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Summer Pharm Exam 1 > ED > Flashcards

ED Flashcards

1
Q

What does a loss of libido indicate

A

An Androgen deficiency

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2
Q

What does a loss of erection indicate

A

Arterial, venous, neurogenic, hormonal, or psychogenic cause

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3
Q

What are some RF for ED

A 
HTN 2/2 Diuretics 
HLD (arteriosclerosis) 
DM 
Metabolic syndrome 
Smoking
Chronic ethanol abuse 
Psychological etiologies
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4
Q

What Antichlinergics can cause ED

A 
Antihistamines 
Antiparkinson's 
TCA
Phenothiazines 
SSRI- Paroxetine, Sertraline, Fluvoxamine, Fluoxetine
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5
Q

What Dopamine antagonists can cause ED

A

Metoclopramide

Phenothiazines

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6
Q

How do Dopamine antagonists cause ED

A

Inhibit PRL inhibitory factor= increased PRL= Inhibit testicular testosterone production

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7
Q

What estrogens and antiandrogens cause ED

A 
LHRH
Digoxin 
Spironalactone 
Ketoconazole 
Cimetidine
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8
Q

What CNS Depressants cause ED

A

Barbituates, narcotics, benzos

They suppress preception of psychogenic stimuli

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9
Q

What agents decrease penile arterial blood flow to corpora

A

Diuretics
peripheral Beta antagonists
Central sympatholytics (methyldopa, clonidine)

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10
Q

Other meds that can cause ED include

A

Gemfibrozil, Finasteride, dutasteride, Clofibrate, MAOI

OPIATES!

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11
Q

What are the types of sexual dysfunction in men

A 
Decreased or Increased libido 
Impotence 
Delayed ejaculation
Retrograde ejaculation 
Infertility
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12
Q

What nervous systems innervate the penis

A

Point and Shoot
PNS= erection (arterial flow increases, venous outflow decreases)
SNS= Ejaculation

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13
Q

What is the order of Tx for ED from least to most invasive

A

Vacuum erection devices
Oral PDE inhibitors (first line!)
Intracavernosal injections or Intraurethral inserts
Surgery for penile prosthetic

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14
Q

Who is VED best for

A

Couples in a stable relationship
They are very obvious and take about 30 min to work- Lasting for about one hour (goal)
Can use constriction band or tension ring to prolong erection

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15
Q

What is the normal job of alpha 1

A

Vasoconstrict in the periphery

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16
Q

What oral meds can be used in the treatment of ED

A 
Yohimbine 
Trazodone 
PDE Inhibitors (Sildenafil, Tadalafil, Vardenafil, Avanafil)
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17
Q

How does Yohimbine work and what are it’s ADE

A

Reduce Alpha adrenergic tone= vasodilation

ADE: Tachy, insomnia, anxiety, HTN

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18
Q

What is Trazodone

A

a poor antidepressant, decent sleep agent

Peripheral alpha adrenergic antagonist

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19
Q

What are key concepts of PDE inhibitors

A

Effective regardless of etiology of ED
Effective in 60-70%
CI in ANYONE taking Nitrates

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20
Q

What is the MOA of PDE inhibitors

A

Sexual stimulation= NO release= increased cGMP= erection
PDE catabolizes cGMP= lose erection
PDE inhibitors= PDE can NOT catabolize cGMP= maintained erection

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21
Q

What is specific about PDE 5

A

Found in genital tissues (also extragenital- peripheral vascular tissue, trachea smooth muscle, and platelets)
Decreases catabolism of cGMP

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22
Q

What is specific about PDE 6

A

Local to rods and cones of eyes

ADE: blurred vision, Cyanopsia (MC with viagra)

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23
Q

What is specific to PDE 11

A

Local to striated muscle

ADE: Myalgia, muscle pain (MC tadalafil)

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24
Q

What PDE-inhibitors need to be titrated

A

Sildenafil (viagra)
Vardenafil (levitra)
Tadalafil (Cialis)

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25
Q

What PDE-inhibitors have delayed absorption when taken with food

A

Sildenafil (viagra)
Verdenafil (levitra)
Staxyn

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26
Q

What PDE-inhibitors can be taken with food

A

Tadalafil (Cialis)

Avanafil (stendra)

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27
Q

What is Staxyn

A

a PDE inhibitor that is dissolved on the tongue 1 hour prior to sex

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28
Q

Why is Tadalafil special

A

It can be taken at a higher dose (5-10mg) 30 min prior to sex, OR, at a low dose (2.5-5mg) daily
BUT* contraindicated in those with severe hepatic impairment

