50. Sexual Dysfunction

Question 1

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 ____

Answer 1

SSRI or SNRI
Bupropion

Question 2

Flibanserin (Addyi) and bremelanotide (Vyleesi) are FDA- approved to treat ______

Answer 2

hypoactive sexual desire disorder (HSDD) in PREmenopausal women ONLY

Question 3

What conditions/issues may contribute to sexual dysfunction?

Answer 3

Psychological issues including depression and stress
Neurological illness such as spinal cord injury, stroke

Question 4

Drugs that can cause ED or sexual dysfunction

Answer 4

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)

Question 5

Natural products used for erectile dysfunction

Answer 5

Yohimbe, L-arginine, and panax ginseng

Note: ginseng can increase risk of bleeding

Question 6

___ are first line for treatment of ED

Answer 6

PDE-5i (sildenafil, vardenafil, tadalafil, avanafil)

Question 7

Why might a pt fail on PDE-5i for ED?

Answer 7

Lack of sexual stimulation, timing of dose, eating large meal with dose

Question 8

T/F: If pt fails on one PDE-5i, switching to another PDE-5i will not be helpful as they have similar efficacy

Answer 8

False - efficacy is similar but pts can still try other options if they do not achieve desired effect

Question 9

Tadalafil (Cialis) is indicated for both ED and ___

Answer 9

BPH (which can treat concurrent ED)

Question 10

Sildenafil (Revatio) and tadalafil (Adcirca, Alyq) are indicated for both EDand ___

Answer 10

pulmonary arterial HTN

Question 11

MOA PDE-5i for ED

Answer 11

Following sexual stimulation, there is a local release of nitric oxide&raquo_space; increases cGMP&raquo_space; smooth muscle relaxation&raquo_space; blood flow = erection

PDE-5i blocks PDE-5 from degrading cGMP allowing for more smooth muscle relaxation&raquo_space; blood flow = erection

Question 12

T/F: PDE-5i do not increase libido (sexual interest), which must be present for drugs to work

Answer 12

True

Question 13

Examples of PDE-5i used in ED

Answer 13

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)

Question 14

Dosing for sildenafil (Viagra) for ED

Answer 14

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

Question 15

Dosing for Vardenafil (Levitra, Staxyn) for ED

Answer 15

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

Question 16

Dosing for Tadalafil (Cialis) for ED

Answer 16

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

Question 17

Dosing for avanafil (Stendra) for ED

Answer 17

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

Question 18

Contraindications with PDE-5i

Answer 18

Do not use with nitrates or riociguat (guanylate cyclase stimulator) - can cause severe hypotension

Question 19

Warnings with PDE-5i

Answer 19

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

Question 20

Side effects with PDE-5i

Answer 20

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

Question 21

Which PDE-5i have decreased efficacy if taken with a high-fat or large meal (common cause of tx failure per guidelines)?

Answer 21

Sildenafil and vardenafil

Question 22

T/F: if pt does not experience desired effects with PDE-5i, they can take another dose after 1hr

Answer 22

False - for ED, no more than 1 dose per day is recommended

Question 23

Which PDE-5i can be taken closest to sexual activity?

Answer 23

Avanafil (Stendra)

Question 24

Alprostadil MOA in ED

Answer 24

Prostaglandin E1, vasodilator that allows blood to flow into cavernosal arteries&raquo_space; enlarges penis
Injected into penis or pellet is inserted through urethra (invasive and painful, does not last as long as PDE-5i)

Question 25

Which formulation of alprostadil needs to be refrigerated?

Answer 25

Both
Alprostadil (Caverject, Caverject Impulse, Edex) - injection
Alprostadil (Muse) - urethral pellets

Question 26

Side effects of alprostadil

Answer 26

Penile pain, pirapism, HA, dizziness

Question 27

Flibanserin (Addyi) MOA in hypoactive sexual desire disorder

Answer 27

agonist activity at 5-HT1A and antagonist activity at 5-HT2A receptors
Unknown MOA for HSDD

Question 28

Bremelanotide (Vyleesi) MOA in hypoactive sexual desire disorder

Answer 28

Nonselective melanocortin receptor agonist
Unknown MOA for HSDD

Question 29

Boxed warnings for flibanserin (Addyi)

Answer 29

Contraindicated with alcohol d/t increased risk of severe hypotension and syncope (REMS program required)
Combination with mod or strong CYP3A4 inhibitors
Hepatic impairment

Question 30

Warnings for flibanserin (Addyi)

Answer 30

Hypotension, syncope, CNS depression

Question 31

Contraindications for Bremelanotide (Vyleesi)

Answer 31

Do not use with uncontrolled HTN or known CV disease