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α-1 adrenoreceptor antagonists and cataract surgery
- Nathaniel E Knox Cartwright (25 January 2008)
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cranberry juice for prophylaxis against recurrent urinary tract infestion in BPH
- oscar,m jolobe (25 January 2008)
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Combined Pharmacotherapy with 5ARI inhibitors and alpha1 adreno receptors inhibitors is not cost effective than surgical TURP for long term treatment of Benign hyperplasia of Prostate in third world countries.
- Professor Pranab Kumar Bhattacharya, Bhattacharya Rupak 7/51 Purbapalli, Sodepur, Kol-110;Bhattacharya Upasana DPS Rubipark, Kolkata ;Chakraborty Anindya Urosurg, Sarkar Diptendra . Asst. Prof. Surgery, Dtutta Pradip Assoc. Prof. Med. IPGME&R 244A AJC Bose Road, Kolkata-20,W.B, India, (12 February 2008)
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Nathaniel E Knox Cartwright, Research fellow Dept of Ophthalmology, King's College London, SE1 7EH
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An important omission from Wilt and N’Dow’s excellent review on the management of benign prostatic hyperplasia (BPH) [1] is a failure to mention that oral á-1 adrenoreceptor antagonists, in particular tamsulosin (Flomax), can cause intraoperative floppy iris syndrome (IFIS).[2] IFIS, which can persist long after the cessation of treatment, is characterised by iris flaccidity and poor pupillary dilatation both of which can complicate cataract surgery and necessitate change in surgical technique. Given the association of both BPH and cataract with increasing age it is important for ophthalmologists to ask whether patients have ever received medical treatment for BPH and for referring doctors to state this fact when referring those who have. It is not known whether stopping treatment preoperatively is beneficial but tamsulosin should not be started in those awaiting cataract surgery. In both the UK and USA labelling of tamsulosin has changed to include this guidance.[3][4] [1] Wilt TJ, N'Dow J. Benign prostatic hyperplasia. Part 2—Management. BMJ 2008;336:206-10. [2] Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg 2005;31(4):664-73. [3] MedWatch. http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#Flomax. Accessed 25 January 2008 [4] Public Assessment Report - Intraoperative floppy iris syndrome (IFIS) and á-1 adrenoceptor antagonists- a class effect? http://www.mhra.gov.uk/home/idcplg?IdcService=GET_FILE&dDocName=con2031031&RevisionSelectionMethod=Latest. Accessed 25 January 2008 Competing interests: None declared |
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oscar,m jolobe, retired geriatrician manchester medical society, c/o john rylands university library, oxford road, manchester M13 9PP
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Benign prostatic hyperplasia(BPH) is a risk factor for recurrent urinary tract infection(UTI) the latter, in turn being an acknowledged indication for surgical treatment of this disorder. Accordingly, in order to enhance the strategy of medical management of BPH, so as to "buy time" to delay interventional treatment, the authors of the review(1) should have discussed the role of lifestyle modalities such as regular intake of cranberry juice, in reducing the recurrence rate of UTI. Regular intake of cranberry juice significantly reduces the recurrence rate of UTI in women, as shown by a study documenting a 20% reduction(95% confidence interval 3% to 36%, p=0.023; number needed to treat=5, 95% confidence interval 3-45) in absolute risk of recurrence in the cranberry juice group compared with the lactobacillus group(2). Vaccinium berries such as cranberry juice contain a polymeric compound, proanthocyanidin, which inhibits the mannose -resistant adhesins of uropathogenic E.Coli(3). The adhesins, in turn, are the ones which enable the hair-like fimbriae of E.Coli to attach to receptors on uroepithelial cells(4). It is through its inhibitory action against the adhesins that cranberry juice reduces recurrence of UTI since adherence of uropathogens to uroepithelial cells is the initial step in the pathogenesis of urinary tract infection(5). References (1)Wilt TJ., N'Dow J Benign prostatic hyperplasia Part 2-Management BMJ 2008:336:146-9 (2)Kontiokari T., Sundqvist K., Nuutinen M., et al Randomised trial of cranberry-lingonberry juice and Lactobacillus GG drink for the prevention of urinary tract infections in women BMJ 2001:322:1-5 (3)Ofek I., Goldhar J., Zafriri D et al Anti-Eschericia coli adhesin activity of cranberry and blue berry juices New England Journal of Medicine 1991:324:1599 (4) Duguid JP., Old DC Adhesive properties of Enterobacteriaceae In: Beachey EH ed Bacterial adherence: receptors and recognition, series B, vol 6. London Chapman and Hall 1980:185-217 (5) Lowe FC., Fagelman E Cranberry juice and urinary tract infections: what is the evidence? Urology 2001:57:407-13 Competing interests: None declared |
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Professor Pranab Kumar Bhattacharya, Professor of Pathology, Incharge of Histopathology Unit, Blood Bank&VCTC,Cytogenetics Institute of Post Graduate Medical Education& Research-244A AJC Bose Road, Kolkata-20,W.B, India, Bhattacharya Rupak 7/51 Purbapalli, Sodepur, Kol-110;Bhattacharya Upasana DPS Rubipark, Kolkata ;Chakraborty Anindya Urosurg, Sarkar Diptendra . Asst. Prof. Surgery, Dtutta Pradip Assoc. Prof. Med. IPGME&R 244A AJC Bose Road, Kolkata-20,W.B, India,
