What is the recommended treatment for Benign Prostatic Hyperplasia (BPH) in an 82-year-old patient with recurrent hypotension?

From the Guidelines

For an 82-year-old patient with BPH and recurrent hypotension, the recommended treatment approach should prioritize minimizing cardiovascular risks, and 5-alpha reductase inhibitors such as finasteride (5mg daily) or dutasteride (0.5mg daily) may be used as they don't significantly affect blood pressure, though they take 3-6 months to show full effect. When considering treatment options for this patient, it's essential to weigh the benefits and risks of each approach. According to the AUA guideline on management of benign prostatic hyperplasia 1, 5 alpha-reductase inhibitors are appropriate and effective treatments for patients with LUTS associated with demonstrable prostatic enlargement. The patient's recurrent hypotension is a critical factor in determining the best course of treatment. Alpha-blockers like tamsulosin should be avoided as they can worsen hypotension in this patient 1. Surgical intervention such as transurethral resection of the prostate (TURP) or minimally invasive procedures like prostatic urethral lift (UroLift) or water vapor thermal therapy (Rezūm) would be preferred over medications that may exacerbate hypotension. However, if medication is necessary, 5-alpha reductase inhibitors are a suitable option. Phosphodiesterase-5 inhibitors like tadalafil (5mg daily) might be considered if erectile dysfunction is also present, but with caution regarding potential hypotensive effects. The patient should be closely monitored for orthostatic hypotension, and any existing antihypertensive medications should be reviewed and potentially adjusted. Lifestyle modifications including limiting evening fluid intake, avoiding alcohol and caffeine, and scheduled voiding are important supportive measures. This approach balances BPH symptom relief while minimizing risks associated with hypotension in this elderly patient. Key considerations in managing this patient's BPH include:

• Avoiding medications that may worsen hypotension
• Considering surgical or minimally invasive procedures
• Monitoring for orthostatic hypotension
• Adjusting existing antihypertensive medications as needed
• Implementing lifestyle modifications to support BPH symptom relief and minimize cardiovascular risks.

From the FDA Drug Label

2.3 Tadalafil Tablets for Once Daily Use for Benign Prostatic Hyperplasia The recommended dose of tadalafil tablets for once daily use is 5 mg, taken at approximately the same time every day.

Recommended Treatment for BPH: The recommended treatment for Benign Prostatic Hyperplasia (BPH) is 5 mg of tadalafil tablets once daily.

• However, it is crucial to consider the patient's renal function and concomitant medications, such as alpha-blockers and antihypertensives, as they may interact with tadalafil and exacerbate hypotension.
• Given the patient's recurrent hypotension, caution is advised when initiating tadalafil therapy, and the patient's blood pressure should be closely monitored.
• Additionally, the patient's age (82 years) and potential renal impairment should be taken into account when determining the appropriate dose and monitoring plan 2.

From the Research

Treatment Options for BPH

• The recommended treatment for Benign Prostatic Hyperplasia (BPH) in an 82-year-old patient with recurrent hypotension involves the use of 5-alpha reductase inhibitors (5-ARIs) such as finasteride and dutasteride, which have been shown to decrease prostate volume, improve lower urinary tract symptoms (LUTS), and urinary flow rates 3.
• Combination therapy with alpha-1 adrenergic receptor antagonists (ARAs) and 5-ARIs is also a viable option, as it has been demonstrated to be more effective than monotherapy in reducing the risk of acute urinary retention and BPH-related surgery 4, 5.

Considerations for Recurrent Hypotension

• When considering treatment options for an 82-year-old patient with recurrent hypotension, it is essential to take into account the potential side effects of alpha-1 blockers, which can exacerbate hypotension 6.
• 5-ARIs, on the other hand, have a slower onset of action but can provide significant improvements in symptoms and reduction in prostate size, making them a suitable option for patients with recurrent hypotension 3, 7.

Efficacy and Safety of 5-ARIs

• Finasteride, a 5-ARI, has been shown to be effective in reducing prostate volume, improving IPSS score, and increasing maximum urinary flow rate, with a moderate to significant effect size 7.
• The safety profile of finasteride is generally favorable, with no severe adverse events or psychiatric disorders reported, although sexual health dysfunctions can be a concern 7.