BCPS / Men’s and women’s health

Answer C. D. Both dutasteride and finasteride are alpha-reductase inhibitors and are isoenzymes of dihydrotestererone and block the conversion testosterone to dihydrotestosterone. Both silodosin and alfuzosin are alpha-adrenergic blockers (prevent smooth muscle contraction in bladder muscles) and tadalafil is a phosphodiesterase-5 inhibitor (promotes smooth muscle relaxation in bladder muscles).
Reference:
McVaryKT, et al. Update on AUA guideline on the management of benign prostatic hyperplasia.J Urol. 2011 May;185(5):1793-803. Epub2011 Mar 21.

Answer A. Tadalafil is the only PDE5 inhibitor that has the potentail to treat BPH and BPH-related LUTS. It does this by increasing levels of cGMP, which relax essential smooth muscles located in the prostate and bladder. Sildenafil, vedenafil, and avanafil are all PDEF inhibitors, but only have indications for treatment of ED.
Reference:
Product information for Cialis. Lilly USA, LLC Indianapolis, IN 46285, USA. April, 2016

Answer D. Pseudoephedrine is an adrenergic agent, so may prevent muscle relaxation in both the bladder and prostate, which can further exasperate symptoms of BPH. Diphenhydramine and other first generation antihistamines are anticholinergic and can inhibit relaxation of essential bladder muscles (i.e. detrusor), further preventing urination and aggravating symptoms of BPH. Diphenhydramine is also on the BEER’s list (sedative effects may increase the incidence of falls), so should be avoided in patients over the age of 65. Guaifenesin is appropriate for this patient.
Reference:
McVaryKT, et al. Update on AUA guideline on the management of benign prostatic hyperplasia.J Urol. 2011 May;185(5):1793-803. Epub2011 Mar 21.

Answer B. Both sildosin and alfuzosin cannot be used in patients with poor renal function (CrCl <30 ml/min), but tamsulosin has no renal dose adjustments.
Reference:
LeporH, KazzaziA, DjavanB. Alpha-blockers for benign prostatic hyperplasia: the new era. CurrOpinUrol2012;22:7-15.

Answer D. 5-alpha reductase inhibitors block the conversion of testosterone to DHT and have the potential to shrink the prostate and treat BPH. They have a longer duration of action than alpha-adrenergic agents (2-6 months). They also lead to a decrease in PSA and have a common side effect of ED. This drug is a pregnancy category X; therefore patients taking this medication may not donate blood, due to the risk of the blood product being received by a pregnant (or soon to be pregnant) mother.
Reference:
TheoretMR, Ning YM, Zhang JJ, Justice R, Keegan P, PazdurR. The risks and benefits of 5a-reductase inhibitors for prostate-cancer prevention.N EnglJ Med. 2011

Answer A. Alpha-1 adrenergic blockers decrease the AUA score by 30-50%, making them a first-line mediction choice for BPH. 5-alpha reductase inhibitors are the class of medications that decrease PSA levels and prostate size.
Reference:
LeporH, KazzaziA, DjavanB. Alpha-blockers for benign prostatic hyperplasia: the new era. CurrOpinUrol2012;22:7-15.

Answer D. Tamsulosin and other alpha-1 adrenergic agents can cause poor iris dilation, leading to complications during cataract surgery. Finasteride and dutasteride are 5-alpha reductase inhibitors and taldafil is a PDE5 inhibitor; these medications do not have this contraindication.
Reference:
Bell CM, et al. Association between tamsulosinand serious ophthalmic adverse events in older men following cataract surgery.JAMA. 2009 May 20;301(19):1991-6.

Answer D. AUA scoring system: 1-7: mild 8-19: moderate 20-35: severe A change in score above 3 is considered to be clinicially signfiicant
Reference:
Barry MJ, et al. (1992). American Urological Association symptom index for benign prostatic hyperplasia. Journal of Urology, 148(5): 1549-1557

Answer D. Tamsulosin is a first-line therepy option for treatment of BPH and does not have to be adjusted for patients with renal complications. In addition, this medication does not increase blood pressure or blood glucose, making it an appropriate therapy option for this patient. Sildosin (alpha adrenergic blocker) and tadalfil (PDEF inhibitor) should not be used in patients with poor renal function (CrCl <30 ml/min), so would not be appropriate for this patient . Finasteride (5-alpha reductase inhibitor) is a second line treatment option for BPH due to its longer treatment duration and increased side effect profile.
Reference:
McVaryKT, et al. Update on AUA guideline on the management of benign prostatic hyperplasia.J Urol. 2011 May;185(5):1793-803. Epub2011 Mar 21.

Answer C. Finasteride (5-alpha reducatse inhibitor) can be added to tamsulosin (alpha adrenergic antagonist) to further help manage this patients BPH. These agents can be used in combination to treat BPH patients that are nonresponsive to first-line monotherapy or for patients who have an enlarged prostate or LUTS. A change of medication would not be appropriate for this patient, nor would the addition of tadalafil. (can interact with tamsulosin: alpha blockers and PDE5 inhibitors should not be used together, as they may cause orthostatic hypotension).
Reference:
McVaryKT, et al. Update on AUA guideline on the management of benign prostatic hyperplasia.J Urol. 2011 May;185(5):1793-803. Epub2011 Mar 21.

