ED Flashcards
List the anticholinergics agents that can cause ED
- Antihistamines
- Antiparkinsonian
- TCA’s
- Phenothiazine
- SSRI’s
List the Dopamine Antagonist that can cause ED. MOA?
Metoclopramide, Phenothiazines
Increase PRL, which inhibits testicular testosterone production
List the Estrogens, antiandrogens that can cause ED. MOA?
- LH-RH
- Digoxin
- Spironolactone
- Ketoconazole
- Cimetidine
Suppress tesosterone-mediated stimulation of libido
List the CNS depressants that can cause ED. MOA?
- Barbiturates
- Narcotics
- Benzodiazepines
- Short-term use of large doses of alcohol
- Anticonvulsants
Suppress perception of psychogenic stimuli
List the agents thats decrease penile blood flow/reduce arteriolar flow to corpora cavernosa
- Diuretics
- Peripheral β-adrenergic antagonists
- Central sympatholytics: Methyldopa, Clonidine
Who are vacuum erection devices most effective for? Why?
Couple in a stable relationship
Slow onset & not discrete
Yohimbine MOA
May reduce peripheral alpha adrenergic tone permitting cholinergic tone= Vasodilate
Yohimbine ADE’s
- Anxiety
- Insomnia
- Tachycardia (increases NE)
- HTN (increases NE)
What are the 3 main concepts of PDE-I?
- Effective regardless of the ED etiology
- Fail in 30-40% of pt’s
- CI in pt’s taking Nitrates
PDE-5-I MOA
Decreases catabolism of cGMP to the inactive form
Where is PDE type 5 enzyme found in the body?
- Genital tissue
- Peripheral vascular tissue
- Tracheal smooth muscle
- Platelets
Where is PDE type 6 enzyme found in the body?
Rods and cones of the eye
What SE is PDE type 6 enzyme associated with?
Blurred vision
Define Cyanopsia
Seeing everything tinted blue
What PDE-I is Cyanopsia MC in?
Sildenafil (Viagra)
Where is PDE type 11 enzyme found in the body?
Striated muscle
What SE is PDE type 11 enzyme associated with? What PDE-I is this MC in?
Myalgia and muscle pain
Tadalafil
List the PDE-5’s that food decreases absorption by 1 hour
- Sildenafil (Viagra)
2. Vardenafil (Levitra)
List the PDE-5’s that may be taken with food/food does not affect drug absorption
- Tadalafil (Cialis)
2. Avanafil (Stendral)
List the PDE-5 that should be taken WITHOUT any food or liquid
Vardenafil (STAXYN)
List the PDE-5’s that may cause orthostatic hypotension when taken with large amounts of ethanol?
- Tadalafil (Cialis)
2. Avanafil (Stendral)
What PDE-5 is CI in sever hepatic disease?
Tadalafil
When should you decrease the Sildenafil dose?
With the use of any potent Cytochrome P450 3A4 inhibitors
List the MOST POTENT Cytochrome P450 3A4 inhibitors
- Ketoconazole
- Ritonavir
Others: Erythromycin, Clarithromycin, Cimetidine, itraconazole
What PDE-5-I is the only PDE-I that does NOT inhibit enzyme 6 (a PDE-6-I) ?
Tadalafil
What PDE-5-I is the only PDE-I that is NOT an active metabolite?
Tadalafil
How long does it take for Tadalafil to reach peak plasma level?
2 hrs
What is the time of onset of Tadalafil? Duration?
Onset=45 minutes
Duration=24-36 hrs
MC PDE-5-I ADE’s
- HA
- Dizziness
- Facial Flushing
- Dyspepsia
- Nasal congestion
What is a MAJOR ADE of PDE-5-1? Sx’s of this ADE?
Nonarteritic anterior ischemic optic neuropathy (NAION):
- Sudden, unilateral, painless blindness
- D/t decreased blood flow to optic nerve
- May be irreversible
What patients are at risk for NAION?
- Glaucoma
- Macular degeneration
- Diabetic retinopathy
- HTN
- Undergone eye surgery/eye trauma
- 50+
- Smokers
What ADE is unique to Tadalafil?
Low back pain
What ADE is unique to Vardenafil?
