50. Sexual Dysfunction Flashcards
In both males and females, sexual dysfunction can be d/t use of ____, or less commonly, another antidepressant. An alt antidepressant can be tried that does NOT cause sexual side effects, such as ____
SSRI or SNRI
Bupropion
Flibanserin (Addyi) and bremelanotide (Vyleesi) are FDA- approved to treat ______
hypoactive sexual desire disorder (HSDD) in PREmenopausal women ONLY
What conditions/issues may contribute to sexual dysfunction?
Psychological issues including depression and stress
Neurological illness such as spinal cord injury, stroke
Drugs that can cause ED or sexual dysfunction
Alcohol
Antidepressants: esp SSRIs and SNRIs including decrease libido
AntiHTN meds: beta-blockers, clonidine, thiazides
Antipsychotics: (e.g. first-gen (e.g. chlorpromazine)), prolactin-raising second gen(e.g. risperidone, paliperidone)
BPH meds: finasteride, dutasteride, and silodosin (mostly retrograde ejaculation)
Others: anticancer drugs leuprolide, flutamide, anticholinergics, atomoxetine, digoxin, H2RAs cimetidine, ranitidine, nicotine, opioids (chronic use, esp methadone)
Natural products used for erectile dysfunction
Yohimbe, L-arginine, and panax ginseng
Note: ginseng can increase risk of bleeding
___ are first line for treatment of ED
PDE-5i (sildenafil, vardenafil, tadalafil, avanafil)
Why might a pt fail on PDE-5i for ED?
Lack of sexual stimulation, timing of dose, eating large meal with dose
T/F: If pt fails on one PDE-5i, switching to another PDE-5i will not be helpful as they have similar efficacy
False - efficacy is similar but pts can still try other options if they do not achieve desired effect
Tadalafil (Cialis) is indicated for both ED and ___
BPH (which can treat concurrent ED)
Sildenafil (Revatio) and tadalafil (Adcirca, Alyq) are indicated for both EDand ___
pulmonary arterial HTN
MOA PDE-5i for ED
Following sexual stimulation, there is a local release of nitric oxide»_space; increases cGMP»_space; smooth muscle relaxation»_space; blood flow = erection
PDE-5i blocks PDE-5 from degrading cGMP allowing for more smooth muscle relaxation»_space; blood flow = erection
T/F: PDE-5i do not increase libido (sexual interest), which must be present for drugs to work
True
Examples of PDE-5i used in ED
Sildenafil (Viagra) - Revatio used for PAH
Tadalafil (cialis) - Cialis also used for BPH, Adcirca, Alyq used for PAH // lasts longest (known as “weekend pill”)
Others: Vardenafil (Levitra, Staxyn), Avanafil (Stendra)
Dosing for sildenafil (Viagra) for ED
On-demand dosing: 25-100mg daily PRN
Start 50mg take ~1hr before sexual activity
Start at 25mg if ≥65yo, using alpha-blocker, using CYP3A4i, severe renal or liver disease
Dosing for Vardenafil (Levitra, Staxyn) for ED
On-demand dosing: 5-20mg daily PRN
Start at 10mg, take ~1hr before sexual activity
Start at 5mg if ≥65yo, using alpha-blocker, using CYP3A4i, severe renal or liver disease
Dosing for Tadalafil (Cialis) for ED
Daily dosing: 2.5-5mg daily
On-demand dosing: 5-20mg daily PRN
Start at 10mg at least 30min before sexual activity
Start at 5mg if ≥65yo, using alpha-blocker, using CYP3A4i, severe renal or liver disease
Dosing for avanafil (Stendra) for ED
On-demand dosing: 50-200mg daily PRN
Start at 100mg, take 15-30min before sexual activity
Start at 50mg if ≥65yo, using alpha-blocker, using CYP3A4i, severe renal or liver disease
Contraindications with PDE-5i
Do not use with nitrates or riociguat (guanylate cyclase stimulator) - can cause severe hypotension
Warnings with PDE-5i
impaired color discrimination (dose-related)
Hearing loss
Vision loss
Hypotension d/t vasodilation
Priapism (seek emergency med attn if >4hr)
CVD, if chest pain occurs, seek immediate medical help
Side effects with PDE-5i
HA, flushing, dizziness, dyspepsia, back pain (mostly with tadalafil)
Others: blurred vision, difficulty with color discrimination, increased sensitivity to light, epistaxis, diarrhea, myalgia muscle/back pain
Which PDE-5i have decreased efficacy if taken with a high-fat or large meal (common cause of tx failure per guidelines)?
Sildenafil and vardenafil
T/F: if pt does not experience desired effects with PDE-5i, they can take another dose after 1hr
False - for ED, no more than 1 dose per day is recommended
Which PDE-5i can be taken closest to sexual activity?
Avanafil (Stendra)
Alprostadil MOA in ED
Prostaglandin E1, vasodilator that allows blood to flow into cavernosal arteries»_space; enlarges penis
Injected into penis or pellet is inserted through urethra (invasive and painful, does not last as long as PDE-5i)
Which formulation of alprostadil needs to be refrigerated?
Both
Alprostadil (Caverject, Caverject Impulse, Edex) - injection
Alprostadil (Muse) - urethral pellets
Side effects of alprostadil
Penile pain, pirapism, HA, dizziness
Flibanserin (Addyi) MOA in hypoactive sexual desire disorder
agonist activity at 5-HT1A and antagonist activity at 5-HT2A receptors
Unknown MOA for HSDD
Bremelanotide (Vyleesi) MOA in hypoactive sexual desire disorder
Nonselective melanocortin receptor agonist
Unknown MOA for HSDD
Boxed warnings for flibanserin (Addyi)
Contraindicated with alcohol d/t increased risk of severe hypotension and syncope (REMS program required)
Combination with mod or strong CYP3A4 inhibitors
Hepatic impairment
Warnings for flibanserin (Addyi)
Hypotension, syncope, CNS depression
Contraindications for Bremelanotide (Vyleesi)
Do not use with uncontrolled HTN or known CV disease
