Dr. Robert J. Anderson Squires and Stags February 3, 2017

Transcription

1 Dr. Robert J. Anderson Squires and Stags February 3, 2017

2 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

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4 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 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

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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 The risk assessment tool below uses information from the Framingham Heart Study to predict a person s chance of having a heart attack in the next 10 years. This tool is designed for adults aged 20 and older who do not have heart disease or diabetes. To find your risk score, enter your information in the calculator below. Age: Gender: Total Cholesterol: HDL Cholesterol: Smoker: Systolic Blood Pressure: Are you currently on any medication to treat high blood pressure. years Female/Male mg/dl mg/dl No Yes mm/hg No Yes

9 Demography Cholesterol Blood pressure Risk factors Age: 68 Total: 169 Systolic: 120 Diabetes: no Gender: male HDL: 59 Diastolic: 76 Smoking: no Race: not African- American On medication: yes

10 Indicated in high risk pts for CVD and CRC Moderate benefit taking low dose (81 mg) age 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 years case by case basis < Age 50 insufficient data to support use > Age 70 insufficient data to support use

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12 All adults aged should be screened for high cholesterol even w/o history of heart disease Age 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 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 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 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 1 st or >1 yr after Pneumovax Pneumovax > age 65 years

16 Blood Pressure: Inc Risk Stroke with Prehypertension /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 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

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20 3 rd 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?

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22 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 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 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 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 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)

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28 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 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

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