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9 - Renal and Urologic Disorders |
247
Surgery
Surgery is another intervention in the manage-
ment of BPH. In situations where medical treat-
ment is ineffective, in patients with moderate to
severe symptoms, or for individuals who prefer
it, surgery is an option.
57
Men experiencing
complications from BPH, such as acute urinary
retention, also may opt for surgical intervention
as an initial therapy, depending on individual
risks versus benefits.
59
Surgical removal of the
prostate, or prostatectomy, provides the highest
rate of symptom improvement, but it also carries
the greatest complication risk.
57
Transurethral
resection of the prostate (TURP) is considered
the standard surgical therapy for BPH because
of the extensive success and follow-up data that
are published with this procedure. Some newer
surgical techniques are available, but the TURP
remains the preferred technique.
58,59
Surgery is more effective for men with
moderate symptoms of BPH or in men with
enlarged prostates <50 g compared to watchful
waiting in improving genitourinary symptoms
and reducing treatment failure.
57,59,96
Compli-
cations reported include sexual dysfunction,
irritation with voiding, bladder neck contrac-
ture, need for blood transfusions, infection, and
hematuria.
59
Newer surgical procedures include
transurethral needle ablation, transurethral inci-
sion of the prostate, and transurethral microwave
therapy. These procedures are minimally inva-
sive, short, and an option for men who are poor
surgical candidates for TURP.
57,58,97
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| Fundamentals of Geriatric Pharmacotherapy
C 1: I N H
R D
Setting:
Quarterly care conference.
Subjective:
JD is an 85-year-old Caucasian male resident of a long-term care facility. He has no
complaints, but the nursing staff is concerned about an increased frequency of UI episodes.
Past Medical History:
JD was admitted to the long-term care facility for care on the Alzheimer Disease and Related
Dementia unit, with a mini-mental exam score of 15/30, a decline of 2 points from 1 year ago.
His past medical history is significant for hypertension and BPH.
Medications:
Donepezil 10 mg once daily, hydrochlorothiazide 25 mg once daily, lisinopril 20 mg daily,
multivitamin daily, docusate 100 mg two times/day, bisacodyl 10 mg once daily as needed for
constipation, tylenol PM one tablet at bedtime.
Allergies:
NKDA.
Social History:
Unknown.
Family History:
Noncontributory.
Objective:
Ht 5´10˝, Wt 72 kg, BP 90/65 mmHg, P 75 BPM, RR 18, and T 37°C.
Physical Examination:
Unremarkable; assessment of his functional abilities shows limitations in his activities of daily
living, requiring assistance with bathing and dressing.
Labs:
Normal CBC, sodium 129 mEq/L, potassium 3.4 mEq/L, chloride 100 mEq/L, carbon dioxide
29 mEq/L, fasting glucose 85 mg/dL, creatinine 1.2 mg/dL, and blood urea nitrogen 28 mg/dL.
(Calculated CrCl = 46 mL/min.)
Assessment:
1.
Urinary symptoms due to untreated BPH exacerbated by unnecessary anticholinergic
medication, diuretic, and cholinesterase inhibitor.
2. Blood pressure and electrolytes such as sodium and potassium are either low or
approaching the low end of the desired range, possibly associated with the thiazide
diuretic.
3. Alzheimer disease: Cognitive symptoms show a slight decline over the previous year
and may be exacerbated by the anticholinergic medication. A drug interaction between
donepezil and the anticholinergic is a concern. Complaints of insomnia are presumably a
reason the Tylenol PM was started; however, this is not formally documented and is not
presenting as a current complaint.
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249
Plan:
1.
Discontinue the Tylenol PM related to urinary retention symptoms. If urinary symptoms
persist, recommend initiation of tamsulosin 0.4 mg daily. Obtain urine sample to rule
out possible UTI as a cause of symptoms. Monitor blood pressure with addition of alpha
blocker. Monitor cognition with removal of anticholinergic medication.
2.
Continue lisinopril and decrease the dose of hydrochlorothiazide to 12.5 mg daily. Monitor
blood pressure and serum electrolytes.
3. Discontinue Tylenol PM (above) and continue donepezil therapy at this time while
observing changes in urinary symptoms and cognition. Monitor sleep patterns and level of
alertness.
Rationale:
1.
It is possible that urinary symptoms may resolve simply with elimination of the
anticholinergic medication. If not, alpha blockers are considered first-line treatment for
BPH symptoms, but nonselective agents such as doxazosin or terazosin may exacerbate
JD’s low blood pressure. This is less of a concern with tamsulosin but can still be
problematic, so careful monitoring of blood pressure is required during drug initiation.
Reduction in the thiazide diuretic dose may offset some of the hypotensive effect of
tamsulosin.
2.
