What is the recommended management for a patient presenting for a refill of finasteride (dutasteride)?

SOAP Note for Finasteride Refill

Subjective

Chief Complaint: "Here for finasteride refill"

History of Present Illness:

• Current finasteride dose and duration of therapy
• Indication for finasteride (BPH vs androgenetic alopecia)
• Symptom improvement assessment:
  • For BPH: Changes in urinary frequency, urgency, nocturia, stream strength, hesitancy, incomplete emptying (quantify using AUA Symptom Index if possible) 1
  • For alopecia: Subjective hair regrowth, stabilization of hair loss
• Medication compliance and timing
• Any missed doses or treatment interruptions

Review of Systems:

• Sexual function: Assess for decreased libido (occurs in 6.4% first year, 2.6% years 2-4), erectile dysfunction (4-15% incidence), ejaculatory dysfunction (3.7% first year, 1.5% years 2-4) 1, 2, 3
• Breast changes: Gynecomastia or breast tenderness 4
• Urinary symptoms: If BPH indication - assess for acute urinary retention, hematuria, recurrent UTIs, bladder stones 1

Past Medical History:

• Prostate cancer screening history and results
• Cardiovascular disease
• Liver disease

Medications: Current finasteride dose, other BPH medications (alpha-blockers), testosterone supplementation

Allergies: Document any prior reactions to 5-alpha-reductase inhibitors

Objective

Vital Signs: Blood pressure (especially if on concurrent alpha-blocker)

Physical Examination:

• Digital rectal exam (DRE): Assess prostate size, nodularity, asymmetry, tenderness 4, 3
• Breast exam: If patient reports gynecomastia symptoms
• Abdominal exam: Assess for suprapubic distension suggesting urinary retention

Laboratory:

• PSA level: Critical - must be interpreted correctly in patients on finasteride. After 6+ months of therapy, double the measured PSA value for comparison with normal ranges in untreated men 4, 3
• Any confirmed increase from the lowest PSA value while on finasteride may signal prostate cancer and requires evaluation, even if values remain within normal range for untreated men 3
• Baseline PSA should be established at least 6 months after starting finasteride 3

Assessment

Primary Diagnosis:

• Benign prostatic hyperplasia (if prostate >30cc) on finasteride therapy 1
  • OR Androgenetic alopecia on finasteride therapy

Treatment Response:

• For BPH: Expected 3-point improvement in AUA Symptom Index, 15-25% prostate size reduction within 6 months 1, 5
• Symptom improvement maintained for 6-10 years in long-term studies 1

Monitoring Considerations:

• PSA monitoring with appropriate doubling adjustment 4, 3
• Sexual side effects assessment (typically decrease after first year) 1, 3
• Treatment duration: For BPH, long-term therapy indicated; for cancer prevention, 7-year duration studied 4

Plan

Medication Management

Continue finasteride 5 mg daily (for BPH) or 1 mg daily (for alopecia) 1, 3

• Counsel that finasteride is coated and should be swallowed whole 3
• May take with or without food 6
• Emphasize that at least 6 months of therapy is required to assess effectiveness 1, 3

Monitoring

• PSA monitoring: Establish new baseline at 6 months if not already done; monitor periodically thereafter with doubling rule applied 4, 3
• Follow-up visit in 6-12 months for symptom reassessment using AUA Symptom Index 1
• If PSA increases despite therapy, evaluate for prostate cancer even if within normal range 3

Patient Education

• Sexual side effects are common (4-15% erectile dysfunction, 6.4% decreased libido) but typically reversible and decrease after first year 1, 2, 3
• Cannot donate blood until 6 months after last dose due to risk to pregnant females 6
• Pregnant females or those who may become pregnant should not handle crushed or broken tablets 3
• Finasteride reduces prostate cancer risk but may increase risk of high-grade (Gleason 8-10) prostate cancer (1.8% vs 1.1% placebo) 4, 3

Combination Therapy Consideration

• If symptoms inadequately controlled on finasteride monotherapy, consider adding alpha-blocker for superior symptom relief 1, 5
• Combination therapy more effective than monotherapy for preventing disease progression and reducing acute urinary retention risk 1

Red Flags Requiring Urologic Referral

• Refractory urinary retention
• Recurrent UTIs
• Recurrent gross hematuria
• Bladder stones
• Renal insufficiency clearly due to BPH 1

Prescription

• Finasteride 5 mg (or 1 mg) tablets
• Quantity: 90 tablets
• Refills: 3
• Dispense as written

Common Pitfall to Avoid: Failure to double PSA values after 6+ months of therapy leads to missed prostate cancer diagnoses 4, 3