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Amongst ageing men, Benign Hyperplasia of Prostate (BHP) [better called Nodular Hyperplasia of prostate or NHP ] is most common cause of lower urinary tract symptoms(LUTS). Clinically NHP is defined at least two of the followings: Moderate to severe LUTS, an enlarged Prostate >30 ml and decreased urinary flow rate [Q max< 15 ml/s]. LUTS describe a combination of storage [ irritative symptoms]e.g. nocturia, increased urinary frequency and urgency and/or voiding[obstructive] disturbances. The prevalence of NHP in West Bengal state increases with age of population. Although there are evidences that androgens and estrogens are involved in growth of stromal and epithelial cells in prostate and induction fibro-muscular overgrowth remain still unclear and seems to be multi factorials like molecular, environmental & hormonal interactions. It has been also postulated that hyperplasia of stromal cells and glandular cells compartment might be induced by stromal growth ,secondary to hypoxia which in turns results abnormal blood flow pattern in prostate tissue. We, suggest also one theory for this hyperplasia. Hypoxia in prostate from atherosclerosed vessels in aged population may trigger prostate growth by up regulating the secretions of several growth factors in response to hypoxia. Prostate hypoxia may occur in patients presenting with generalized or localized vascular damage. Several studies before suggested an association of NHP between presences of vascular disorders such as Coronary heart diseases or diabetes mellitus type2. It has been also reported that compared to healthy control, DM men have significant low perfusion rates in TZ zone of prostate, where NHP arises first. The role of á adrenergic receptors in the causation of NHP is a well accepted theory. These receptors seem not only to increase tone of prostate smooth muscles, but also modify prostate growth and contribute to LUTS by effects on bladder and spinal cord. These á1 adrenoreceptors subtypes (1) have been also identified in conjunction with NHP. Subtypes are á1a, á1b,and á1d which are predominantly situated in prostate smooth muscles and have a direct effect on voiding symptoms of NHP(2). The gene for á1 adreno receptors ( ADRA1-1) are found on chromosome 8p21-p11.2and has polymorphic allele at various locations and to date there are six validated single nucleotide polymorphism in that gene found(2) .So á1 selective blockers are today one of treatment modality as mono therapy or along with 5á Reductase inhibitors(5ARI). 5ARI prevents conversion of testosterone to its active metabolite Dihydrotestesterone(DHT). DHT is also responsible for prostate glandular and stromal enlargement In the first world countries, pharmacotherapy that combines á1 adrenergic receptor blocker and 5ARI is probably the new standard treatment for NHP. Dutasteride- a selective 5ARI inhibits 5 á reductase that catalyses the conversion of testosterone to DHT. The other is Fenasteride. However Dutasteride significantly found to reduce prostate volume, improves urinary symptoms & flow and reduces long term risk of acute urinary retention, need for NHP related surgery in men with symptomatic NHP. It is superior to fenasteride. Fenasteride has side effects reported.>1% pt, like sexual dysfunction, breast enlargement or tenderness , rashes, cardiovascular, orthostatic hypotension & CNS dizziness more than Dutasteride (3) based on a double blind phase III study with 2340 symptomatic patients with NHP(3,4). Generally choice of treatment of NHP may be watchful waiting, surgical TRUP or pharmaceuticals. Pharmaceutical therapy is cost effective than TURP in case of short time for 2-4 years and for higher socioeconomic people. The caveat is association between long term 5ARI & alpha1 adrenoreceptor combination when used for long term and when NHP develops in patients at age<55 years. Cost of Combined therapy in West Bengal state per year, per man is around Rs 8500/= orUs $240 and treatment is life long. As such a man of 55yrs age when asked for combined therapy and if continues for 25 years [up to age 80 yrs] cost of combined therapy is Rs 2, 12,500/= or us $ 5,900. The first author’s 82 years old father is on combined pharmacotherapy for his NHP since 1998. Further there remains question of adherence of treatment. There is tradition of poor country people/third world that once patient feels better he stops drug. But TURP costs even in a private hospital set up, < Rs 50,000/= or Us $ 1390and in public hospital costs < Rs 10,000/= and the process is one off procedure, though possibility of prostatic remnants remains in TURP. However combined therapy is less invasive than TURP and may be preferred in the oldest age group who are at greater risk of progression. So in our opinion for third world countries TRUP is best treatment of choice References 1)Michel. MC, Kenny B, Schwinn DA “ Classification of Alpha 1 Adreno receptors subtype “ Naunyn, Schiedebers Arch. Pharmacol.352;1-10;1995 2)Chaidir VA Mochtar, Winjanand Laan, Kjeld P Van Houwelingen etal “ Polymorphism in the Alpha-1 adreno-receptors gene do not modify the short and long term efficacy of Alpha 1 adreno-receptors antagonist in the treatment of BPH “ BJU international 97;852-55;2007 3)ClR k rv, Hermann DJ . Cunninghum GR “Marked suppression on DHT in Men with BPH by Dutasteride- a dual 5 alpha reductase inhibitors”- J clin. Endocrinol. Metab 89:2719-24;2004 4)Claude Sculman, Peter Pommerville, Klaus Hoofner etal “ Long term therapy with Dual 5 alpha reductase inhibitor dutasteride is well tolerated in men with symptomatic BPH “ BJU international 97;73-80;2005 Corresponding Author’s Address-: Professor Pranab Kr Bhattacharya
,Professor Dept. of pathology, In charge of Histopathology Unit, in charge
of Cytogenetics, Ex-In charge of 24 hours Ronald Ross Malaria clinic,
Technical Supervisor In charge of Blood Bank, 3rd floor, Dept. Of
Pathology,Institute of Post Graduate Medical Education& Research
(IPGMER) ;244A AJC Bose Road, K0lkata-700020, India
Competing interests: None declared |
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