Answer: C. Influenza vaccine is recommended annually, thus JM is a candidate, as he hasn’t received it since 2013. Patient is also a candidate for the herpes zoster vaccine as he is over the age of 60. A Tdap booster is recommended every 10 years, thus JM is a candidate as his last Tdap was 12 years ago. Lastly, patient is a candidate for the PCV13 vaccine as it is recommend 1 or more years after PPSV23 shot (given 3 yeas ago.) Patient is not a candidate for MMR, as individuals, who have been born prior to 1957 are considered immune to measles and mumps (patient born in 1944.)
Reference:
1. Adult Immunization Schedule. Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/schedules/hcp/adult.html. Updated April 20, 2016. Accessed September 5, 2016 


Answer: B. A single dose of zoster vaccine is recommended for all adults 60 years or older, regardless of whether they report a prior episode of herpes zoster, thus A is wrong. Also, although 2nd and 3rd episodes of herpes zoster can occur, the annual incidence of recurrence is not known. Although the FDA recommends the administration of the vaccine for individuals 50 years or older, the ACIP recommends that vaccinations begin at 60 years, thus C and D are incorrect.
Reference:
1. Shingles | Clinical Overview - Varicella Vaccine | Herpes Zoster | CDC. Cdcgov. 2016. Available at: http://www.cdc.gov/shingles/hcp/clinical-overview.html. Accessed September 27, 2016.
2. Adult Immunization Schedule. Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/schedules/hcp/adult.html. Updated April 20, 2016. Accessed September 27, 2016

Answer: A Rationale: Adults who are 19 years or older with immunocompromising conditions such as multiple myeloma, who have not received either PCV13 or PPSV23  administer PCV13 followed by PPSV23 at least 8 weeks after PCV13, thus B, C, and D are wrong.
Reference:
1. Adult Immunization Schedule. Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/schedules/hcp/adult.html. Updated April 20, 2016. Accessed September 27, 2016

Answer: B Adults aged 65 or older who are immunocompetent and who have not received PCV13 but who have 1 or more doses of PPSV23at age <65 years administer PCV13 at least 1 year after the most recent dose of PPSV23, thus C is wrong. Then, administer a dose of PPSV23 at least 1 year after PCV13 and at least 5 years after the most recent dose of PPSV23, thus D is wrong. The interval between PPSV23 doses should be at least 5 years, thus A is wrong.
Reference:
1. Adult Immunization Schedule. Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/schedules/hcp/adult.html. Updated April 20, 2016. Accessed September 27, 2016 


Answer: D. Adults who are 65 years or older, who have previously received one or more doses of PPSV23, should receive a dose of PCV13 if they have not received it. A dose of PCV13 should be given one or more years after receipt of the most recent PPSV23 dose, thus C is wrong. In this case, the patient would be receiving it 2 years after her PPSV23 shot. No additional dose of PPSV23 is indicated for adults vaccinated with PSC23 at age 65 or older, thus B is wrong. The recommended lifetime maximum dose of PCV13 is 1, and 3 doses of PPSV23. The interval between PPSV23 doses should be at least 5 years, thus A is wrong.
Reference:
1. Adult Immunization Schedule. Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/schedules/hcp/adult.html. Updated April 20, 2016. Accessed September 27, 2016 


Answer: C All adults 65 years or older, should receive a dose of PCV 13 followed by a dose of PPSV23 6-12 months after (if immunocompetent), thus A is incorrect. Adults aged ≥65 years with immunocompromising conditions, functional or anatomic asplenia, cerebrospinal fluid (CSF) leaks, or cochlear implants are recommended to receive PCV13 first, followed by PPSV23 ≥8 weeks later, thus D is incorrect as it does not apply to this patient. When both PCV13 and PPSV23 are to be administered, PCV13 is recommended before PPSV23, based on studies demonstrating a better response to serotypes common to both vaccines when PCV was given first, thus B is incorrect.
Reference:
1. Pinkbook | Pneumococcal | Epidemiology of Vaccine Preventable Diseases | CDC. Cdcgov. 2016. Available at: http://www.cdc.gov/vaccines/pubs/pinkbook/pneumo.html. Accessed September 27, 2016.
2. Intervals Between PCV13 and PPSV23 Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Cdcgov. 2016. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6434a4.htm. Accessed September 27, 2016.

Answer: D Change can be classified as “antigenic drift”, indicating continual small changes that occur in the genes (surface antigens) of influenza viruses during replication. These changes lead to the requirement of having to review flu vaccine composition yearly, in order to update vaccines to keep up with evolving viruses. “Antigenic Shift,” on the other hand, is a major genetic change in the influenza A viruses. Influenza A virus subtype that occurs as a result from antigenic shift has the potential to cause pandemics. Lastly, the majority of adults have a protective antibody response within 2 weeks after vaccination.
Reference:
Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices – United States, 2016-17 Influenza Season. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/65/rr/rr6505a1.htm. Updated August 25, 2016. Accessed September 27, 2016.