Treatment of Men’s common Health Issues

1. Treatment of Men’s common Health Issues Dr. Robert J. Anderson Squires and Stags February 3, 2017

2. Benign Prostatic Hypertrophy (BPH) • Incidence: 10% per year starting at age 50 • Prostate gland pinches the urethra=urinary Sx • Frequency • Urgency • Hesitancy • Weak Stream • Incomplete Bladder Emptying • Straining, Dribbling, etc. • Symptoms mimic Prostate Cancer (DRE), Overactive Bladder

4. Treatment of BPHControl > Cure; Rx based on Severity • Non-Pharmacological • avoiding caffeine, alcohol and limiting any fluid in the evening; • avoiding drugs that can aggravate symptoms such as antihistamines, decongestants, pain medication, antidepressants and testosterone; • double voiding to overcome incomplete bladder emptying.

5. Treatment of BPH • Alpha blockers (Terazocin, Tamulosin) • MOA: relax smooth muscle to inc urine flow • SE: initial dizziness, hypotension • 5-Alpha Reductase Inhibitors (Proscar, Avodart) • MOA: decrease DHT to shrink prostate gland (6-12 months) • SE: sexual dysfx • Low dose PDE5 Inhibitors (Cialis) • Combo Rx: Jalyn, Flomax plus Proscar

7. Low T—dec 1-2% per year > age 40 years T needed for muscle mass, BMD and sex drive Rx for hypogonadism: Sx + low T blood levels Sx: fatigue, loss of energy/sex drive, depression, etc. Rx inc 10X in last decade; benefit vs. risk? vs. PDE5 prn drugs? Available in many formulations SE: liver disease, aggression, personality changes, aggravate BPH, 30% inc risk of strokes, MI, death

8. Risk Assessment Tool for Estimating Your 10-year Risk of Having a Heart Attack http://tools.acc.org/ASCVD-Risk-Estimator/

9. 10 Year CVD Risk 13.8%!

10. Aspirin Use for Primary Prevention?USPTF Recommendations June 2016 • Indicated in high risk pts for CVD and CRC • Moderate benefit taking low dose (81 mg) age 50-59 years who have at least a 10% risk of CVE, low bleeding risk and life expectancy of at least 10 years; adequate evidence that aspirin use reduces the incidence of CRC in adults after 5 to 10 years of use • Age 60-69 years case by case basis • < Age 50 insufficient data to support use • > Age 70 insufficient data to support use

12. US Preventive Services Task Force Recommendations • All adults aged 40-75 should be screened for high cholesterol even w/o history of heart disease • Age 40-75 Rx with elevated risk (>10%) of MI • With new guidelines—13M more need a statin! • Are statins overprescribed? Risk > Benefit?? • Dose-related inc risk (46%) for diabetes due to insulin resistance and dec insulin secretion • Statins may inc risk of cataracts by 27%

13. Use of Statins for High CholesterolBenefit vs. Risk • Patients with CVD • High dose in those < age 75 years • Moderate to low dose in those > age 75 years • Patients with high LDL (> 190 mg/dl) • Patients with DM and LDL > 70 mg/dl • High dose with 10 year risk of > 7.5% • Moderate dose with 10 year risk of 5-7.5% • Patients with 10 year risk >7.5%, LDL >100 mg/dl • Patients > age 75 dec risk of MI and stroke?

14. Use of Vitamin D? • Natural sources: fish, fortified foods, sun • RDA: 600 I.U per day • Supplements reduce risk of fractures? • The USPSTF has previously concluded in a separate recommendation that vitamin D supplementation is effective in preventing falls in community-dwelling adults aged 65 years or older who are at increased risk for falls.

