Terazosin Hydrochloride

TERAZOSIN HYDROCHLORIDE- terazosin hydrochloride capsule
Aphena Pharma Solutions — Tennessee, LLC

DESCRIPTION

Terazosin hydrochloride, an alpha-1-selective adrenoceptor blocking agent, is a quinazoline derivative represented by the following chemical name and structural formula: (RS)-Piperazine, 1-(4-amino-6,7-dimethoxy-2-quinazolinyl)-4-[(tetrahydro-2-furanyl)carbonyl]-, monohydrochloride. It has the following structural formula:

Terazosin hydrochloride is a white, crystalline substance, freely soluble in water and isotonic saline and has a molecular weight of 459.93. Terazosin capsules, USP, for oral administration, are supplied in four dosage strengths containing terazosin hydrochloride, USP equivalent to 1 mg, 2 mg, 5 mg, or 10 mg of terazosin. Inactive ingredients: Crospovidone, lactose (monohydrate), magnesium stearate, and microcrystalline cellulose. May contain corn starch. The capsule shells and imprinting inks contain: D & C Yellow #10 Aluminum Lake, FD & C Blue #1 Aluminum Lake, FD & C Blue #2 Aluminum Lake, FD & C Red #40 Aluminum Lake, gelatin, propylene glycol, shellac, synthetic black iron oxide, and titanium dioxide. The 5 mg also contains: D & C Red #28.

CLINICAL PHARMACOLOGY

Pharmacodynamics

A. Benign Prostatic Hyperplasia (BPH)

The symptoms associated with BPH are related to bladder outlet obstruction, which is comprised of two underlying components: a static component and a dynamic component. The static component is a consequence of an increase in prostate size. Over time, the prostate will continue to enlarge. However, clinical studies have demonstrated that the size of the prostate does not correlate with the severity of BPH symptoms or the degree of urinary obstruction. The dynamic component is a function of an increase in smooth muscle tone in the prostate and bladder neck, leading to constriction of the bladder outlet. Smooth muscle tone is mediated by sympathetic nervous stimulation of alpha-1 adrenoceptors, which are abundant in the prostate, prostatic capsule and bladder neck. The reduction in symptoms and improvement in urine flow rates following administration of terazosin is related to relaxation of smooth muscle produced by blockade of alpha-1 adrenoceptors in the bladder neck and prostate. Because there are relatively few alpha-1 adrenoceptors in the bladder body, terazosin is able to reduce the bladder outlet obstruction without affecting bladder contractility.

Terazosin has been studied in 1222 men with symptomatic BPH. In three placebo-controlled studies, symptom evaluation and uroflowmetric measurements were performed approximately 24 hours following dosing. Symptoms were quantified using the Boyarsky Index. The questionnaire evaluated both obstructive (hesitancy, intermittency, terminal dribbling, impairment of size and force of stream, sensation of incomplete bladder emptying) and irritative (nocturia, daytime frequency, urgency, dysuria) symptoms by rating each of the 9 symptoms from 0 to 3, for a total score of 27 points. Results from these studies indicated that terazosin statistically significantly improved symptoms and peak urine flow rates over placebo as follows:

* Highest dose 10 mg shown. † Significantly (p ≤ 0.05) more improvement than placebo. ‡ 23% of patients on 10 mg, 41% of patients on 20 mg. § 67% of patients on 10 mg.
	Symptom Score (Range 0-27)			Peak Flow Rate (mL/sec)
	N	Mean Baseline	Mean Change (%)	N	Mean Baseline	Mean Change (%)
Study 1 (10 mg) * Titration to fixed dose (12 wks)
Placebo Terazosin	55 54	9.7 10.1	-2.3 (24) -4.5 (45) †	54 52	10.1 8.8	+1.0 (10) +3.0 (34) †
Study 2 (2, 5, 10, 20 mg) ‡ Titration to response (24 wks)
Placebo Terazosin	89 85	12.5 12.2	-3.8 (30) -5.3 (43) †	88 84	8.8 8.4	+1.4 (16) +2.9 (35) †
Study 3 (1, 2, 5, 10 mg) § Titration to response (24 wks)
Placebo Terazosin	74 73	10.4 10.9	-1.1 (11) -4.6 (42) †	74 73	8.8 8.6	+1.2 (14) +2.6 (30) †

In all three studies, both symptom scores and peak urine flow rates showed statistically significant improvement from baseline in patients treated with terazosin capsules from week 2 (or the first clinic visit) and throughout the study duration.

Analysis of the effect of terazosin capsules on individual urinary symptoms demonstrated that compared to placebo, terazosin capsules significantly improved the symptoms of hesitancy, intermittency, impairment in size and force of urinary stream, sensation of incomplete emptying, terminal dribbling, daytime frequency and nocturia.

Global assessments of overall urinary function and symptoms were also performed by investigators who were blinded to patient treatment assignment. In studies 1 and 3, patients treated with terazosin capsules had a significantly (p ≤ 0.001) greater overall improvement compared to placebo treated patients.

In a short term study (Study 1), patients were randomized to either 2, 5 or 10 mg of terazosin capsules or placebo. Patients randomized to the 10 mg group achieved a statistically significant response in both symptoms and peak flow rate compared to placebo (Figure 1).

FIGURE1, STUDY1

† for baseline values see above table

* p ≤ 0.05, compared to placebo group

In a long-term, open-label, non-placebo controlled clinical trial, 181 men were followed for 2 years and 58 of these men were followed for 30 months. The effect of terazosin capsules on urinary symptom scores and peak flow rates was maintained throughout the study duration (Figures 2 and 3):

FIGURE 2. Mean Change in Total Symptom Score from Baseline Long-Term, Open-Label, Non-Placebo Controlled Study (N=494)

* p ≤ 0.05 vs. baseline; mean baseline = 10.7

FIGURE 3. Mean Change in Peak Flow Rate from Baseline Long-Term, Open-Label, Non-Placebo Controlled Study (N=494)

*p ≤ 0.05 vs. baseline; mean baseline = 9.9

In this long-term trial, both symptom scores and peak urinary flow rates showed statistically significant improvement suggesting a relaxation of smooth muscle cells.

Although blockade of alpha-1 adrenoceptors also lowers blood pressure in hypertensive patients with increased peripheral vascular resistance, terazosin treatment of normotensive men with BPH did not result in a clinically significant blood pressure lowering effect:

Mean Changes in Blood Pressure from Baseline to Final Visit in all Double-Blind, Placebo-Controlled Studies

* p ≤ 0.05 vs. placebo
	Group	Normotensive Patients DBP ≤ 90 mm Hg Mean		Hypertensive Patients DBP > 90 mm Hg Mean
	N		Change	N	Change
SBP (mm Hg)	Placebo Terazosin	293 519	-0.1 -3.3 *	45 65	-5.8 -14.4 *
DBP (mm Hg)	Placebo Terazosin	293 519	+0.4 -2.2 *	45 65	-7.1 -15.1 *