ehrmann, 2016). These women often have difficulty getting pregnant as they generally do not have a regular menstrual cycle related to excessive androgen inhibiting ovulation. Additionally, PCOS is a multi-system metabolic disorder resulting in obesity, hypertension, dyslipidemia, and insulin resistance (Rosenfield & Ehrmann, 2016). Pregnant women with PCOS have a three times greater risk of pregnancy related hypertension, gestational diabetes, and preeclampsia
LW is currently taking medications that are contraindicated in pregnancy, which means a thorough medication reconciliation and resultant recommendation needs to be completed. The American College of Obstetricians and Gynecologists strongly recommends a reduction in weight in overweight or obese women before becoming pregnant, as pregnancy places an increased physiological demand on the body (&na;, 2013). As LW’s physical indicates obesity, this is the primary recommendation before she becomes pregnant. As she is already taking rosuvastatin, which is contraindicated in pregnancy, she needs to decrease her cholesterol as well, indicating the need for dietary education.
Previously metformin was listed as a category C medication, meaning one must evaluate the risk vs the benefits, however, this labeling system is no longer in use and each medication is evaluated differently. Current evidence-based research suggests that metformin can be safely used in pregnancy. One study even found evidence that support metformin use in the first trimester of women with PCOS led to a decrease in early pregnancy loss (Zeng et al., 2016). While metformin is relatively safe, insulin is a better option during pregnancy and can be adjusted to maintain blood glucose levels. Finally, lisinopril has demonstrated teratogenic properties and should be avoided in pregnancy (Panchal et al., 2019). The first line recommended anti-hypertensive during pregnancy is methyldopa and should be given instead of lisinopril (Brown & Garovic, 2014).
While it is a primary care provider’s responsibility to be aware of contraindications in medication management for patients, as a PCP is the first line of contact for a patient, when a patient has medical complexity, they should be referred to a specialist. In the case of our previous patients, GD should be referred to a urologist, although rescheduled to see the primary provider in 2-4 weeks to follow up with the new medication regime. As LW is at risk for pregnancy complications, she should be referred to a high-risk obstetrician.
References
&na;. (2013). Committee opinion no. 549. Obstetrics & Gynecology, 121(1), 213–217. https://doi.org/10.1097/01.aog.0000425667.10377.60
Brown, C. M., & Garovic, V. D. (2014). Drug treatment of hypertension in pregnancy. Drugs, 74(3), 283–296. https://doi.org/10.1007/s40265-014-0187-7
Gravas, S., & Dimitropoulos, K. (2015). Solifenacin/tamsulosin fixed-dose combination therapy to treat lower urinary tract symptoms in patients with benign prostatic hyperplasia. Drug Design, Development and Therapy, 1707. https://doi.org/10.2147/dddt.s53184
Gravas, S., & Dimitropoulos, K. (2016). New therapeutic strategies for the treatment of male lower urinary tract symptoms. Research and Reports in Urology, 51. https://doi.org/10.2147/rru.s63446
Guzmán, R., Fernández, J. C., Pedroso, M., Fernández, L., Illnait, J., Mendoza, S., Quiala, A. T., Rodríguez, Z., Mena, J., Rodíguez, A., Campos, M., Sánchez, C., Alvarez, Y., & Jiménez, G. (2019). Efficacy and tolerability ofroystonea regialipid extract (d-004) and terazosin in men with symptomatic benign prostatic hyperplasia: A 6-month study. Therapeutic Advances in Urology, 11, 175628721985492. https://doi.org/10.1177/1756287219854923
Kakizaki, H., Lee, K.-S., Yamamoto, O., Jong, J., Katou, D., Sumarsono, B., Uno, S., & Yamaguchi, O. (2020). Mirabegron add-on therapy to tamsulosin for the treatment of overactive bladder in men with lower urinary tract symptoms: A randomized, placebo-controlled study (match). European Urology Focus, 6(4), 729–737. https://doi.org/10.1016/j.euf.2019.10.019
Oelke, M., Speakman, M. J., Desgrandchamps, F., & Mamoulakis, C. (2015). Acute urinary retention rates in the general male population and in adult men with lower urinary tract symptoms participating in pharmacotherapy trials: A literature review. Urology, 86(4), 654–665. https://doi.org/10.1016/j.urology.2015.06.025
Palomba, S., de Wilde, M. A., Falbo, A., Koster, M. P., La Sala, G., & Fauser, B. C. (2015). Pregnancy complications in women with polycystic ovary syndrome. Human Reproduction Update, 21(5), 575–592. https://doi.org/10.1093/humupd/dmv029
Panchal, B. D., Cash, R., Moreno, C., Vrontos, E., Bourne, C., Palmer, S., Simpson, A., & Panchal, A. R. (2019). High-risk medication prescriptions in primary care for women without documented contraception. The Journal of the American Board of Family Medicine, 32(4), 474–480. https://doi.org/10.3122/jabfm.2019.04.180281
Rosenfield, R. L., & Ehrmann, D. A. (2016). The pathogenesis of polycystic ovary syndrome (pcos): The hypothesis of pcos as functional ovarian hyperandrogenism revisited. Endocrine Reviews, 37(5), 467–520. https://doi.org/10.1210/er.2015-1104
van der Worp, H., Jellema, P., Hordijk, I., Lisman-van Leeuwen, Y., Korteschiel, L., Steffens, M. G., & Blanker, M. H. (2019). Discontinuation of alpha-blocker therapy in men with lower urinary tract symptoms: A systematic review and meta-analysis. BMJ Open, 9(11), e030405. https://doi.org/10.1136/bmjopen-2019-030405
Zeng, X.-L., Zhang, Y.-F., Tian, Q., Xue, Y., & An, R.-F. (2016). Effects of metformin on pregnancy outcomes in women with polycystic ovary syndrome. Medicine, 95(36), e4526. https://doi.org/10.1097/md.0000000000004526
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Consider the following scenarios:
LW is a 32 year old female patient who comes to your medical clinic for primary care. She has been on hormonal contraceptives for years, although she’s just been married and has stopped her pills in hopes of becoming pregnant. Her PMHx includes obesity, HTN (diagnosed 3 years ago), familial hypercholesterolemia, and PCOS. Her current medications are as follows: Metformin 2000 mg PO daily, Lisinopril 10 mg PO daily, rosuvastatin 5 mg PO daily, and a multivitamin.
GD is an 82-year-old patient is taking 2 mg of terazosin for BPH every morning. He comes in complaining of dizziness, generalized muscle weakness and persistent lower urinary tract symptoms (LUTS).
How should you advise these patients and manage their medications? What was the process you went through to assess the current medications and to recommend an updated regimen?
Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight. Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced. A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.