JD is receiving appropriate medications for an individual with hypertension and CKD;
however, his blood pressure is low and he is experiencing a mild amount of hyponatremia
and hypokalemia. It is not clear the extent to which the diuretic may be exacerbating
incontinence symptoms, but this can be re-evaluated as therapy for BPH if initiated.
3.
It is difficult to evaluate JD’s true magnitude or quality of response to a cholinesterase
inhibitor while there is an antagonizing medication taken concomitantly. Therefore, no
changes to the donepezil should be made until this complicating factor is removed. It is
also unclear whether the cholinesterase inhibitor is worsening urinary symptoms, but due
to JD’s stable cognitive status changes to donepezil should be avoided. After the effects of
the tamsulosin and diuretic reduction have been observed, possible interactions between
the cholinesterase inhibitor and urinary symptoms can be evaluated. It is difficult to
discern whether the lack of a documented indication for the Tylenol PM is simply oversight
or if the drug can be accurately assessed as unnecessary. In light of his urinary symptoms
and dementia with cholinesterase inhibitor use, it is more prudent to discontinue Tylenol
PM at this time, while monitoring for any possible re-emergence of insomnia symptoms.
Case Summary:
JD is typical of an older man with multiple coexisting medical conditions and
pharmacotherapeutic treatments. The chief complaint involves urinary symptoms; however, it
is evident that the current medication regimen and any changes made to it carries implications
for his other comorbid conditions. Drug therapy interventions must be made in a careful
stepwise approach considering the potential impact on the target disease state and comorbid
disease states. In this case, discontinuation of Tylenol PM and reduction of hydrochlorothiazide
are the only two interventions taken initially, followed by possible initiation of tamsulosin
if urinary symptoms persist. At the same time, the hope is to maximize the effectiveness
of donepezil and defer making any changes to donepezil unless absolutely necessary. The
two initial changes may not only impact the chief complaint but also the blood pressure,
electrolytes, and cognition.
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| Fundamentals of Geriatric Pharmacotherapy
C 2: A C-D W
H
Setting:
Outpatient/assisted living setting.
Subjective:
MM is a 92-year-old Caucasian woman who resides in an assisted living facility. She is being
evaluated today in the emergency department of her local hospital. Although there are no
known baseline deficits in cognition and she is usually continent, she has developed new onset
of confusion and falls. Staff report she was found on the floor of her room and complained of
hitting her head.
Past Medical History:
MM has a history of glaucoma, hypertension, osteoarthritis, and osteopenia. She had an
appendectomy in 1976 and was treated for a UTI 3 weeks ago.
Medications:
Timolol 0.25% solution, instill 1 drop in both eyes twice daily, acetaminophen 500 mg four
times daily, calcium carbonate 500 mg three times daily, vitamin D 800 IU daily, lisinopril
10 mg daily, hydrochlorothiazide 25 mg daily, omeprazole 20 mg daily.
She recently completed a course of antibiotics for the UTI. She receives medication reminders
from facility staff, who confirm that she took all of her antibiotic and regularly-prescribed
medications.
Allergies:
Penicillin.
Social History:
Retired music teacher, widowed 9 years ago. Two adult children in good health.
Objective:
Ht 5´2˝, Wt 48 kg, BP 114/65 mmHg, P 85 BPM, RR 18, T 38°C
Physical Examination:
Thin, confused elderly female in mild distress; otherwise, physical findings are unremarkable.
Labs:
UA reveals cloudy urine, negative for nitrite and leukocyte esterase, with no bacteria or WBC.
CBC reveals WBC 7.2, hemoglobin 12.1, hematocrit 36%, platelets 202.
Chemistry Panel:
Sodium 123 mEq/L, potassium 4.0 mEq/L, chloride 110 mEq/L, and carbon dioxide 28 mEq/L,
glucose 92 mg/dL, creatinine 1.0 mg/dL, and blood urea nitrogen 38 mg/dL. Calcium
9.2 mg/dL, phosphorus 2.9 mg/dL, and magnesium 1.5 mg/dL. (Calculated CrCl = 26 mL/min.)
Assessment:
1.
Falls
2. Hyponatremia
3. Hypomagnesemia and need for medication management
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Plan
1.
Perform a complete falls assessment. This includes imaging of her brain to rule out head
trauma.
2. Discontinue hydrochlorothiazide.
3.
Discontinue omeprazole 20 mg daily.
Rationale:
1.
MM should receive imaging of her brain to rule out head trauma, such as a subdural
hematoma. Her assisted living environment should be assessed for clutter, loose carpets,
and other fall hazards. In addition, her serum electrolyte abnormalities should be
addressed to further decrease her risk factors for falls (see rationales below). Physical
therapy can be recommended to restore any loss of ambulation ability from the recent fall.