15. ACIP/CDC Vaccine Recommendations • Flu vaccine every year • Tdap (> Td) vaccine (Boostrix); Td booster q 10 yrs • > age 50 years??: shingles (Zostavax) • Efficacy 50% in prevention • Efficacy 67% in prevention post-herpetic pain • Pneumonia • One time PCV-13 (Prevnar) recommended 1st or >1 yr after Pneumovax • Pneumovax > age 65 years

16. Health Screenings • Blood Pressure: Inc Risk Stroke with Pre-hypertension 120-139/80-89 mm Hg; incidence 49 million! lifestyle changes vs. Rx?? • Blood Sugar: >50% > age 65 are pre-diabetic; partial remission with lifestyle changes • Colon Cancer: screening starting at age 50 years and continuing until age 75 years • Prostate Cancer: DRE + PSA levels??

17. Minimize Risk/Progression of Prostate Cancer--Lifestyle Interventions • Maintain a healthy weight, avoid tobacco products, physical exercise to keep blood sugar and cholesterol under control • Maintain a healthy diet • Cruciferous veges—dec risk 10% • Flaxseed, soy, coffee, green tea, tomatoes • Avoid/minimize meat, dairy • Foods more important than supplements

20. Lifestyle and Colon Cancer • 3rd most common cancer • Diet responsible for 70-90% of all cases • Inc risk red meat > fish, white meat • Dec in intake of saturated fat may dec risk • High fiber diet recommended • Diets rich in folate (dark green veges, beans) are beneficial • Minimize alcohol intake • Calcium/Vit D foods/sun/supplements beneficial • Polyphenols (antioxidants) may be beneficial?

22. Memory Loss Warning SignsNormal Aging • Walking into a room and forgetting why • Having trouble recalling names of unfamiliar people • A change in memory compared to when you were younger • Memory changes similar to other folks your age • Misplacing items but later recalling where you put them

23. Protect Your Telomeres! Causal relationship between telomere shortening and age-related diseases such as dementia and Alzheimer’s disease Due to increase in oxidative stress on the body Solution: “chill out” and increase exercise!!

24. Memory Loss Warning SignsPotential Signs of Cognitive Decline • Getting lost in familiar surroundings • Having difficulty remembering important details of recent events • Difficulty following the plot of a TV program, movie or book due to memory problems • Memory changes that are worse than those in your age group • Misplacing items and being unable to relocate them later

25. Pharmacological TreatmentAlzheimer’s Disease • Mild to Moderate disease • Cholinesterase inhibitors—Aricept (donepezil), Exelon, Razadyne • Moderate to Severe disease • NMDA antagonists—Namenda (memantine), Exelon patch, Namzaric (combination Namenda ER/Aricept) • Taper slowly due to side effects (GI, CNS)

26. Impact of ObamaCare Repeal on Consumer-Friendly Medicare Benefits • Health care spending may accelerate again • Less monitoring of waste, fraud and excessive payments • Drugs costs may increase (11 million patients saved >$20B with tapering of “doughnut hole”) • Free preventative services may be impacted • Flu shots • Cancer screenings (mammograms, colonoscopy) • Diabetes screenings (> 8 million undiagnosed)

28. TrumpCare 2017?? • Transitional repeal of ACA? • Pledges to keep selective provisions of ACA • Portability of insurance coverage • Adult children covered until age 26 • Initiate market vs. government bidding on prescription drugs (i.e. VA, DOD, Canada)?? • Decrease regulations, increase drug mfg in US • Adopt/Modify Ryan Proposal—fixed dollar subsidy or voucher system; inc age to 67 yrs?

29. Growth of US Spending on Medications in 2017 • Expected decrease from 12% in 2015 to 6-7% in 2017 due to: • Decrease in prescribing of specialty medications especially for Hepatitis C • Increase in patent expiration of brand-name drugs • Increase in dispensing of lower cost generics • Introduction of “biosimilars” to the market—generic equivalents of high cost biotech drugs • Decrease in rate of costs for both generics and brand name drugs • Out-of-Pocket co-pays expected to decrease Source: Quintile IMS Institute: Outlook for Global Medicines Through 2021