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29
Q

What PDE-inhibitors are not to be taken with alcohol

A

Tadalafil (cialis)
avanafil (stendra)
–Can cause orthostatic hypotension

30
Q

How does Tadalafil work

A

Blocks PDE 5 and 11 (not 6- so no vision ADE)
Takes 45 minutes to onset, and 2 hours to peak (longer onset)- but lasts 24-36 hours
has NO active metabolite

31
Q

What drug interaction is important with Sildenafil (viagra)

A

Decrease viagra dose with CYP45- 3A4 inhibitors (Ketoconazole, Ritonavir, Cimetidine, Erythromycin, Clarithromycin, Itraconazole, Squinavir)- must know all those

32
Q

When must you reduce Tadalafil’s dose

A

Only with the most potent CYP450 3A4 inhibitors (Ketoconazole, Itraconazole)

33
Q

What are the MC ADE of PDE inhibitors

A 
HA
Facial flushing 
Dyspepsia
Nasal congestion
Dizziness 
(all 2/2 vasodilation or smooth muscle relaxation from PDE5 in extragenital tissues)
34
Q

What is the worst ADE of PDE inhibitors

A

NAION- nonarteritic anterior ischemic optic neuropathy (AKA decreased blood flow to optic nerve)
Sudden, unilateral, painless blindness, irreversible

35
Q

What patients are high risk for NAION

A 
Glaucoma 
macular degeneration
diabetic retinopathy 
HTN
s/p eye surgery/eye trauma 
50+ y/o 
smokers (alters platelets)
36
Q

What ADE is specific to Tadalafil (Cialis)

A

low back pain– linked to PDE 11 inhibition (striated muscle)

37
Q

What ADE is specific to Vardenafil

A

QT prolongation (can cause torsades- Tx with mag!)

38
Q

What can cause a priapism

A

Sildenafil and Vardenafil (shorter half life)
Excess PDE-Inhibitor dose
Concomitant therapy with other erectogenic drugs

39
Q

How do you treat a priapism

A
  1. Icepack to perineum and penis
  2. Walk upstairs to get blood flowing (arterial steal phenomenon)
  3. External perineal compression
    - If these fail, HOSPITAL
40
Q

What is medical treatment of a priapism

A

oral pseudoephedrine 60-120 mg (alpha-agonist= constriction)
Phenylephrine, epinephrine, methylene blue into corpus cavernosa

41
Q

What drugs can interact with PDE inhibitors

A

Organic nitrates (severe hypotension)
CCB
adrenergic antagonist
morphine

42
Q

How do Nitrates interact with PDE-inhibitors

A

They produce hypotension on their own, so combined it’s even stronger
NO can increase tissue levels of cGMP

43
Q

Who should and should not take PDE inhibitors based on cardiovascular risk

A

Low risk: Can be started on PDE-I
Intermediate: need cardio workup and treadmill stress test to assess tolerance to increased myocardial energy consumption
High risk: PDE-I contraindicated

44
Q

What is “low risk”

A
  • Asx w/ <3 CVD RF
  • HTN well controlled
  • mild CHF (NYHA I or II)
  • mild valvular disease
  • MI >8 weeks ago
45
Q

What is “intermediate risk”

A
  • 3+ CVD RF
  • mild/mod stable angina
  • MI/stroke w/in 2-8 weeks
  • mod CHF (NYHA class III)
  • Hx of CVA/TIA/PAD
46
Q

What is “high risk”

A
  • Unstable/refractory angina
  • HTN uncontrolled
  • Severe CHF (NYHA IV)
  • MI/stroke w/in 2 weeks
  • Mod/severe valve disease
  • High risk cardiac arrhythmias
  • Obstructive HCM
47
Q

Who can be treated with testosterone

A

Sx patients;

-Hypogonadism + Decreased libido and low serum testosterone

48
Q

What is “male menopause”

A

When testosterone starts declining (age 40) by 10% per decade

49
Q

What are symptoms of low testosterone

A 
decreased libido 
ED
gynecomastia
small testes
less body hair/beard 
less muscle mass
more body fat 
**If untreated, anemia and osteoporosis
50
Q

When should you measure testosterone

A

Early morning (8AM)
Normal is 300-1100
*Measure with LH

51
Q

Why do we measure LH with testosterone

A

To determine the type of hypogonadism
Primary: elevated LH
Secondary: decreased LH

