Eric Yarnell, ND, RH(AHG) 2012

Transcription

1 Benign Prostatic Hyperplasia Eric Yarnell, ND, RH(AHG) IPSS Questionnaire Useful clinical tool Freely available Well validated Available in many languages Gives some objective support for what we do Allows comparison to other tx 2 Measures Postvoid residual (PVR) urine Maximum flow rate (Qmax) Red flag symptoms Acute urine retention (AUR) Urinary tract infections (UTI) Acute renal failure (ARF) 3 When to Treat IPSS >8 and patient is bothered Qmax <6-7 ml/sec PVR >100 ml Worsening symptoms History of acute retention (!), ARF (!!), other severe complications 4

2 = Secretory epithelium and duct 2 = Stroma (fibroblasts, smooth muscle cells) 5 Types of BPH Stromal Epithelial Mixed CT, smooth muscle Second most common Epithelium Least common Both Most common Spasm Sheer size Spasm and size Less hormonal More hormonal Mixed hormonal 6 Stromal BPH 7 Key Features Irritative symptoms: Nocturia Frequency Urgency Prostate tends to be small (<40 g) Metabolic syndrome (not always) 8

3 CH 3 Herbs vs. Drugs Spasmolytic Herbs Ammi v, Piper m, Pedicularis, Gelsemium, Valeriana, etc. Mixed actions Relatively cheap Alpha Blocker Drugs tamsulosin, alfuzosin, terazosin Alpha-1 Adrenergic Antagonists New drugs expensive, old ones cheap 3-4 x/d dosing 1-2 x/d dosing Minimal adverse effects; sleepiness (rare) Retrograde ejaculation, hypotension, asthenia 9 khellin CH 3 visnadine Ammi visnaga (khella) 10 Piper methysticum (kava) Photo 2012 D. Howell used with permission 11 Photo 2012 Heron Botanicals Used with permission 12

4 Patient utcome BfArM MCA Tx duration Kavapyrones (months) (mg/d) 39 f good f 24 up to 210 good f good f lethal f good f good f 7 60 liver transplant f liver transplant, lethal +/ f?? good?? 56 f?? good m two liver transplants m good f several 120 good f liver cirrhosis f good f 0.25? good +/ f liver transplant, lethal f 6? liver transplant f 6 60 good f liver transplant ++ + Table 1 from Phytomedicine 2003;10: Compare Acetaminophen FDA required warning 2006, Severe liver damage may occur, worse with ethanol (further intensified 2009) 50% of acute liver failure in US due to acetaminophen Clin Toxicol 2009;47: Pedicularis bracteosa Louseworts Pedicularis racemosa 15 Viburnum opulus (crampbark) 16

5 Valeriana sitchensis (Sitka valerian) Photo 2012 Heron Botanicals Used with permission 17 Gelsemium sempervirens Photo 2012 Howell Used with permission 18 Pulsati!a occidentalis (western pasque flower) 19 Pedicularis bracteosa (or Piper methysticum) Base Formula Lead spasmolytic 30-55% Ammi visnaga (or Gelsemium*) Fouquieria splendens (or Ceanothus) Supporting spasmolytic Supporting pelvic lymphagogue 20-40% 5-10% Glycyrrhiza glabra (or Zingiber) * Max 1 ml/dose Synergizer 5-10% 1 tsp tid (last dose hs) 20

6 Avoid Diuretics 21 Serenoa repens Creative Commons license 22 The Big Negative Study Bent, et al (published in N Engl J Med of course) n = 225, 1 yr, double-blind v placebo Moderate-to-severe BPH (!) Bottom line: Study population not same as other trials 23 Long-Term Studies Pytel 2002 pen; n = 155 Lopatkin 2007 Djavan 2005 pen; n = 219 pen; n = mg bid 2 yr 160 mg bid (w/ Urtica) 1.8 yr 320 mg qd 2 yr Pierre pen; n = 160 mg bid 2 yr Fabre Effective for sx Effective for sx Effective for sx & worsening Effective for sx 24

7 Effect on 5α-Reductase Testosterone Dihydrotestosterone (DHT) 5α-Reductase 50% inhibition Serenoa extract 50% reduction Epidermal Growth Factor (EGF) Prostate 1998;37: Comparative Effect on 5α-Reductase Testosterone Dihydrotestosterone (DHT) 5α-Reductase 32% inhibition 80% inhibition Serenoa extract Finasteride Urology 2001;57: Molecular Targets for Serenoa Testosterone 5α-Reductase DHT Sex Hormone Binding Globulin Estrogens Aromatase Androgen Receptor Estrogen Receptor DNA SHBG Receptor Growth Factors (eg EGF) Prostatic Hyperplasia Receptors (eg EGFR) Catecholamines α2 Adrenergic Receptors Tissue spasm 27 Hormonal BPH 28

8 Hormonal BPH Theory: excess estrogens Result: prostate size 50 cc Predominant sx: Weak stream (low Qmax) Hesitancy, dribbling Incomplete emptying (high PVR) ften mixed with spasmotic BPH Much harder to treat naturally 29 Herbs vs Drugs Hormone-Modulating Herbs Polygonum, Epimedium, Serenoa, Nuphar, etc. Poorly tested (mostly) Very safe Unknown effect on prostate cancer 5-a-Reductase Inhibitor Drugs finasteride, dutasteride Well tested, only help if prostate >50 g Low libido, ED common Known to mildly reduce risk of prostate cancer 30 Polygonum multiflorum (he shou wu) 31 Polygonum multiflorum (he shou wu) Photo 2012 Heron Botanicals Used with permission 32

9 Epimedium grandiflorum (yin yang huo) 33 Pueraria montana var lobata (kudzu) 34 Legume Psoralea corylifolia (blackdot) Genistein (ppm) Daidzein (ppm) Kudzu Yellow split pea Black beans Baby limas Anasazi Soy Pinto Fava 20 5 J Altern Complement Med 1997;3: Public domain Nuphar polysepalum (yellow pond lily) 36

10 Photo 2012 Heron Botanicals Used with permission Nuphar polysepalum (yellow pond lily) 37 Aconitum spp (aconite) Photo 2012 G. Maroney Used with permission 38 Urtica dioica 39 Molecular Targets for Urtica Testosterone 5α-Reductase DHT Sex Hormone Binding Globulin Estrogens Aromatase Androgen Receptor Estrogen Receptor DNA SHBG Receptor Growth Factors (eg EGF) Prostatic Hyperplasia Receptors (eg EGFR) Amer. Herbal Pharmacopoeia Catecholamines α2 Adrenergic Receptors Tissue spasm 40

11 Treatment Regardless of Type 41 Diet and Lifestyle At least some vegan days (or pescovegan) rganic, free-range animal products Phytoestrogenic foods Regular exercise Avoid estrogenic chemicals 42 Phytoestrogens Lower doses act as estrogen antagonists Linum usitatissimum (flax) Pueraria lobata (kudzu) Trifolium spp (red clover, etc.) Complex actions 43 3rd Int Consultation on BPH, Paris

12 Avoid Xenoestrogens Phthalates Parabens Bisphenol A Atrazine Lindane DDT Nonylphenyl 45