2. MM is an elderly woman with hyponatremia that is likely due to hydrochlorothiazide.
Even mild hyponatremia increases the risk of falls and may also be responsible for the
change in mental state and confusion. Also, based on her present creatinine clearance
calculation, MM doesn’t meet the minimal renal function parameters for successful
hydrochlorothiazide use. Addition of salt tablets to the regimen would not correct the
underlying cause. Discontinuation of the diuretic is best in this case because the cause is
more linked to a water deficit and not to a deficiency of salt.
3.
MM does not have a diagnosis that justifies use of omeprazole and has mild
hypomagnesemia, which could be an adverse effect of omeprazole. Symptoms of the low
magnesium, such as muscle cramps and nausea, do not seem to be present. Therefore,
discontinuation of the proton pump inhibitor is recommended. Serum magnesium should
be monitored after discontinuation of omeprazole and supplementation with magnesium
citrate can occur if the magnesium serum concentration does not return to normal
(1.8–3.0 mg/dL).
Case Summary:
MM illustrates a common situation, in which a frail elderly woman develops electrolyte
disturbances and falls that might be due to her medication regimen. Thiazide diuretics are
not recommended in patients with very low creatinine clearance and are a frequent cause
of hyponatremia among elderly patients. In addition, MM is receiving omeprazole without
a documented need or diagnosis. Chronic use of omeprazole in the elderly with impaired
renal function may lead to low magnesium levels. The best approach to this problem is to
discontinue the omeprazole.
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| Fundamentals of Geriatric Pharmacotherapy
C S
Renal function declines with age, and older
patients will frequently develop CKD as they
enter their 80s and 90s. Also, the elderly often
have other comorbid diseases, such as diabetes
and hypertension, which may lead to further
deterioration in their renal function. This decline
in renal function, in addition to diuretic use and
changes in cognition and environment, increase
the risk of dehydration and imbalances in serum
sodium. To estimate renal function, pharmacists
must calculate the patient’s creatinine clear-
ance and assess the older patient’s medication
regimen to be sure that appropriate renal protec-
tion therapies are being utilized and that drugs
are screened for their potential to accumulate.
The prevalence of UI increases with age,
although it is not considered an expected part
of aging. Age-related physiologic changes must
be taken into consideration when diagnosing
and classifying the various forms of UI. Behav-
ioral rehabilitation techniques, medications, and
surgery are all possible treatments but must be
chosen only after reviewing the goals of therapy
with the individual patient. BPH is the most
common urologic condition of aging men. A wide
range of signs and symptoms occur in BPH,
and it is the individual’s ability to tolerate the
symptoms that is usually the motivating factor in
seeking treatment. Alpha blockers and/or 5ARIs
are the drugs utilized most, as well as surgical
intervention. Information from future long-term
studies will help define the role of medication
therapy for both symptom improvement and to
delay disease progression of BPH.
S-A Q
1. What are the common changes in physi-
ology of the kidney that occur with age, and
how do these changes impact the develop-
ment of CKD?
2. What are the advantages and disadvan-
tages in older persons of the commonly
used equations to calculate creatinine clear-
ance?
3. Explain what common electrolyte disorder
might occur in an older person on a thia-
zide diuretic. What is the mechanism for this
effect?
Clinical Pearls
• Overuse of loop diuretics is an important contribution to dehydration in the elderly.
Often, the dose of diuretic needed to manage acute heart failure is greater than the
dose required to maintain a patient with chronic heart failure. Where possible, patients
and caregivers should be taught to gauge their fluid response to a loop diuretic by using
daily weights. The negative or positive change in weight, in comparison to a person’s
dry weight, is helpful in managing the appropriate dose of the diuretic.
•
The two 5ARIs, finasteride and dutasteride, are both Pregnancy Category X and require
labeling regarding risk of birth defects. Although these medications are prescribed for
male patients, the potential for medication handling by female caregivers should not be
overlooked. In any circumstance where a caregiver is concerned about the safety of
handling drug products, recommendations should be made to wash hands before and
after medication administration or to wear gloves.
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9 - Renal and Urologic Disorders |
253
4. What are the major differences between
the signs and symptoms of the types of UI?
Explain how these symptom differences can
help differentiate the types of UI in a patient.
5.
Under what circumstances would an alpha
blocker cause UI? Under what circum-
stances would an alpha blocker be helpful
in treating UI?
6.
In a patient with OAB, how do you choose
between the different anticholinergic medi-
cations approved to treat this disorder?
7. In an older man with BPH involving severe
LUTS, what is a recommended treatment?
8.
In a man with BPH, under what circum-
stances is it most justified to use the combi-
nation of an alpha blocker and an alpha-
reductase inhibitor?
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