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)
