A 66-year-old man comes to the office for hypertension follow-up. The patient takes lisinopril and amlodipine, but his blood pressure recordings have been 140-150/85-95 mm Hg over the past 2 office visits. He has had no chest pain or shortness of breath. The patient also reports worsening urinary symptoms over the past year that include hesitancy, straining during urination, poor urinary flow, and waking up once or twice a night to urinate. He feels the symptoms are bothersome but are not affecting his quality of life. The patient has no other medical conditions and does not use tobacco, alcohol, or illicit drugs. Blood pressure is 142/88 mm Hg and pulse is 70/min. Physical examination shows a mildly enlarged, smooth prostate but is otherwise unremarkable. Serum chemistry studies and urinalysis are normal. Which of the following medications would be most effective for treating both of this patient's medical issues?
This patient's obstructive urinary symptoms and mildly enlarged prostate are consistent with benign prostatic hyperplasia (BPH). In addition, he has hypertension that has not been well controlled. When possible, it is desirable to choose drugs that can address multiple issues to minimize adverse effects and drug interactions.
In this patient, an alpha-1 blocker (eg, doxazosin, prazosin, terazosin) can be used to treat both the BPH symptoms and the hypertension. Although alpha-1 blockers are not first-line medications for hypertension, they can be useful second-line drugs in hypertensive patients with concomitant BPH.
Alpha-1 blockers work by relaxing smooth muscle in the bladder neck and prostate, opening up the bladder outlet and decreasing the resistance to the flow of urine. They also relax smooth muscle tone in arterial walls, thus decreasing blood pressure. Uroselective alpha-1 blockers (specific for alpha-1A subtype), such as alfuzosin, silodosin, and tamsulosin, affect only the urinary tract smooth muscles; therefore, they would not be helpful in decreasing blood pressure (Choice F).
(Choice B) Finasteride is a 5-alpha-reductase inhibitor that is effective for the treatment of BPH but has no effect on blood pressure. It works by inhibiting the conversion of testosterone to dihydrotestosterone, the hormone that causes progressive glandular enlargement in BPH. After being administered for several months, finasteride decreases the size of the prostate.
(Choice C) Hydralazine is a powerful, typically third-line antihypertensive that works by relaxing smooth muscles in the arterial walls. It would not be useful in the treatment of BPH.
(Choice D) Hydrochlorothiazide is a thiazide diuretic that functions at the distal convoluted tubule of the nephron to prevent the reabsorption of sodium, chloride and water by blocking a Na/Cl co-transporter. It is one of the first-line medications for the treatment of primary hypertension. Diuretics have no role in the treatment of BPH.
(Choice E) Metoprolol is a selective beta-1-receptor blocker used to treat hypertension and coronary artery disease. It works by blocking adrenergic stimulation of the heart, causing the heart to contract less forcefully and less frequently. Beta-1-receptor blockers would not help with BPH symptoms.
Educational objective:
Alpha-1 blockers such as doxazosin, prazosin, and terazosin are useful for the treatment of both benign prostatic hyperplasia and hypertension. To minimize adverse effects and drug interactions, it is desirable to prescribe a medication that can address multiple issues at once.