52
Q

What does testosterone replacement actually do

A

-Improves libido secondarily correcting ED
BUT, testosterone does not directly correct ED
-Corrects Sx of hypogonadism: malaise, low strength, depression

53
Q

Who should never receive testosterone

A

Men w/ normal testosterone levels
ASx patient with hypogonadism
Pt with ED as only sign of hypogonadism

54
Q

What does testosterone replacement stimulate

A

-Directly stimulates androgen receptors in CNS

+/- stimulates NO synthase= more NO in cavernosa= enhanced PDE5 effects

55
Q

What are oral testosterone supplements

A
  • Methyltestosterone (not recommended, hepatotoxic)

- Fluoxymesterone (not recommended, hepatotoxic- alkylated androgen)

56
Q

What is the testosterone buccal system

A

Place just above incisor, remove before every morning and night tooth brush
DO NOT chew or swallow
ADE: gum irritation, bitter taste

57
Q

What are parenteral testosterone options (IM)

A
  • Cypionate (ADE mood swings 2/2 supraphysiologic serum concentrations- CI in severe hepatic or renal dz)
  • Enanthate (ADE mood swings- steer clear if w/ severe hepatic or renal dz)
  • *the above have ADE of mood swings, gynecomastia, polycythemia, HLD
  • Undecanoate (need REMS program to Rx- single dose)
58
Q

What is significant about the testosterone patch (androderm)

A

Admin at bedtime to testosterone is produced in circadian pattern
Apply to upper arm, back, abd, or thigh- rotate q7 days
Dont swim, shower, or wash w/in 3 hours of application
ADE: Dermatitis

59
Q

What are the testosterone gel options

A

Androgel/Testim 1% (apple in AM to shoulder, up arms, or abd- Titrate @ 14d interval- cover and wash hands with soap and water after placement- kids and women avoid touching)
Androgel 1.6% (apply in AM to shoulder and up arms- Titrate after 14-28 d)

60
Q

How do you use Testosterone spray

A 
4 sprays to front and inner thighs
Cover after application
avoid contacting women and children 
wash hands w/ soap and water 
Titrate at 14-35 day intervals
61
Q

How do you use testosterone solution

A

Apply to axilla only (deoderant can be used prior to Axiron)
Dont swim or shower for 2 hours after applying
Titrate at 14-35 day intervals

62
Q

How do you use a testosterone pellet

A

Forearm incision and subQ implant under local anesthesia
1 pellet= 75mg testosterone (use 2-6)
Results NOT immediate (3-4 months)
Needs to be placed by trained health professional
ADE: can be extruded accidentally

63
Q

What is significant about oral testosterone

A

It really should not be used- causes HLD and sodium retention
Oral alkylated (Fluoxymesterone) will achieve normal testosterome srum level, but it is very hepatotoxic
So just steer clear of oral testosterone

64
Q

What do we need to know about testosterone admin time and monitoring

A

Gel and patch are more circadian

65
Q

What is Alprostadil

A

intracavernosal injection or intraurethral pellet to Tx ED
(MUSE efficacy is 43-65%)
(Caverject and Edex efficacy is 70-90%)
With training, pt can self administer

66
Q

What is the Intraurethral pellet

A

Alprostadil (MUSE)

67
Q

What are the Intracavernosal injection options

A

Alprostadil (Caverject or Edex)
Papaverine (PDE5 inhibitor)
Phentolamine (nonselective a-adrenergic blocker= dilation)

68
Q

How do Caverject and Edex work (injection)

A

stimulate adenyl cyclase= more cAMP= less intracell calcium= smooth muscle relaxation= more blood flow in corpora
(NO independent, good for DM pt, s/p radical prostatectomy, and PDE failure pt)
-Acts w/in 5-15 min, should last no more than 1 hour (half life 5-10 min)- duration related to dose
*Can use with VED

69
Q

How does MUSE work (pellet)

A

Admin 5-10 min before sex, no more than 2x day
Void completely before placing
Most is removed by first pass through LUNGS- so minimal systemic absorption!
Use with constriction band to improve, or with VED

70
Q

What is penile prosthesis

A

Surgical insertion to treat ED for pt who dont respond to or are not candidates for any other Tx

71
Q

What can you do for “non-responders”

A

Switch from one PDE5 inhibitor to another
-No response to viagra= give Vardenafil
Switch to as needed daily Tadalafil
May combine PDE5 inhibitor with Alprostadil in some patients

Summer Pharm Exam 1 (8 decks)

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