QT Prolongation
What is a rare, but urologic emergency PDE-5-I ADE?
Priapism
What PDE-5-I’s is priapism MC in? Why?
Sildenafil and Vardenafil
Shorter plasma half-lives
How can you help prevent priapism?
Avoid EXCESSIVE DOSES
Conservative Priapism treatment measures
- Ice packs
- Walk up stairs (artery steal phenomenon)
- External perineal compression
- Oral pseudoephedrine, 60-120 mg
If these conservative measures fail, next step in treating priapism?
Needle aspiration of corpus cavernous with intracavernous injection:
- Phenylephrine/Epinheprhine(alpha agonists)
- Methylene blue
PDE-5-I drug interaction
Organic Nitrates: Severe Hypotension
List the Low CV Risk’s
- Asx CV dz w/ <3 RF’s
- Well-controlled HTN
- Mild CHF (Class I or II)
- Mild valvular heart dz
- MI > 8 wks
Management approach in pt’s with Low CV risks?
Patients can be stated on PDE-I’s
List the Intermediate CV Risk’s
- > or equal to 3 RF’s for CVD
- Moderate CHF (Class III)
- Mild/Moderate, STABLE angina
- MI or Stroke in the past 2-8 wks
- H/o CVA, TIA, or PAD
Management approach in pt’s with Intermediate CV risks?
Complete CV work-up and stress test to determine tolerance to increased myocardial energy consumption (during sex)
List the High CV Risk’s
- Unstable/refractor angina
- Uncontrolled HTN
- Severe CHF (Class IV)
- Moderate/Severe valvular dz
- MI or Storke w/in past 2 wks
- High-risk cardiac arrhythmia
- Obstructive hypertrophic cardiomyopathy
Management approach in pt’s with high CV risks?
PDE-I CI
Sx’s of late-onset hypogonadism? (decreased testosterone levels starting at age 40)
- Gynecomastia*
- Decreased libido
- ED
- Small testes
- Decreased muscle mass
What may the patient develop if late-onset hypogonadism is left untreated?
- Anemia
2. Osteoporosis
Who is testosterone replacement NOT recommended in?
- Men with NORMAL testosterone levels
- Asx hypogonadism
- Isolated ED
Testosterone MOA
- Corrects sx’s of hypogonadism
- Directly stimulate androgen receptors in CNS (responsible for sex drive)
- Stimulate NO synthase
Why is Methyltestosterone
and Fluoxymesterone NOT recommended?
Heptatotoxicity
What do you want to make sure you do with the administration/dosing with testosterone buccal system? Why?
Time the dose so that buccal system is removed q AM and PM toothbrushing d/t:
- Gum irritation
- Bitter taste
What is IM Testosterone Cypionate CI?
Severe Hepatic or Renal impairment
IM Testosterone Cypionate and Enanthate ADE’s
- Mood swings
- Gynecomastia
- Polycythemia
- Hyperlipidemia
What testosterone treatment produces normal circadian pattern of testosterone levels?
- Patch- IF placed at night
2. Gel
Testosterone gel ADE
May be transferred to others who rub against the treats skin
Testosterone Transdermal solution (Axiron) application instructions
- Limit application to AXILLA
2. Apply deodorant prior to application of Axiron
Time of onset in Testosterone SQ implant pellet?
Delayed= 3-4 months
Testosterone SQ implant pellet ADE
Pellet may be extruded accidentally, losing drug effect
Oral Alkylated androgen ADE
Hepatotoxicity
What testosterone treatment produces normal pattern of serum androgen metabolites
- Patch
2. Gel
Aloprostadil (Caverject and Edex intracavernosal) MOA
Smooth muscle relaxation of arterial blood vessels and sinusoidal tissues in corpora= Enhanced blood flow
Onset of Alporstadil? Duration of erection?
Onset= 5-15 minutes= RAPID Duration= No more than 1 hr
What do you combine with intraurethral alprostadil (MUSE) to improve the treatment response?
Penile contsriction band
What should you advise your patient to do before administrating intraurethral alprostadil (MUSE)?
Empty bladder, voiding completely
What is the MOST INVASIVE treatment option in ED?
Penile Prosthesis
